How Medicaid NEMT Contracting Actually Works
Broker networks, managed-care carve-ins, fee-for-service, county rides: the four ways an operator gets paid, and how to break into each.
New operators tend to discover the NEMT industry's structure the expensive way: buy vans first, then find out who actually assigns trips in their state. This is the map — read it before the vans.
1. Broker networks (most states)
In broker-model states, the state Medicaid agency pays a broker (Modivcare, MTM Health, Verida, or a regional player) a capitated or administrative fee to manage the benefit. The broker builds a network of transportation providers, credentials them, assigns trips and pays per-trip rates it sets. For an operator, "getting the contract" means joining the broker's network:
- Credentialing packet: corporate documents, W-9, vehicle roster with VINs and inspections, driver roster with license checks, background screens, drug testing program, training certificates (defensive driving, passenger assistance/PASS, CPR/first aid are common), and insurance certificates at the broker's required limits.
- Insurance is the most common stall point. Broker requirements typically include commercial auto liability at limits many new operators don't carry by default, plus general liability and workers' comp where drivers are employees — with the broker named as certificate holder and often additional insured. Our requirements guide covers the specifics.
- Rates are published, not negotiated at typical fleet sizes. Your business case is your cost per trip against the broker's rate card.
2. Managed-care carve-ins
Some states put transportation inside the managed-care plans' contracts instead of hiring a statewide broker. California is the largest example — each Medi-Cal managed-care plan (or its transportation subcontractor) builds its own network. That means multiple smaller contracting relationships instead of one big one. Step-by-step: our Medi-Cal enrollment guide.
3. Direct fee-for-service (the seven non-broker states)
In Alabama, Alaska, Maryland, Montana, North Dakota, South Dakota and Wyoming, operators enroll directly with the state Medicaid agency as transportation providers and bill the state fee schedule per trip. No broker gatekeeper — but also no broker feeding you volume: you build referral relationships with dialysis centers, clinics, hospitals and care coordinators yourself.
4. Everything that isn't Medicaid
The operators with the strongest margins rarely run Medicaid-only. The same vans serve hospital discharge contracts, VA and TRICARE-adjacent work, managed-care supplemental benefits, private-pay families and facility contracts — each with its own paperwork, and most with lighter requirements than Medicaid brokers impose. Diversification is also the hedge against the broker-transition risk we cover here.