How to Start an Ambulance Company in 2027: Adding BLS Ambulances to a NEMT Business

A stretcher van and a basic life support ambulance can pull up to the same nursing home for the same bed-bound rider. On paper, the ambulance pays far more. That gap pulls many van owners toward ambulances, but adding them means a new regulator, often a need test, a medical director, certified crews, and Medicare as a payer. Which rides belong in each vehicle is covered in NEMT vs ambulance. This guide covers what it takes to run the ambulance.

Why an ambulance company is a different business

Four things change the day you add an ambulance:

• The regulator. Your state EMS office licenses the service, permits each vehicle, and inspects both. Your NEMT license, broker contracts, and Medicaid enrollment do not cover it.
• The vehicle. Medicare pays only for a vehicle specially designed to respond to medical emergencies or give acute care, with the warning lights, siren, radio or phone, stretcher, oxygen, and lifesaving equipment that state or local law requires (42 CFR 410.41).
• The crew. A basic life support (BLS) ambulance needs at least two people, and at least one must be a state-certified EMT-Basic who is legally allowed to run every piece of lifesaving equipment on board (42 CFR 414.605).
• The payer. Medicare pays for ambulances when the patient’s condition requires one. Since April 1, 2002, ambulance suppliers must accept Medicare’s allowed amount as payment in full and may collect only the Part B deductible and coinsurance from the patient (42 CFR 414.610(b)).

Your NPI record changes too. Ambulance companies use the Land Ambulance taxonomy code, 3416L0300X, in NUCC code set version 26.1. See how to get an NPI number for NEMT.

Step one: find out whether your state limits new ambulance services

Some states let any qualified company in. Others make you prove the area needs another service, and existing services and hospitals get notice and a chance to object. Check this before you buy a vehicle, because a denial ends the plan.

State	Approval of need	Who decides	How long
New York	Yes, a public need determination	Regional EMS council, appeal to the state council	60 days to decide, 30 days to appeal
Kentucky	Yes, with narrow city, county, and hospital exemptions	Cabinet for Health and Family Services	A 90-day formal review, in batched cycles
Arizona	Yes, a certificate of necessity	Department of Health Services	180 days, plus your time answering questions
Texas	A letter of approval from your city or county	City council or county commissioners court	Set locally
Ohio	No state need test	No one; the EMS board only licenses	No need review

New York

No ambulance service may operate without an operating certificate, and since January 1, 2000 a registration no longer counts (Public Health Law 3005). A new service must first win approval of public need from its regional EMS council. You file a sworn application naming your primary territory. The council mails notice to the chief executive of every general hospital, ambulance service, and municipality in the county, and each may comment. The council decides within 60 days, and you or any concerned party may appeal to the state council within 30 days (Public Health Law 3008). The state must also find the owners competent and fit. A certificate lasts two years, and the first one costs $100. See the New York NEMT guide.

Kentucky

Kentucky counts ambulance providers as health facilities under its certificate of need law (KRS 216B.015). The exemptions in KRS 216B.020, effective June 27, 2025, cover only emergency service run by a city or county after a public hearing, a hospital’s service for trips from its own hospital, and a city service working in a neighboring city by agreement.

The statute gives the faster nonsubstantive review to city, county, and hospital services. A private company goes through the Cabinet for Health and Family Services’ formal review, which the statute defines as a 90-day review. The cabinet’s Office of Inspector General batches ground ambulance applications into review cycles, and affected parties have 15 days after a cycle is announced to ask for a public hearing (Certificate of Need Newsletter, September 2026).

The State Health Plan, in its January 2026 update, applies to Class I, II, and III ground services, so a non-911 service needs a certificate too. You must notify every licensed ambulance and first response agency in your proposed service area. When applications compete, the plan prefers the one offering the higher level of service.

With the certificate in hand, you apply to the Kentucky Board of Emergency Medical Services through its online system (202 KAR 7:501, effective October 22, 2025). Your written service area must match the certificate. The board inspects your premises before licensing, and the license covers only the owner, service area, premises, and number of ambulances on the application. It cannot be transferred, and it expires every December 31.

Fees under 202 KAR 7:030 (effective February 16, 2024) are $3,000 for the initial prelicense, $500 to renew, $50 per ambulance inspected, and $150 for each added or replacement ambulance. A cited deficiency costs $100, or $500 if it is critical. Since January 1, 2026, a service doing only interfacility and non-emergency transport is licensed as Class IIa (202 KAR 7:545). See the Kentucky NEMT guide.

Ohio

Ohio’s certificate of need law reviews only long-term care facilities (Ohio Revised Code 3702.511, effective October 3, 2023), so a new ambulance service needs no approval of need. It does need a license from the State Board of Emergency Medical, Fire, and Transportation Services, the same board that licenses ambulettes (ORC 4766.04).

You apply online and list your medical director with their Ohio medical license number, your Medicare and Medicaid numbers, your highest level of service, your counties, and each vehicle, with a color photo of your vehicle markings (OAC 4766-2-02, effective May 1, 2026). The fees are $100 a year for the license, $100 a year for each ambulance permit, and $100 for each inspection (OAC 4766-2-03). The board decides a permit within 45 days of a complete application (ORC 4766.07). You also need liability coverage of at least $500,000 per occurrence and in the aggregate, and vehicle coverage of at least $100,000 per person, $300,000 per accident, and $50,000 for property damage (ORC 4766.06). See the Ohio NEMT guide.

Arizona and Texas

In Arizona, the Department of Health Services decides a certificate of necessity within 180 days, not counting the time you take to answer its questions (A.R.S. 36-2233). Cities, fire districts, existing certificate holders, and hospitals in the area can weigh in. AHCCCS will not register an ambulance company as provider type 06 without the certificate, apart from tribal providers that sign its attestation of equivalency (fee-for-service manual chapter 14, revised July 31, 2026).

Texas licenses ambulance companies as EMS providers. A new private applicant needs a letter from its city, or its county if outside a city, finding that another provider will not hurt existing service, will fix a shortage, and will not cause an oversupply. For two years after licensing you may not station vehicles in another city or county except under that city’s or county’s contract, mutual aid, or a state disaster activation (Texas Health and Safety Code 773.0573).

You also need a $100,000 letter of credit for the first license and a $50,000 surety bond if you bill Medicaid (773.05711). The state must approve your administrator of record, who must qualify as an EMT or other licensed health professional, pass a criminal history check, and not work for another private EMS company (773.05712).

Vehicles: the build standard your state names

States set the build standard by rule or statute, and the vehicle must show proof of it at inspection. The names you will see are the federal KKK-A-1822 specification, national standards approved by the American National Standards Institute (ANSI), and the Ground Vehicle Standard from the Commission on Accreditation of Ambulance Services (CAAS).

• Kentucky (202 KAR 7:550, effective December 13, 2023). An ambulance built before January 1, 2019 must meet the KKK-A-1822 version in effect when it was made. A new ambulance ordered after that date must meet the CAAS Ground Vehicle Standard, July 2022 edition, with a manufacturer decal or letter at inspection. A remount on a new chassis needs a letter from the conversion company.
• Ohio (ORC 4766.07, effective October 3, 2023). The board inspects each ambulance against the KKK-A-1822 version, an ANSI-approved national standard, or a CAAS standard in effect when it was built. You prove it with a placard, a manufacturer certificate, or a signed manufacturer affidavit, and a vehicle not titled as an ambulance cannot get an ambulance permit. A service licensed only for BLS non-emergency work must also letter “Non-emergency transports only,” at least 3 inches tall, on the rear and both sides (OAC 4766-2-08).

CAAS released version 4.0 of its standard on July 1, 2025. If your state’s rule names an earlier edition, as Kentucky’s does, ask the state EMS office which editions it accepts before you order. A used ambulance should come with its compliance decal or paperwork, because Ohio requires that proof for each ambulance and Kentucky requires it for any ambulance ordered after January 1, 2019.

Crews, a medical director, and safety programs

Medicare’s floor is two crew members, one an EMT-Basic, and an advanced life support unit adds a paramedic or an EMT certified for advanced services (42 CFR 410.41). States set the details. In Ohio, a BLS non-emergency ambulance runs with at least one EMT, advanced EMT, or paramedic and a driver who has completed an emergency vehicle operator course meeting NHTSA’s 1995 national standard curriculum. The company must also train that driver on driving the ambulance, moving patients on the stretcher, loading it, using a stair chair, and the bloodborne pathogens rules (OAC 4766-2-13).

EMTs are certified by the state. Where the state uses the National Registry exam, each attempt at the EMT exam costs $104 as of October 2026. See how to hire NEMT drivers for the screening that still applies.

Medical direction

An ambulance service works under a physician’s protocols:

• Ohio (OAC 4765-3-05). An Ohio-licensed physician with emergency care or EMS oversight experience in three of the last five years, plus an approved EMS medical director course, an emergency medicine residency, or EMS board certification.
• Kentucky (202 KAR 7:801, effective August 18, 2026). A Kentucky-licensed physician certified as an agency medical director through EMS board certification, emergency medicine board certification plus the state’s introductory course, or another specialty board plus the state’s full course and current ATLS, ACLS, and pediatric life support.
• Texas (DSHS initial license checklist, revised July 17, 2023). A Texas-licensed physician, under a contract or letter of agreement, who approves and signs your treatment and transport protocols and your equipment, supply, and medication list.

Bloodborne pathogens

EMTs have occupational exposure to blood, so OSHA’s bloodborne pathogens standard applies. You need a written exposure control plan, reviewed at least once a year, and you must offer the hepatitis B vaccine within 10 working days of a worker’s first assignment unless an exception applies (29 CFR 1910.1030).

Medicare enrollment and what Medicare pays

Ambulance companies enroll on Form CMS-855B and complete Attachment 1 (form version 12/2025). It asks whether you will run non-emergency trips, emergency trips, or both, and lists the cities, counties, and ZIP codes you serve. It also takes your state license, with a copy attached, and each vehicle’s VIN, make, model, year, and levels of service, with its registration. If you garage vehicles in another Medicare contractor’s area, you file a separate 855B there. Crews’ recertification records stay on file in case the contractor asks.

CMS treats ambulance suppliers as moderate risk, which adds an on-site visit to the standard checks (42 CFR 424.518). The application fee is $750 for applications submitted in 2026. After you enroll, report a change of ownership or control, an adverse legal action, or a change of location within 30 days, and other changes within 90 days (42 CFR 424.516).

2026 Medicare rates for a non-emergency BLS trip

Medicare’s base rate for a non-emergency BLS trip (A0428) depends on where the pickup is, and the 2026 fee schedule file shows it for every locality. Super rural pickups, in the lowest 25th percentile of rural areas by population density, get the highest rate.

Pickup locality (2026)	Urban	Rural	Super rural
Kentucky	$267.70	$270.32	$331.41
Ohio	$272.57	$275.25	$337.46
Rest of Texas	$279.89	$282.63	$346.50
Rest of New York	$280.09	$282.84	$346.76
Manhattan	$323.17	$326.33	$400.08

Ground mileage (A0425) is $9.33 a mile for urban pickups and $9.42 for rural ones, with $14.13 for each of the first 17 rural miles. These amounts include temporary add-ons that Congress extended through December 31, 2027. A 10-mile urban trip in Kentucky is allowed $267.70 plus $93.30, or $361.00. Medicare pays 23 percent less, on both base and mileage, for non-emergency BLS trips to dialysis (42 CFR 414.610). For which Medicare riders qualify, see does Medicare cover NEMT.

Medicaid can pay far less. Kentucky Medicaid pays a $55 base and $2 a mile for a non-emergency ambulance trip in which the rider needs no medical care on the way (907 KAR 1:061), billed as an A0428 stretcher trip on its fee schedule effective January 1, 2026. The same 10-mile trip brings $75.

Paperwork for repeat trips

A scheduled, repeating non-emergency trip needs a physician certification statement dated no more than 60 days before the trip (42 CFR 410.40). CMS’s prior authorization model for these trips reached New York on June 1, 2022 and Kentucky, Ohio, and the rest of the country by August 1, 2022. It is voluntary, and the first three round trips may be billed without it. If you have not requested it by the fourth round trip in a 30-day period, later claims face prepayment review. Since January 9, 2025, a standard review takes 7 calendar days.

How to start an ambulance company, step by step

1. Check the need rules. Call your state EMS office and ask whether a new service needs a certificate of need, a public need determination, or a local letter.
2. Pick your level. BLS non-emergency service keeps staffing and equipment simplest, such as Ohio’s BLS non-emergency level or Kentucky’s Class IIa.
3. Sign a medical director. Confirm they meet your state’s qualifications before you apply, because many applications ask for them by name.
4. Line up insurance. Price liability and vehicle coverage at your state’s minimums or higher. See NEMT insurance requirements.
5. Buy compliant ambulances. Ask for the build standard decal or letter, and title each one as an ambulance.
6. Hire and train crews. Verify state EMT certification, train drivers, and write your bloodborne pathogens plan.
7. Get licensed and inspected. File the state application, pay the fees, and pass the premises and vehicle inspections.
8. Update your NPI and enroll. Add the Land Ambulance taxonomy, file the 855B, and enroll with your state Medicaid program as an ambulance provider.
9. Win the work. Approach the discharge planners, nursing homes, and dialysis centers you already serve. The steps that grew your vans still apply; see how to grow a NEMT business.