# Rural NEMT in 2027: How to Run Long-Distance Medicaid Rides and Stay Profitable

Canonical URL: https://nemtguide.com/guides/rural-nemt/ · Updated 2026-09-28

Rural NEMT is Medicaid transportation over long distances with few riders per mile. Medicaid pays a base rate per trip plus loaded miles only, and some states pay more for rural trips, such as Arizona and South Dakota. You stay profitable by cutting empty miles: share rides where your state pays for them, wait at the clinic when wait time is paid, and plan will-call returns before the day starts.

- Medicaid pays loaded miles only, so empty miles decide whether a long rural trip makes money.
- Some states pay rural rates, like Arizona and South Dakota. Others, like Colorado, pay one rate everywhere.
- States bill shared rides very differently. Check your state's rule before you pair two riders.
- Federal hours-of-service rules reach NEMT only in commercial motor vehicles on interstate trips.
- Colorado moves every NEMT trip to one statewide broker on January 1, 2027.

## How Medicaid pays for a long rural ride

Every state must get its Medicaid members to care, however far away it is. Federal rule 42 CFR 431.53 requires each state plan to say the Medicaid agency will ensure necessary transportation to and from providers, and to describe how. Congress wrote the same duty into the Social Security Act in 2021.

CMS sets out the rules in its Medicaid Transportation Coverage Guide (SMD 23-006, September 28, 2023). Three of them shape every rural trip:

- **Least costly, most appropriate mode.** States use free rides from family or friends first. Among the modes that fit the rider's condition, they must pick the least costly.
- **Nearest qualified provider.** Without a medical reason to go farther, the state generally pays only for the trip to the nearest qualified provider. Colorado defines that as a provider within 25 miles of home, or the nearest one if none is that close.
- **Loaded miles only.** Miles with no member on board generally cannot be paid, though states may build their cost into the rate. Arizona's manual (revised July 31, 2026) bars any claim for unloaded mileage.

CMS notes that a rural provider may drive so far for one member that it cannot carry anyone else that day. It strongly encourages states to reflect rural costs in their rates, and says they may set higher base rates or pay rural supplements. Since September 28, 2023, states may also pay wait time or unloaded miles in limited cases, after CMS approves a state plan amendment.

Overnight trips carry extra coverage. Under 42 CFR 440.170(a), transportation includes meals, lodging, and an attendant when needed, and CMS says states must cover them on overnight long-distance trips.

### The codes on a long-trip claim

| Code | What it covers | On rural trips |
|---|---|---|
| A0080 | Mileage, volunteer with no vested interest | Volunteer drivers |
| A0090 | Mileage, the member, family, or a neighbor | Member mileage reimbursement |
| A0120 | Mini-bus, mountain area, or other transportation systems | Ambulatory vans, rural transit |
| [A0130](https://nemtguide.com/glossary/a0130/) | Wheelchair van | Wheelchair base rate |
| A0140 | Air travel, private or commercial | Flights to specialty care |
| A0170 | Parking fees, tolls, and other | Tolls on long runs |
| A0180 to A0210 | Lodging and meals for the member or an escort | Overnight trips |
| T2001 | Patient attendant or escort | An escort's travel |
| T2005 | Stretcher van | Stretcher base rate |
| S0209, S0215, T2049 | Mileage for a wheelchair van, other NEMT, a stretcher van | Loaded miles |
| T2007 | Waiting time, per half hour | States that pay wait time |

Two modifiers matter too: TN means rural or outside the provider's usual service area, and TK means an extra passenger. The descriptions come from the CMS HCPCS file for October 2026. Your state decides which codes it pays, so read its fee schedule next to the [Medicaid billing guide](https://nemtguide.com/guides/how-to-bill-medicaid-for-nemt/).

## What rural trips pay in three states

Rural premiums range from large to none, as three fee-for-service schedules show.

| State and code | In town | Rural | Effective |
|---|---|---|---|
| Arizona A0130, wheelchair van base | $11.15 | $12.21 | October 1, 2026 |
| Arizona S0209, wheelchair van mile | $1.54 | $1.66 | October 1, 2026 |
| Arizona A0120, ambulatory base | $6.64 | $7.27 | October 1, 2026 |
| Arizona S0215, mile | $1.28 | $1.63 | October 1, 2026 |
| Arizona T2005, stretcher van base | $49.09 | $86.70 | October 1, 2026 |
| Arizona T2007, wait per half hour | $4.59 | $4.59 | October 1, 2026 |
| Colorado A0130, wheelchair van base | $34.14 | $34.14 | July 1, 2026 |
| Colorado S0209, wheelchair van mile | $2.74 | $2.74 | July 1, 2026 |
| South Dakota A0120, one-way trip | $5.20 | $7.80 | July 1, 2026 |
| South Dakota A0120, extra rider (TK) | $2.60 | $3.90 | July 1, 2026 |
| South Dakota S0215, mile | Not paid | $1.04 | July 1, 2026 |

- **Arizona (AHCCCS).** Trips that start in the Phoenix or Tucson metro areas are urban. Every other trip is rural and carries the TN modifier, which AHCCCS says covers dirt roads, long drives, and a lack of providers. Fee-for-service trips over 100 miles in a day need prior authorization.
- **Colorado.** There is no rural rate, only a higher mileage review limit. Since September 30, 2025, a mileage claim over 52 miles is held for review, and the limit rises to 125 miles round trip a day for members in 40 designated rural counties. Rates also move fast: the ambulatory base rate, A0120, fell from $36.40 to $12.15 on July 1, 2026.
- **South Dakota.** Rides outside the city pay more, with the TN modifier. S0215 mileage is paid only on trips outside the city of 21 miles or more one way, and only once per trip, however many passengers ride.

Two changes are scheduled for 2027. On January 1, 2027, Colorado moves every NEMT trip to one statewide broker: all trips are scheduled and paid through it, and you need a contract with it to drive. In Minnesota, the statute's rural add-ons expired for fee-for-service on July 1, 2026 and expire for managed care on January 1, 2027. They set super rural base rates at 111.3% of the standard rate and paid higher mileage on rural trips up to 50 miles.

If you work through a [broker](https://nemtguide.com/glossary/nemt-broker/) or health plan, your contract sets your rate, but the state schedule is still a useful benchmark when you negotiate.

## Deadhead math on a long trip

[Deadhead miles](https://nemtguide.com/glossary/deadhead-miles/) are the miles you drive with nobody on board. On a rural run they can outnumber the paid miles.

Here is a hypothetical rural Arizona fee-for-service trip at the TN rates effective October 1, 2026. The distances, appointment length, and running cost are example numbers. One wheelchair rider lives 5 miles from your garage and has a 4-hour appointment at a clinic 45 miles away. In Plan A the driver goes back to base during the appointment. In Plan B the driver waits at the clinic.

| Example trip | Plan A: drive back to base | Plan B: wait at the clinic |
|---|---|---|
| Miles driven | 190 | 100 |
| Loaded miles (paid) | 90 | 90 |
| Empty miles | 100 (53%) | 10 (10%) |
| Base rates, 2 × $12.21 | $24.42 | $24.42 |
| Loaded miles × $1.66 | $149.40 | $149.40 |
| Wait time, 8 half hours × $4.59 | $0 | $36.72 |
| **Total pay** | **$173.82** | **$210.54** |
| Running cost at an example $0.75 a mile | $142.50 | $75.00 |
| **Left for driver pay and profit** | **$31.32** | **$135.54** |

Two formulas do the work:

**Empty-mile share = empty miles ÷ total miles driven**

**Pay per mile driven = total pay ÷ total miles driven**

Plan A earns $0.91 per mile driven and Plan B earns $2.11. Plan A only wins if the driver fills those four hours with paid trips near base. Arizona pays wait time only when the distance makes a return to base impractical, and the odometer must not move between drop-off and pickup. Put your own cost per mile into the table before you choose.

## How to plan a rural day

1. **Sort riders by destination.** Group standing orders by clinic and appointment time, not by home town.
2. **Check the shared-ride rule before you pair riders.** The table below shows how differently four programs pay for one shared van.
3. **Hold ride time inside the limit.** MTM Health's Virginia handbook (May 2026) says no member in a multi-load should ride more than 45 minutes longer than the average direct trip unless authorized.
4. **Decide wait or return for each long leg,** using the deadhead math and your own cost per mile.
5. **Place every will-call return** on a van before the day starts.
6. **Keep each rider inside mileage limits,** such as Arizona's 100-mile authorization line.
7. **Hand back trips you cannot cover the day before.** A missed rural pickup strands a rider far from care.
8. **Record loaded and empty miles for every van, every day.** The trend shows which routes pay.

### How shared rides are paid

| Program | How a shared ride is billed |
|---|---|
| Arizona fee-for-service | A separate Daily Trip Report per member, each billed for that member's direct-route miles. Wait time is paid for one member only. |
| Colorado | Several members in one vehicle to the same place: only one member's ID is billed, and the mileage is paid once. |
| South Dakota | Each extra rider is billed with the TK modifier at a lower base rate. Mileage is paid once per trip. |
| Virginia (MTM Health) | Pay reflects miles driven, mode, and multiloading. Extra ride time is capped at 45 minutes over the average direct trip unless authorized. |

### Will-call returns from far-away clinics

A [will-call](https://nemtguide.com/glossary/will-call-trip/) return has no set time: the rider calls when the visit ends. MTM Health's Virginia handbook requires the van within 45 minutes of the call, and within three hours for hospital discharges, with liquidated damages for missing that window. A van 45 miles away cannot make 45 minutes, so plan for it:

- **Ask the clinic** for a realistic finish time and a call when about 30 minutes remain.
- **Stage the van nearby** when the deadhead math favors waiting.
- **Pair the return** with another member leaving the same facility, where shared rides are allowed.
- **Call the broker early** if you cannot make the window, so it can reassign the trip.

CMS weighs the same choice. It says a second driver for the return can cost less than a long wait, but that sometimes the long wait is the most economical way home.

## Driver hours and fatigue on long days

Federal hours-of-service rules reach NEMT only when two things are true. First, the vehicle is a commercial motor vehicle under 49 CFR 390.5: rated or weighing 10,001 pounds or more, or designed or used to carry more than 8 people including the driver for pay. Second, the trip is interstate: it crosses a state line, passes through another state, or is the in-state part of a trip that starts or ends out of state.

| Your vehicle | Trips stay in your state | Paid trips cross a state line |
|---|---|---|
| Car, minivan, or wheelchair van for 8 or fewer people, under 10,001 pounds | No federal rules. Your state's may apply. | No federal hours rules. It is not a commercial motor vehicle. |
| Van for 9 to 15 people, under 10,001 pounds | No federal rules. Your state's may apply. | With direct pay per ride, parts 390 to 396 apply, including driving limits and logs. |
| Any vehicle rated 10,001 pounds or more | No federal rules. Your state's may apply. | Parts 390 to 396 apply, including driving limits. |
| Designed for 16 or more people | A CDL is required even in state (49 CFR 383.5). | A CDL plus the full federal rules. |

For 9 to 15 passenger vans, the form of pay matters. FMCSA defines direct compensation as payment by the passengers, or someone acting for them, for the ride, and its November 15, 2022 guidance treats a specific fee for the ride as direct. If these vans cross state lines on paid trips, plan on the full rules and confirm with FMCSA at 800-832-5660.

When the rules apply, a passenger-carrying driver may drive up to 10 hours after 8 consecutive hours off (49 CFR 395.5). No driving after 15 hours on duty, or after 60 hours in 7 days (70 in 8 days if you run every day). Off-duty time does not count toward the 15 hours. Waiting in readiness to drive does, unless the driver is relieved from duty (49 CFR 395.2), so a long clinic wait eats into the day.

Drivers who stay within 150 air miles of their work reporting location, are released within 14 hours, and get 8 hours off between shifts do not need logs. You still keep 6 months of time records showing report time, on-duty hours, and release time (49 CFR 395.1(e)(1)).

Most rural NEMT vans fall outside these rules, but fatigue does not. Hold every driver to the federal passenger limits anyway, and never start a two-hour return at the end of a 14-hour day.

## Keeping high-mileage vans on the road

Rural vans pile up miles fast, and a breakdown far from base strands a rider. MTM Health's Virginia handbook requires every vehicle to pass inspection before it carries members and again twice a year, and vehicles out of compliance may be pulled from service. It also requires an accurate odometer and a GPS or current maps on board. A van that counts as a commercial motor vehicle on interstate trips also needs FMCSA inspection, repair, and maintenance records under part 396. Keep those records either way, because brokers and auditors ask for them.

- **Service by the odometer, not the calendar.** If your owner's manual has a schedule for heavy or severe use, follow it.
- **Inspect before every shift** with the free [vehicle inspection checklist](https://nemtguide.com/templates/nemt-vehicle-inspection-checklist/).
- **Have a breakdown plan.** Know which spare van or partner can reach each route. In Arizona, a driver who switches vehicles mid-day needs a new Daily Trip Report for each vehicle.
- **Carry spare securement straps and belt extensions** so one failed part does not end a wheelchair trip.

The [NEMT vehicle requirements guide](https://nemtguide.com/guides/nemt-vehicle-requirements/) has the full federal, state, and broker checklist.

## Trip records in cell dead zones

Trip records are due even where there is no signal. The FCC National Broadband Map shows each carrier's 3G, 4G LTE, and 5G coverage, modeled for outdoors or a moving vehicle, and the FCC says real coverage varies with the phone and terrain. Use it to spot likely dead stretches, then confirm them on a drive.

Programs differ on what they need:

- **Virginia (MTM Health).** Location tracking stays on for the full ride, and drivers carry a working phone. The electronic trip log needs the trip ID, scheduled and actual pickup times, departure and arrival times, and the member's signature, or the claim is denied.
- **Arizona.** The Daily Trip Report can be on paper in blue or black ink, or on a tablet, and goes with the claim. Multi-stop trips need addresses, times, and odometer readings for each segment. If outbound and return miles differ, explain why or the mileage may be cut.
- **Minnesota.** Records may be paper or electronic but must be produced on request. The driver signs for the actual miles, and a location with no address gets a description.

CMS notes that drivers can use odometer readings or GPS coordinates when there is no street address. Build that into a dead-zone routine:

1. **Test your driver app with no signal** and confirm it keeps recording and uploads later.
2. **Carry the paper form your broker accepts.** Arizona accepts only its own Daily Trip Report.
3. **Write down the odometer at every pickup and drop-off,** even when the app records GPS.
4. **Note the reason for any detour,** such as a closed road.
5. **Set check-in points** where drivers call dispatch once they have signal.

The free [trip log template](https://nemtguide.com/templates/nemt-trip-log-template/) has columns for all of these.

## Rural transit, volunteer drivers, and mileage reimbursement

Other programs also carry rural members, and some of them make good partners.

### Rural transit agencies (FTA Section 5311)

The FTA's Formula Grants for Rural Areas program (49 U.S.C. 5311) funds capital, planning, and operating costs for public transportation in areas under 50,000 people. FTA apportioned $956,643,454 for fiscal year 2025. Funds reach local governments, nonprofits, and transit operators, and eligible uses include non-emergency medical transportation and buying transportation services. So a rural transit agency may contract with you for trips it cannot cover.

Two rules come with that work. As a contractor to an agency funded by Section 5311, you fall under the FTA drug and alcohol testing rule, 49 CFR part 655. And CMS says a transit agency that coordinates NEMT must be picked through competitive bidding, with Medicaid paying for rides, not vehicles.

### Volunteer driver programs

The FTA's Section 5310 program funds rides for older adults and people with disabilities, through the state department of transportation in rural areas. Volunteer driver programs qualify, as do NEMT and contracted transportation. Medicaid pays volunteer mileage under A0080: $0.44 a mile in Arizona (October 1, 2026), $0.47 in Colorado (July 1, 2026), and $0.70 in South Dakota (December 1, 2025).

### Member mileage reimbursement

Members with a car, or a relative with one, can claim mileage under A0090 instead of riding in a van. Colorado pays $0.47 a mile, per vehicle, for the most direct route, and the trip must be approved in advance. Colorado also bars NEMT providers from billing standard NEMT for their own family or household members, who must use mileage reimbursement instead. South Dakota pays $0.70 a mile. For an overnight stay for specialty care at least 150 miles from the member's city, it adds $40 a day for meals, or $150 a day for meals with lodging.

These programs carry riders who can ride in a private car. That leaves wheelchair, stretcher, and hands-on riders for vans like yours, and nearby transit and volunteer programs are natural sources of those referrals.

## Frequently asked questions

### Does Medicaid pay more for rural NEMT trips?

In some states. Arizona pays higher rates on most codes for trips that start outside the Phoenix and Tucson metro areas, billed with the TN modifier. South Dakota pays more for community transportation outside the city. Colorado pays one rate everywhere but raises its daily mileage review limit from 52 to 125 miles for members in 40 rural counties. CMS says states may set higher base rates or pay rural supplements, so check your state fee schedule and your broker contract.

### Do I get paid for the empty miles to a rural pickup?

Generally not. CMS guidance says miles with no member on board generally cannot be paid, though states may build their cost into the rate. Since September 28, 2023, a state can choose to pay unloaded miles in limited cases where the most economical provider would face extraordinary costs, but only after CMS approves a state plan amendment. Ask your state Medicaid agency whether it has one.

### Can I bill for waiting at a far-away clinic?

Only where your state pays wait time. Arizona pays $4.59 per half hour (T2007, October 1, 2026 rates) when the distance makes returning to base impractical. It does not pay for waits under 30 minutes, one-way trips, trips of 10 miles or less, round trips that use two vehicles or drivers, or waits where the odometer changes between drop-off and pickup. Colorado lists waiting time as a service it excludes.

### Do FMCSA hours-of-service rules apply to NEMT drivers?

Only when the vehicle is a commercial motor vehicle used in interstate commerce. That means a vehicle rated 10,001 pounds or more, or one designed or used for 9 or more people including the driver for pay, on a trip that crosses a state line or is part of an interstate trip. A typical sedan, minivan, or small wheelchair van on in-state trips is outside the federal rules. Your state may have its own.

### Can I carry two Medicaid riders at once on a long trip?

Usually, if your broker or state allows it, but pay differs. Arizona bills each member separately with that member's direct-route miles. Colorado bills only one member when the same vehicle takes several members to the same place. South Dakota pays a lower extra-rider rate with the TK modifier and one mileage allowance per trip. MTM Health's Virginia handbook limits extra ride time to 45 minutes over the average direct trip.

### Who pays for meals and lodging on an overnight medical trip?

Medicaid does, when the state finds them necessary. Federal rule 42 CFR 440.170(a) includes meals and lodging on the way to and during care, and CMS says states are required to cover these costs on overnight long-distance trips. Colorado pays up to $100.18 a day for lodging and $43.96 for meals (July 1, 2026). South Dakota pays $150 a day for meals with lodging on overnight specialty care trips at least 150 miles from the member's city.

## Official resources

- [CMS: Medicaid Transportation Coverage Guide (SMD 23-006)](https://www.medicaid.gov/federal-policy-guidance/downloads/smd23006.pdf)
- [AHCCCS: Ground transportation fee schedules by year](https://www.azahcccs.gov/PlansProviders/RatesAndBilling/FFS/transportationground.html)
- [Colorado HCPF: NEMT Billing Manual](https://hcpf.colorado.gov/nemt-billing-manual)
- [South Dakota Medicaid: Transportation Services Fee Schedule](https://dss.sd.gov/docs/medicaid/providers/feeschedules/Other_Services/Transportation_Services_Current.pdf)
- [FMCSA: Small passenger-carrying vehicles](https://www.fmcsa.dot.gov/registration/small-passenger-carrying-vehicles)
- [FMCSA: Summary of hours of service regulations](https://www.fmcsa.dot.gov/regulations/hours-service/summary-hours-service-regulations)
- [FTA: Formula Grants for Rural Areas (Section 5311)](https://www.transit.dot.gov/rural-formula-grants-5311)
- [FTA: Enhanced Mobility of Seniors and Individuals with Disabilities (Section 5310)](https://www.transit.dot.gov/funding/grants/enhanced-mobility-seniors-individuals-disabilities-section-5310)
- [FCC National Broadband Map (mobile coverage by address)](https://broadbandmap.fcc.gov/)