Can You Start a NEMT Business with No Money in 2027? The Costs You Cannot Skip

You can get your tax ID and your NPI without spending anything but time, and forming the company costs little. The trouble starts at the first ride. Before a broker or your state lets you carry a Medicaid member, you need insurance in force, a vehicle that passes inspection, and drivers who have passed their checks. Then you carry the costs until the first payment arrives. This guide separates the costs you cannot skip from the ones you can shrink, as of September 2026.

Can you start a NEMT business with no money?

Not with none, but several early steps are free or cheap. Here is what each one costs:

Step	Cost	Who sets it
Employer identification number (EIN)	Free. The IRS says you never have to pay a fee for one.	IRS
National Provider Identifier (NPI)	Free. HHS does not charge a fee to get one.	HHS, through NPPES
Business counseling from SBA partners, such as Small Business Development Centers and SCORE	Free or low cost	SBA
Forming an LLC	$50 in Arizona, or $85 expedited (Rev. 3.2026)	Your Secretary of State or corporation commission
Medicaid application fee	$750 for applications from January 1 to December 31, 2026, where your state charges NEMT companies	CMS and your state
State license	New Jersey: $1,500 plus $100 per vehicle for a new mobility assistance vehicle service	Your state licensing agency
Commercial insurance	Your insurer’s quote, at the limits your brokers require	Your insurer
A vehicle that passes inspection	Its price, or its down payment and monthly loan payment	You and your lender
Driver checks and training	Vendor and course fees	Your screening vendors and trainers
Cash to run until payers pay	Your monthly costs times the months until payments arrive	Your payers’ schedules

The top half of that table is small. The bottom half is where the money goes. For a line-by-line budget with more state fees and vehicle prices, see how much it costs to start a NEMT business.

The costs you cannot skip

Insurance, in force before the first ride

Insurance comes first because licenses and broker contracts ask for proof of it. New Jersey wants certificates of insurance before it licenses you, and a licensed service must stop all rides the moment any required coverage lapses (N.J.A.C. 8:40-3.3). MTM Health’s standard agreement ends immediately if coverage is not kept in force (section 9.C).

Who sets it	Auto liability	General liability
New Jersey, licensed mobility assistance vehicle services	$500,000 per occurrence for each vehicle	$300,000
MTM Health’s standard agreement, January 1, 2023 version posted by Pennsylvania	$500,000 combined single limit	$500,000 per occurrence
MediTrans, Louisiana (September 2026)	$1,000,000 per occurrence	Required
MTM Health, Rhode Island (September 2026)	$1,500,000	$1,500,000

Insurers set premiums from your vehicles, drivers, history, and limits, so there is no standard price. The SBA notes that poor credit history can affect insurance rates too. Get quotes at the highest limit any of your brokers requires, and get them before you buy a vehicle. See NEMT insurance requirements.

A vehicle that passes inspection

You cannot skip the vehicle, and some states want proof of it with the application. Arizona’s NEMT enrollment packet (rev 09/2026) asks for vehicle insurance, registration for company vehicles, and a for-hire permit from the state transportation department with the application. Arizona then checks for your company logo on every vehicle at its site visit.

A cheap old vehicle may not qualify:

• Rhode Island accepts a vehicle added after July 31, 2024 only if it is no more than four model years old with no more than 150,000 miles at its first inspection. It may serve until 250,000 miles. Vehicles in the NEMT fleet may carry only NEMT riders (policy effective October 31, 2024).
• Portland, Oregon bars a vehicle from NEMT work 15 years after its manufacture date, with an age exemption some wheelchair-accessible vehicles can apply for (City Code 16.40.750).
• MTM Health may refuse to pay for any trip in a vehicle used before it is approved (standard agreement, section 4.D).

The type of rider you carry sets the price of the vehicle. On Florida’s public transit contract, a new lowered-floor ramp minivan cost $70,771 with its required seating (order form effective February 20, 2025). Riders who walk can ride in far cheaper vehicles: MTM Health’s Virginia handbook allows sedans, passenger vehicles, and minivans for ambulatory members. See NEMT vehicle requirements, wheelchair van cost, and using a personal vehicle for NEMT.

Enrollment and license fees

The federal Medicaid application fee is $750 for applications submitted in 2026. It applies to institutional providers, and each state decides which of its provider types count as institutional. CMS’s enrollment guidance, updated November 17, 2025, names non-emergency transportation providers that bill Medicaid fee-for-service as an example of those who must pay. Arizona’s packet lists the fee as required. The amount changes each calendar year with inflation, and you pay the amount in effect for the year you apply (42 CFR 424.514).

State licenses cost more where they exist. New Jersey charges a new mobility assistance vehicle service $1,500 plus $100 per vehicle, or $1,250 plus $50 per vehicle in the second year of its two-year cycle. The fee is due with the application, is not refunded, and must be paid by certified bank check, such as a cashier’s check, or money order (N.J.A.C. 8:40-2.5, readopted in 2023 and in effect until September 25, 2030). See NEMT license requirements.

You also need a real company. MTM Health’s standard agreement requires a business that is incorporated or organized and in good standing, with a certificate of good standing on request (section 2.B).

Driver checks and training

Every driver passes checks before the first ride, and that includes you. Modivcare lists a hands-on wheelchair training certificate (PASS), first aid and CPR, defensive driving, a drug screen, a motor vehicle report, and a background check. Arizona makes the owner responsible for CPR, first aid, and HIPAA training for every driver. It screens NEMT companies at its high risk level, with a site visit and fingerprint-based background checks of anyone who owns 5 percent or more (42 CFR 455.434). The owner must also complete the state’s online NEMT certification course and upload its certificate with the enrollment.

Some of it costs nothing. MTM Health’s Virginia handbook says the training that Virginia Medicaid and MTM require is provided at no cost to the provider. First aid and defensive driving come from outside courses. See NEMT driver requirements.

Cash to run until the first payment

Payers pay after the ride. MTM Health’s standard agreement pays uncontested invoices within 30 days after electronic submission (section 6.A). MediTrans processes claims in 7 to 14 business days and pays every other Friday. Your insurance, fuel, phone, and any loan payment keep coming in the meantime.

Some costs never come back. CMS says miles with no member on board generally cannot be paid, and neither states nor providers may charge a member for a no-show (SMD 23-006, September 28, 2023). The SBA suggests counting at least one year of monthly expenses in your startup plan. The cash reserve calculator sizes the cushion from your payers’ schedules.

Ways to start a NEMT business with less money

1. Start with one van and drive it yourself. You save a driver’s wages and, in some programs, workers’ compensation. MediTrans offers a waiver form for owner-operators without employees, and Modivcare says coverage is required in most states if you have employees. See how to start with one van.
2. Start with riders who walk. A sedan or minivan costs far less than a converted wheelchair van, where your state and brokers allow one. See how to start an ambulatory transportation business for the rules.
3. Finance the vehicle. A down payment instead of the full price cuts the cash you need to open. At 10 percent down, the $70,771 Florida minivan takes $7,077 up front. The vehicle loan calculator shows the monthly payment that comes with it.
4. Buy used, but only within the rules. Check age and mileage limits, like Rhode Island’s and Portland’s, and the inspection checklist before you pay for any vehicle.
5. Ask brokers before you buy. MediTrans says acceptance depends on regional saturation and fleet type needs. MTM Health estimates an 8 to 12 month wait to join its Rhode Island network, as of September 2026. A vehicle for a network that is full earns nothing.
6. Line up everything else first. Form the company and get your EIN, NPI, driver files, and broker interest before the vehicle and insurance start costing you money every month. Where your state wants the vehicle with the application, as Arizona does, that sequence matters even more.
7. Ask about the application fee. You owe no fee if you are already enrolled in Medicare or another state’s Medicaid, or paid the fee there (42 CFR 455.460). You can also request a hardship exception, described below.
8. Keep your paycheck while approvals run. MediTrans says its onboarding typically takes 2 to 4 weeks from your letter of intent. Income from a job can also back a personal loan that counts toward an SBA down payment.

The Medicaid fee hardship exception

Federal law lets CMS waive the application fee case by case when paying it would be a hardship. CMS’s Medicaid enrollment compendium (last updated November 17, 2025) lays out the process:

1. Write a letter to your state Medicaid agency describing the hardship and why it justifies an exception.
2. Attach financial records. CMS recommends your most recent business tax return, profit and loss reports, and three or more bank statements.
3. The state reviews it. It can deny the request on its own or recommend approval to CMS. Only CMS can approve.
4. CMS answers the state within 60 days of the state’s request, and the state tells you the result. If CMS asks for more records, the state has 30 days to send them.

Ask your state how it takes these requests before you file your enrollment.

How to pay for the costs you cannot skip

Grants rarely fit. The SBA says it does not provide grants for starting and expanding a business. Federal Section 5310 funds for seniors and people with disabilities go to states, local governments, private nonprofits, and operators of public transportation, and the capital share goes mainly to nonprofits and qualifying public agencies (49 U.S.C. 5310). Buying transportation services is an eligible use of that money, so a for-profit company can be paid as a contractor. See NEMT grants.

SBA microloans go up to $50,000, with an average of about $13,000, terms up to seven years, and rates generally between 8% and 13%, as of September 2026. Nonprofit intermediary lenders make them and set the terms. They can pay for working capital, equipment, and supplies, but not existing debts or real estate.

SBA 7(a) loans need money from you. Under SBA’s rules effective October 1, 2026, a business open a year or less must put in at least 10 percent of total project costs, meaning all the costs to become operational. For every $10,000 of project cost, that is at least $1,000 of your own. SBA Express loans are the exception, since the lender decides whether to ask for money down. These can count toward your share:

Counts toward your 10 percent	Does not count
Cash you did not borrow, including a gift from family	Money you spent on courses, education, or advisory services
A personal loan repaid from income outside the business, such as a job	Fees paid to an agent who packages the loan
Business costs you already paid, if the lender verifies them as eligible prepaid expenses	A personal loan you plan to repay from the business
Assets such as a vehicle, valued by an independent third party when above book value	Equity an investor can pull back before the SBA guaranty ends
A grant with no repayment during the loan

For a standard 7(a) loan, start-ups also show projections with a debt service coverage of at least 1.15 within two years of funding, meaning expected cash flow covers the loan payments with 15 percent to spare. The NEMT business loans guide covers the rest of the lender’s list.

Your credit matters. The SBA says loan eligibility for a new business is typically based on the owner’s personal credit score. It also says even those with bad credit may qualify for startup funding, and that some SBA-backed loans need no collateral. Small Business Development Centers offer free or low-cost counseling to help you prepare before you apply.

Savings and family keep you in full control. The SBA warns against spending more than you can afford, and says to check the fees and penalties before tapping a retirement account early.

A bare-bones start: the lines you can price today

This example is an Arizona company with one vehicle and the owner as the only driver. The priced lines are published fees. The rest need your own quotes.

Line	Amount	Basis
LLC articles of organization	$50	Arizona Corporation Commission, Rev. 3.2026
EIN	$0	IRS
NPI	$0	HHS. Arizona’s packet does not require one for NEMT companies.
Medicaid application fee	$750	Required in Arizona’s packet (rev 09/2026). 2026 amount.
The owner’s NEMT certification course	Online through the state’s training site	Required in Arizona’s packet
For-hire permit from the Arizona Department of Transportation	The permit fee	Required in Arizona’s packet
Commercial auto and general liability	Your quote	At the limits of each broker or plan you join
The vehicle, registered to the company, with your logo	Price or down payment	Checked at Arizona’s site visit
CPR, first aid, and HIPAA training for each driver, and the owners’ fingerprint background checks	Course and vendor fees	Arizona’s packet
Running costs until payments arrive	Your monthly total × months	SBA: count at least a year of monthly costs in the plan
Published fees	$800

The published fees are the smallest part. Put the quotes into the startup cost calculator and the NEMT business plan template before you apply for money, since the SBA says lenders compare expected costs with projected revenue.

Promises of a free start to be wary of

• No one can sell you trips. MTM Health’s standard agreement guarantees no minimum number of trips (section 2.K). It gives you no right to carry any particular rider or anyone at a particular facility (section 2.Q), and it bars money or gifts to MTM staff in exchange for trips (section 2.G).
• A paid course is not a down payment. SBA does not count money spent on education or advisory services toward your equity.
• Your state and broker list the training you need. Virginia’s required modules through MTM are free. Pay for outside courses only when a rule you can point to requires them, such as first aid or defensive driving.
• Driving before approval earns nothing. MTM’s agreement may not pay for trips by drivers or in vehicles it has not credentialed (section 2.N).
• A broker contract is not income yet. Even with one, you carry the costs until claims pay, so plan the cash before you sign a loan.

If you decide to go ahead with little money, the steps to start a NEMT business show the order that keeps the monthly bills from starting too early, and is NEMT a good business weighs the risks.