Out-of-State NEMT Trips in 2027: Medicaid Approvals, Border Zones, and Federal Carrier Rules

A dialysis center just across a river. A children’s hospital two states over. A cancer center that has treated the member for years. Out-of-state trips come in all of these shapes, and two questions decide each one. Will the member’s Medicaid program pay for the care and the ride? And is your company registered to carry a paid passenger across the line?

When Medicaid pays for care in another state

Federal rule 42 CFR 431.52(b) requires every state to pay for services a resident gets in another state, to the same extent as at home, in four cases:

1. A medical emergency.
2. The member’s health would be endangered by traveling back to the home state.
3. The care is more readily available there. The state decides this on medical advice, for the service itself or the resources that go with it.
4. Local practice. It is general practice for members in a particular area to use medical resources in the other state.

The ride follows the care. Under 42 CFR 440.170(a), Medicaid transportation covers the travel the agency finds necessary to secure medical examinations and treatment. Colorado’s NEMT billing manual (revised July 17, 2026) puts it plainly: NEMT can only be used to reach approved medical services, and its rules require medical services to be provided in Colorado unless they are not available in the state.

CMS adds limits and extras in its Medicaid Transportation Coverage Guide (SMD 23-006, September 28, 2023):

• Nearest qualified provider. Unless there is a medical need to go farther, the state generally must ensure transportation to the nearest qualified provider. A distant provider with special capabilities, or a relationship that would harm the member to end, can justify a longer trip.
• Children. When a child needs someone along, the state must cover that person’s trips, including out-of-state round trips for admission and discharge. See EPSDT.
• Disasters. NEMT can move a member from a nursing home or other medical facility that is no longer safe to one that is, even when the closest one is out of state.
• Personal moves are out. NEMT is not available to move a member from one community setting to another for personal reasons, such as being closer to family.

A member visiting from another state stays on that state’s Medicaid, so whether a ride is covered is that state’s call under the same four cases. Your state must have procedures to help those members get care while they are present (431.52(c)), but the approval and the payment for the ride come from the home program. Call that program’s broker before you drive.

Border zones: trips many states treat as local

Many programs name a border zone, in line with the fourth case in 431.52. Inside it, a ride across the line is handled like any local trip. Past it, the care and the ride need approval first. Here is how twelve programs draw the line.

State (source date)	Covered like a local trip	Past the zone
Missouri (NEMT manual, April 2026)	Providers in the eight bordering states: Arkansas, Illinois, Iowa, Kansas, Kentucky, Nebraska, Oklahoma, and Tennessee	Trips to non-bordering states. The broker gets MO HealthNet prior authorization.
Georgia (NEMT manual, July 1, 2026)	Providers up to 50 miles beyond Georgia’s borders, through the county’s broker	Farther trips may qualify for Exceptional Transportation Services, arranged by DFCS at 404-657-7543, not the broker
North Dakota (NEMT manual, January 2026)	Providers within 50 miles of the nearest North Dakota border	Farther trips need a service authorization from ND Medicaid
Oklahoma (out-of-state rules since September 1, 2019)	A SoonerCare-contracted provider within 50 miles of the border	Farther trips need out-of-state prior authorization, with documents to OHCA 10 days ahead, except emergencies
Washington (WAC 182-501-0175 and 182-546-5800)	Twelve named cities: Coeur d’Alene, Moscow, Sandpoint, Priest River, and Lewiston in Idaho, and Portland, The Dalles, Hermiston, Hood River, Rainier, Milton-Freewater, and Astoria in Oregon	Every other out-of-state trip. Requests reach the Health Care Authority at least 7 business days before travel.
Arkansas (broker bid 710-25-049, 2025)	The broker covers rides to out-of-state providers enrolled in Arkansas Medicaid within 50 miles of the border	The broker is not responsible for trips more than 50 miles past the border
Indiana (transportation module, August 19, 2025, and out-of-state providers module, May 29, 2026)	Rides to designated sister cities. For the care itself, providers in listed counties around Chicago, Cincinnati, Louisville, Evansville, and South Bend count as in-state.	Interstate rides and every other out-of-state pickup or destination need prior authorization
New Jersey (broker facility page, as of September 2026)	Out-of-state trips as far as the next county in a neighboring state, booked the usual way	Farther trips wait on NJ Medicaid authorization
North Carolina (one health plan’s rules, as of September 2026)	Carolina Complete Health: trips less than 40 miles over the border	Trips 40 or more miles over the border, and trips over 75 miles one way, need the plan’s approval. Other plans set their own limits.
Colorado (billing manual, July 17, 2026)	Routine care in the border towns listed in the manual’s Appendix F	Train, air, and every other out-of-state trip need Department prior authorization
Montana (DPHHS page, as of September 2026)	No zone named	Any out-of-state travel, and trips over 100 miles one way
Louisiana (Medicaid Services Manual, July 14, 2025)	No zone named	All out-of-state medical care needs approval from the LDH fiscal intermediary, and the broker approves the ride only after the care is approved. The ride may be included in that approval.

A zone rule says the trip is local for Medicaid. It does not make the trip local for federal carrier rules. A paid ride across the line is still interstate, as the section on carrier rules below explains. For each state’s program and broker, see the state guides and NEMT brokers by state.

How approval works for an out-of-state ride

Prior authorization for an out-of-state trip usually runs in this order.

1. The medical visit is approved. In Indiana, out-of-state services in general need prior authorization, except emergencies, pharmacy, telehealth, and providers enrolled with in-state status (Out-of-State Providers module, May 29, 2026). Louisiana’s fiscal intermediary approves the care first.
2. The ride is requested. The member, the medical provider, or a facility asks the broker or health plan. At Carolina Complete Health, the member calls its broker, MTM, which tells the plan, and the plan contacts the member’s doctor.
3. The paperwork goes to the state or plan. In Colorado, the broker sends the NEMT Air, Train, and Out-of-State Request Form with the most recent clinical notes and a letter of medical necessity, and the Department decides.
4. The approval comes back to the broker. Indiana says its broker, not the individual transportation provider, secures any required prior authorization for brokered fee-for-service trips.
5. You receive the trip with the approval on it. Check it before you accept.

Timing matters. Washington wants the request at least 7 business days before travel. Oklahoma wants the prior authorization documents 10 days before the care, outside emergencies. Approvals can also run for a set period: Indiana can approve out-of-state medical care for any period from one day to one year. For a standing trip across the line, note when the approval ends.

When a trip is exempt from the broker, the provider files the request itself. For those Indiana trips, the request lists the procedure codes, the member’s age, the type of service, the reason for and destination of the trip, how often and for how long, the total miles per trip, and the total waiting time per trip.

Driving before the approval exists usually means no payment. Colorado does not pay for rides given without authorization. North Dakota makes the member responsible for travel costs tied to an out-of-state service it did not authorize. Neither leaves money for you.

Meals, lodging, and flights on long trips

Federal rules treat the costs of a long trip as part of transportation. Under 42 CFR 440.170(a)(3), travel expenses include meals and lodging on the way to care and while receiving it, plus an attendant’s travel, meals, lodging, and salary when the attendant is not family. CMS says states are required to cover related travel expenses on overnight long-distance trips (SMD 23-006).

States decide the details:

• Louisiana covers meals, lodging, and related costs for the member and one attendant when total travel time, including the appointment, exceeds 12 hours. The broker’s policy may not pay more than the federal GSA per diem rates.
• North Dakota pays meals and lodging only when care or travel requires an overnight stay, and only to enrolled providers, never to the member. It may authorize meals and lodging for a driver. An attendant’s costs need the referring provider to find an attendant medically necessary, and both are paid only if one person cannot be driver and attendant.
• Flights. Louisiana pays the lowest refundable coach fare for the member and at most one attendant, and only when the care is not available in Louisiana and other travel would put the member’s health at grave risk. In Oklahoma, OHCA makes the flight arrangements itself.

Your van may carry the airport legs of a flight trip. FMCSA can treat a ground ride that is part of an interstate flight as interstate commerce, even when the ride stays in your state. The USDOT number guide covers that rule and its airport exemption.

These are the national codes for the extra pieces of a long trip, from the CMS HCPCS file for October 2026. Your state decides which it pays and who bills them.

Code	What it covers
A0110	Bus, intrastate or interstate carrier
A0140	Air travel, private or commercial, intrastate or interstate
A0170	Parking fees, tolls, and other
A0180	Lodging for the member
A0190	Meals for the member
A0200	Lodging for the escort
A0210	Meals for the escort
T2001	Patient attendant or escort

For the base and mileage codes, see NEMT billing codes. For how to price a private trip that no program pays, see long-distance medical transport.

Federal carrier rules once your van crosses the line

Medicaid approval covers the payment. Federal motor carrier law covers your company, whoever pays for the ride.

When a trip is interstate

Under 49 CFR 390.5T, a trip is interstate commerce when it runs:

• from a place in one state to a place outside it,
• between two places in one state, but through another state on the way, or
• between two places in one state as part of a trip that starts or ends outside the state.

Your trip	Interstate?	What it means for you
From your state to a clinic across the line and back	Yes	Federal registration applies
Between two towns in your state on a road that cuts through the next state	Yes	Federal registration applies
A ride to the airport for a member flying to out-of-state care	Can be	Read the airport rules in the USDOT guide, and ask FMCSA
A ride that starts and ends inside the other state	No, it is intrastate there	That state’s passenger carrier rules apply
Every trip stays inside your state	No	Your state’s rules only

What a paid interstate trip requires

• Operating authority and a USDOT number. FMCSA says for-hire carriers in interstate commerce must get operating authority registration “no matter how small or light the vehicle(s) used, unless exempted,” plus safety registration (Appendix A to 49 CFR part 390). A trip paid by Medicaid, a broker, or a health plan is a paid trip.
• Filed liability coverage. For-hire interstate passenger carriers must carry at least $1.5 million for vehicles seating 15 or fewer, driver included, and $5 million for 16 or more (49 CFR 387.33T). Your insurer files the proof with FMCSA. See NEMT insurance requirements.
• Unified Carrier Registration. The UCR Plan says for-hire interstate passenger carriers must register every year, even when they run only small vehicles. The fee depends on how many commercial vehicles you run, and a company with 0 to 2 pays the lowest bracket: $46 for 2026 and $55 for 2027, under a rule effective October 1, 2026, the day 2027 registration opens.
• One trip is enough. FMCSA keeps jurisdiction over a carrier, its vehicles, and its drivers for 4 months after a trip in interstate commerce.

Brokers check. Virginia’s fee-for-service NEMT rules (updated May 26, 2026) require providers that accept out-of-state trips to hold FMCSA operating authority.

The federal safety rules reach further only when a vehicle is a commercial motor vehicle: rated at 10,001 pounds or more, or designed or used for 9 or more people, driver included, for pay. Then driver files, medical cards, hours of service limits, and maintenance records apply. For vans built for 9 to 15 people, how you are paid can change which of those rules reach you, as the USDOT guide explains. Most minivans and small wheelchair vans stay under both lines. See do NEMT drivers need a CDL for the license lines.

Exemptions to ask about first

Two exemptions matter most near a state line, and both have conditions (49 U.S.C. 13506):

• Commercial zones. Trips entirely within a city, neighboring cities, or the commercial zone around them are exempt from operating authority. On a route that crosses a state line, the exemption holds only if you lawfully provide intrastate passenger service over the entire route under each state’s laws.
• Taxicab service. Taxicab service is exempt from operating authority. Federal law defines it as rides in a vehicle for 8 or fewer people, driver included, not run on a regular route, that is licensed as a taxi, or offers local rides priced mainly by distance and does not mainly serve airports (49 U.S.C. 13102).

Get FMCSA’s answer in writing before you rely on either one. The USDOT number guide walks through the filings, fees, and each exemption.

The other state’s rules on its roads

A trip that starts and ends inside the other state is intrastate commerce there, so that state’s rules for paid passenger carriers apply. That can happen on the way home: a broker in the other state offers you a local trip there, and it needs that state’s permits. See NEMT license requirements for each state’s carrier license.

Two more checks before the first trip:

• Insurance. Ask your agent in writing whether your commercial auto policy covers trips in the other state, and at what limits.
• Driver hours. Long out-of-state days need rest plans even when federal hours rules do not reach your van. The rural NEMT guide shows how federal limits work, and the long-distance guide plans crew time and hotel nights.

Getting trips from the program next door

A company near a state line can often serve both programs. Each one screens and credentials you on its own.

• Brokers recruit across the line. Minutes of the Oklahoma Health Care Authority board (January 17, 2024) record its broker contracting providers in bordering states, including a Joplin-based provider for northeastern Oklahoma and a Dallas-based provider for southeastern Oklahoma.
• States enroll out-of-state NEMT companies. North Carolina’s provider permission matrix (August 16, 2026) lists NEMT van organizations located out of state as well as in state. Both are screened at moderate risk, with a federal site visit, the federal application fee, and an NEMT Driver Attestation form. See provider risk levels and the Medicaid site visit.
• Deadlines can differ. Texas Medicaid gives out-of-state providers 365 days from the date of service to file a fee-for-service claim, against 95 days for most in-state claims (Provider Procedures Manual, September 2026).

To start, see how to become a Medicaid transportation provider and working with multiple NEMT brokers.

Before you accept an out-of-state trip

1. Find the approval. Check the trip for an authorization or trip number, the approved destination, and the approved dates.
2. Read the level of service. Confirm the mode, any escort, and any approved meals or lodging.
3. Check your federal registration. Operating authority, a USDOT number, the insurance filing, and UCR must be in place before the first paid interstate trip.
4. Check the vehicle. If it is a commercial motor vehicle, driver files, medical cards, and hours records apply.
5. Plan the driver’s day. Count every hour on duty, and ask the broker in writing whether a hotel room and meals for the driver are approved.
6. Plan the return. Decide who brings the member home if the appointment runs long, and how the will-call return is dispatched from out of state.
7. Document both states. Record full addresses, times, odometer readings, and the signature your broker requires. See NEMT trip documentation.
8. Bill with the approval. Put the approval number and the right codes on the claim, and keep a copy with the trip log.