Tribal NEMT in 2027: How Rides Work for Tribal Members and How to Work With Tribal Programs

Who pays for a tribal member’s ride

Tribal NEMT has two payers to understand: Medicaid and the Indian Health Service (IHS). IHS’s fact sheet dated October 2024 says members of 574 federally recognized tribes are eligible for its services, and it serves about 2.8 million of the nation’s estimated 3.7 million American Indians and Alaska Natives. Care comes three ways: from IHS directly, from programs tribes run themselves, and through services bought from private providers.

Much of that system is run by tribes, not IHS. Under the Indian Self-Determination and Education Assistance Act, Public Law 93-638, tribes administer 22 hospitals, 330 health centers, 76 health stations, and 146 Alaska village clinics, against 21 hospitals, 53 health centers, and 25 health stations run by IHS (October 2024). People call the tribal ones 638 programs. When you sign an agreement to drive for a clinic, the other party is often a tribe or tribal health organization.

Medicaid pays first

IHS is the payer of last resort under 42 CFR 136.61. It does not pay for care that Medicaid, Medicare, a state program, or private insurance would cover, even if the patient has not applied. So when a tribal member has Medicaid, the ride to a covered appointment is a Medicaid ride, booked and paid like any other in that state. For how enrollment works, see how to become a Medicaid transportation provider.

When IHS buys the ride

IHS’s Purchased/Referred Care (PRC) program buys care from private providers when no IHS or tribal facility exists or a facility cannot provide the care. Patient transportation is one of the spending categories IHS tracks for PRC, alongside inpatient and outpatient care. Under 42 CFR 136.23, PRC serves eligible people who live on a reservation inside a PRC delivery area, or elsewhere in that area if they belong to the tribe or have close economic and social ties to it. It runs on these rules:

• A purchase order comes first. IHS pays nothing to an outside provider without a purchase order from the ordering official (42 CFR 136.24).
• Notice before routine care. For nonemergency care, IHS must be told beforehand. For emergencies, the patient or provider has 72 hours to notify it.
• Distance matters. The Indian Health Manual says routine care generally is not bought through PRC when an IHS facility that can provide it is within 90 minutes of the patient’s home by road.
• Rates follow a set order. If you negotiated a rate at least as good as your best customer rate, PRC pays it. Otherwise it pays the lowest of the Medicare rate, a repricing network rate, or your best customer rate. Only when no Medicare rate exists and none of those other methods is available does it pay 65% of authorized charges (42 CFR 136.203). This applies to IHS programs and to tribal programs that agreed to it.

The patient never pays for an authorized PRC service. Under 25 U.S.C. 1621u, once IHS notifies you, you have no further recourse against the patient. Medicaid adds its own protection: under 42 CFR 447.56, an American Indian or Alaska Native who has ever been served by an Indian health care provider or through a PRC referral pays no Medicaid cost sharing at all.

How states arrange Medicaid rides for tribal members

CMS addresses tribal rides directly in its Medicaid Transportation Coverage Guide (SMD 23-006, September 28, 2023). IHS and tribal health programs can provide Medicaid transportation if they meet the state’s standards, and they need no state license to do it (42 CFR 431.110). Tribes can also act as transportation brokers under 42 CFR 440.170(a)(4). CMS adds that every state Medicaid agency has a tribal liaison whom tribal health programs and members can contact for help getting rides.

The same guide names the barriers on tribal land: homes with no formal street address, homes far from a road, and unpaved, rugged roads that need special vehicles. It says drivers can use odometer readings or GPS coordinates to find a home and figure mileage, and that long trips may need overnight stays. For the economics of long empty miles, see rural NEMT.

These states handle tribal members’ rides in their own way, and each rule changes how you get the trips:

State	Who arranges the ride	What to know
Arizona	AHCCCS pays rides for American Indian Health Program members, who ride with an AHCCCS-registered company	Any on-reservation pickup or drop-off needs that tribe’s business license on file
Alaska	Tribal travel offices at ANTHC, TCC, and YKHC book travel for their patients	Members may be approved to travel to the nearest tribal facility (April 27, 2025 guide)
Utah	Tribal NEMT contracts with the Navajo Nation, the Confederated Tribes of the Goshute Reservation, and the Paiute Indian Tribe of Utah	Members in eight counties must ride with the tribal provider, even off the reservation (July 2026)
Oklahoma	SoonerRide, OHCA’s statewide ride program; a tribe can join as a contractor or by mileage reimbursement (April 2026)	Members going to a tribal or IHS facility may ride to any one equipped for their care (OAC 317:30-5-327.1)
North Dakota	A human services zone or tribal office approves each trip on form SFN 1507	Get the form before the ride; for urgent weekend, evening, or holiday rides, request it within 72 hours (January 2026)
Maine	Regional brokers	Brokers must sign a service agreement with any recognized tribe that wants to transport and qualifies
North Carolina	The local Department of Social Services, for members of the Eastern Band of Cherokee Indians (EBCI) Tribal Option	Those members book through DSS, not a health plan

Two more details change the work. Maine’s rule (Section 113, effective April 5, 2015) requires brokers to pay tribal transporters no less than other transporters get. In Alaska, state plan amendment AK-25-0009, approved December 18, 2025 and effective July 1, 2025, lets tribal health organizations that manage travel bill for taxis, wheelchair vans, rideshare, lodging, and meals; see Alaska’s tribal travel change.

Working on tribal land: licenses and hiring rules

Arizona has the clearest rule. AHCCCS’s fee-for-service manual (revised July 31, 2026) says that since October 1, 2014, every NEMT company that picks up or drops off an AHCCCS member on a reservation must get that tribe’s business license and send a copy to AHCCCS Provider Registration. Without it, AHCCCS denies prior authorization for the trip and recoups claims on audit. AHCCCS’s member handbook (September 11, 2026) tells American Indian Health Program members to ask a company, before booking, whether the tribe has given it permission.

AHCCCS posts a monthly list of registered NEMT companies by tribal license. Outside the Navajo Nation, few registered companies hold a tribe’s license. As of September 7, 2026:

Tribe, as AHCCCS lists it	Registered NEMT companies with its license
Navajo Nation	138
Hopi Tribe	15
Gila River Indian Community	9
Salt River Pima-Maricopa Indian Community	6
Colorado River Indian Tribe	3
Pascua Yaqui Tribe	3
White Mountain Apache Tribe	3
Cocopah Indian Tribe	1
Tohono O’odham Nation	1
Yavapai Prescott Indian Tribe	1
No tribal license on file	295

A company can appear under more than one tribe. In AHCCCS fee-for-service, a trip over 100 miles (one way, round trip, or several trips in one day) needs prior authorization, unless an IHS or tribal 638 transportation provider drives it. See prior authorization for how approvals work.

Hiring and contracting preference

Each tribe sets its own business and hiring rules. Federal law, 25 U.S.C. 5307(c), says that for a self-determination contract meant to benefit one tribe, that tribe’s own employment and contract preference laws govern. Some tribes have a Tribal Employment Rights Office (TERO), and South Dakota’s DOT lists TERO offices for eight tribes (updated July 16, 2025). Call the tribe’s TERO and business licensing offices before you base a van or hire drivers on tribal land, and ask about licenses, fees, and hiring preference. The South Dakota guide covers that state’s offices.

Contracting with tribal health programs

States and tribal clinics both have a reason to bring in outside ride companies this way. Under section 1905(b) of the Social Security Act, the federal government pays 100% of the cost of Medicaid services received through an IHS or tribal facility, instead of its usual matching share. CMS letter SHO 16-002 (February 26, 2016) extends that to services an outside provider gives at the facility’s request, and it names non-emergency medical transportation, meals, lodging, and attendants.

A ride counts for the 100% funding when all of these are true:

• Both are enrolled. The IHS or tribal facility and your company are both enrolled Medicaid providers.
• The patient is theirs. The member has an established relationship with a practitioner at the facility.
• There is a written agreement. You and the facility sign a care coordination agreement, and the facility’s practitioner stays responsible for the patient’s care.
• The facility asks for the ride. A request from the patient or from another outside provider does not count.

The agreement can be a contract, a provider agreement, or a memorandum of understanding, and CMS says it is not governed by federal procurement rules to the extent that fits IHS authority. When you bill the state directly, the state must pay you the same rate it pays for that ride for anyone else. Participation is voluntary for everyone, and members keep their free choice of provider.

Preference for Indian-owned businesses

Contracts and subcontracts under the Indian Self-Determination Act and other federal laws for Indian programs must, to the greatest extent feasible, give preference to Indians in employment and training and to Indian organizations and Indian-owned enterprises in subcontracts (25 U.S.C. 5307(b)). If you are not Indian-owned, expect that preference when a tribe buys rides with these funds, and consider hiring locally or partnering with a tribal enterprise.

Tribal transit money

Federal rural transit law sets aside 5% of each year’s Section 5311 rural formula funds for public transportation on Indian reservations: 20% awarded competitively and 80% by formula (49 U.S.C. 5311(c)). A tribe may use its formula funds to pay a non-tribal provider for public transportation that connects tribal lands with nearby communities or improves access to health care (49 U.S.C. 5311(j)(2)). So a tribe can pay an outside transit company to run public service for its members.

How to start serving tribal communities

1. Enroll with your state’s Medicaid program or broker first. Most of the work above starts there, and a care coordination agreement requires it.
2. Find the tribal programs near you. Ask the state Medicaid agency or your broker which tribal programs arrange rides, which tribes run their own transportation, and whether any use care coordination agreements.
3. Get each tribe’s permission. In Arizona that means a tribal business license filed with AHCCCS. Elsewhere, ask the tribe’s business licensing office and TERO.
4. Visit the clinic’s PRC and patient travel staff. Ask how they arrange rides today, whether they would sign a care coordination agreement, and how purchase orders work.
5. Put your rate in writing. A negotiated PRC rate keeps the default payment rules from applying, and a care coordination agreement should state who bills.
6. Plan for distance and addresses. Record odometer readings or GPS points for homes with no street address, and price for long empty miles. For trips to distant specialists, see long-distance medical transport.
7. Never bill the patient. Collect no Medicaid copay from members served by Indian health programs, and nothing at all for a PRC-authorized ride.