NEMT Rate Sheet Template for Private-Pay and Facility Rides

A rate sheet is the one page a family, a hospital case manager, or a senior living director keeps by the phone. It shows what a ride costs before anyone books, and it keeps every quote from your office the same. Fill in this template with your own prices, then read the rules under it before you hand it out, because a private price list can change what Medicaid pays you.

How to use this template

1. Work out your costs first. Every price on the sheet comes from two numbers: what an hour of van and driver time costs you, and what a mile of driving costs you. The worksheet after the template turns them into a base fee, a mile rate, and a wait rate. How much to charge for NEMT explains each step, and the trip price calculator prices a single ride.
2. Fill in Parts 1 through 6. Write “Not offered” on any line you do not provide, so no one assumes you do.
3. Date the sheet. Put the effective date in Part 1. When a price changes, issue a new dated sheet and keep the old one on file.
4. Check it against the rules below the template. Pay close attention to Medicaid claims, riders who use wheelchairs, and state rate filings.
5. Give facilities a packet. Put the rate sheet with your certificate of insurance and a sample agreement. Start the agreement from the facility transportation agreement template.
6. Quote from it every time. Give the rider or facility the full price before the ride, then an itemized receipt or invoice after it. The NEMT invoice template uses the same lines.

The template

Part 1: Company details

Line	Entry
Company name
Phone for booking rides
Email or website
Service area (cities, counties, or miles from your base)
Hours you take bookings
Hours you run rides
How far ahead to book
Prices effective from (date)
Replaces the sheet dated

Part 2: Ride prices by level of service

Each price is for one one-way ride. A round trip is two rides.

Level of service	Base fee	Miles included in the base	Each mile with rider aboard	Free waiting (minutes)	Waiting, each 15 minutes
Walking rider, with or without a cane or walker
Wheelchair, rider stays in their own chair
Wheelchair, we supply the chair
Bariatric wheelchair (rider and chair over ___ pounds)
Stretcher, two crew members
Other:

Miles are counted from pickup to drop-off by the most direct route, measured with: ____________________.

Part 3: Added services

Service	Price	Charged per
Second crew member		Hour or ride
Help from inside the home to inside the office		Ride
Stairs, each flight		Flight
Extra stop on the way, such as a pharmacy		Stop
Companion or caregiver riding along		Person
Early or late rides (before ___ a.m. or after ___ p.m.)		Ride
Weekends and holidays (list the holidays)		Ride
Same-day booking (less than ___ hours’ notice)		Ride
Pickup or drop-off outside the service area		Each mile past the edge of the area
Long trips over ___ miles	Quoted in writing	Trip
Tolls and parking	What we pay, with receipt	Trip

Part 4: Cancellations and no-shows

Rule	Entry
Cancel at least ___ hours before pickup for no charge
Late cancellation fee
No-show fee (van arrived, rider did not ride)
Minutes the driver waits after the pickup time
Driver calls or texts the rider before leaving

These fees apply only to rides paid by a rider, a family, or a facility that agreed to them in writing. They never apply to a ride Medicaid or a Medicaid health plan covers. Pair this part with the NEMT no-show policy template.

Part 5: How to pay

Who pays	How	When
Rider or family, one ride	Card, check, or cash
Rider with regular rides	Card on file
Long trip	Deposit of ________	Deposit at booking, the rest after the ride
Facility	Monthly invoice	___ days after the invoice date
Late payment or returned check fee

Part 6: Facility prices

For hospitals, clinics, dialysis centers, and senior living communities that pay for rides themselves.

Option	Price	What it includes
By distance	________ a mile, plus waiting	Rides booked one at a time
By the hour	________ an hour, ___ hour minimum	A van and driver held for set hours
By the route	________ a run	One set daily run, repriced if the route changes
Monthly minimum	________ a month	Capacity held for the facility

Facility prices are the same for every facility with similar volume. They do not depend on any other business a facility sends us.

Part 7: Print at the bottom of the sheet

• Prices are for rides paid by the rider, a family, or a facility.
• We do not charge Medicaid members for rides Medicaid covers. Call your Medicaid plan’s ride line to book those rides.
• Every ride comes with an itemized receipt showing the date, the pickup and drop-off, and each charge.
• Prices can change with ___ days’ written notice. The date at the top shows which prices apply.

Worksheet: turn your costs into prices

Keep this part for yourself. Fill the last column from your own books and trip records. The example column uses the example costs from how much to charge for NEMT. They show the math and are not averages.

Line	How to find it	Example	Yours
A. Cost per van hour	Driver pay with payroll taxes, plus one van’s monthly fixed costs ÷ its paid service hours	$52.00
B. Cost per minute	A ÷ 60	$0.867
C. Cost per mile	Fuel price ÷ miles per gallon, plus tires and repairs per mile	$0.50
D. Minutes to reach a typical pickup	Your trip records	12
E. Empty miles to a typical pickup	Your trip records	5
F. Minutes to load and unload	Your trip records	15
G. Minutes per mile with a rider aboard	Your trip records	2
H. Profit margin	Your choice	20%
Base fee	((D + F) × B + E × C) ÷ (1 minus H)	$32.38, rounded to $32.50
Rate per mile	(G × B + C) ÷ (1 minus H)	$2.79, rounded to $2.80
Waiting, each 15 minutes	A ÷ 4 ÷ (1 minus H)	$16.25

With the example prices, a 12-mile one-way ride is $32.50 plus 12 × $2.80, or $66.10. Run the worksheet once for each level of service, because loading time and crew size change lines A and F.

The drive to the pickup goes into the base fee on purpose. A private rider or facility pays only for the ride you quote, so the deadhead miles to reach them have to be priced into it. Medicaid works the same way: CMS says miles driven with no member aboard generally cannot be paid as a separate service, though states may build their cost into the rate (SMD 23-006, September 28, 2023). The wait rate uses the full hourly cost because, for employees, waiting while on duty is work time under federal wage rules (29 CFR 785.15). Your driver is paid whether the van moves or not.

Rules your rate sheet has to follow

Medicaid members never pay for covered rides

A Medicaid provider must accept the program’s payment, plus any cost sharing the state plan sets, as payment in full (42 CFR 447.15). CMS adds that states and providers may not charge a Medicaid member for no-shows (SMD 23-006). North Dakota’s manual (updated January 2026) still lets a provider bill members directly for missed rides when the same policy applies to every rider and is posted or given to riders in writing, so get North Dakota Medicaid’s answer in writing before you rely on it. Broker contracts go further. MTM Health’s standard agreement, in the January 1, 2023 version Pennsylvania posts, bars billing or seeking payment from a member for rides you give under the agreement, even when MTM does not pay, unless MTM or its client authorizes a copayment. Your rate sheet is for private-pay and facility rides only. See private pay NEMT for who those riders are.

Your private prices can cap your Medicaid pay

Some Medicaid programs compare each claim with what you charge everyone else.

Program	The rule
North Dakota Medicaid (manual updated January 2026)	Bill your usual and customary fee, the one you charge your largest share of non-Medicaid business. You cannot charge Medicaid more than your non-Medicaid riders. If you discount shared rides for private riders, members get the same discount and the same rates, free rides included. Payment is the lesser of your usual charge or the state’s rate.
Texas Medicaid (provider manual, September 2026)	Each claim filed with TMHP certifies that charges are usual and customary and not higher than the fees charged to private-pay patients. Any reduced, free, or special fee advertised to the public must also be offered to Medicaid clients.
New York Medicaid (transportation manual, effective August 25, 2023)	No payment when a fee is listed but no effort is ever made to collect it from people outside Medicaid, or when the ride is available free to others in the community.
Federal, 42 CFR 1001.701	OIG may exclude a provider that bills Medicare or Medicaid substantially more than its usual charges, unless unusual circumstances or other good cause explain it.

In practice, charge the prices on your sheet, and write down every discount and the reason for it. Look up your state’s rate before you set a private price below it. In a state that pays the lesser of your charge and its rate, a lower private price lowers what Medicaid pays you too.

Facility prices and kickback rules

When a hospital or clinic gives patients free rides under the federal local transportation safe harbor, drivers and anyone arranging the rides cannot be paid per patient carried (42 CFR 1001.952(bb)). When OIG created the safe harbor, it said a facility that hires a transport company may pay based on the total distance the vehicle travels (81 FR 88387, December 7, 2016). That is why Part 6 prices by distance, hour, or route, and never per patient.

Never trade a low price for referrals. OIG’s compliance guidance for nursing facilities (November 2024) warns against swapping: a facility taking a low price on services it pays for in exchange for referring business the supplier bills to a federal health care program. It lists prices below what a supplier charges other customers with similar volume as suspect. OIG’s guidance for ambulance suppliers says any link, explicit or implicit, between the price for business the buyer pays for and referrals of federal program business implicates the federal anti-kickback statute (68 FR 14252, March 24, 2003). See how to get NEMT facility contracts.

Riders who use wheelchairs

DOT’s ADA rules bar special charges on riders with disabilities, including wheelchair users, for services the rules require or that are needed to accommodate them (49 CFR 37.5(d)). DOT’s guidance on that section (Appendix D to Part 37) says a charge is a special charge when it is higher than the charge for the same or comparable service to other riders. Its examples include charging more because a rider needs a lift-equipped van, and higher mileage charges for using an accessible vehicle. The same guidance says a provider may still charge fees that do not discriminate.

Part 2 lets you price each level of service on its own line, and Medicaid fee schedules price them separately too. A wheelchair rider who pays the same as a walking rider for the same trip is not paying a special charge under that guidance. Before you publish a higher price tied to a wheelchair, an accessible van, or any other mobility device, such as a bariatric chair, have a transportation attorney review the sheet and tell you how each price difference fits this rule. See ADA requirements for NEMT.

States that set or file transportation prices

• Connecticut. The Commissioner of Public Health sets rates for licensed ambulance services and invalid coaches, the state’s term for vehicles used only to carry riders who cannot walk and are not on stretchers (Connecticut General Statutes 19a-175 and 19a-177). For calendar year 2026, a service could raise its approved maximum rates by up to 2.1 percent with the short-form application, and larger raises needed the full application. The invalid coach schedule on that form has lines for a base rate, two patients, a per-mile charge, a second attendant, and waiting time.
• Pennsylvania. Paratransit rates must follow the tariff the carrier files with the Public Utility Commission, and the tariff states the minimum advance booking time (52 Pa. Code 29.355, current through July 4, 2026). A paid trip that starts and ends in Pennsylvania needs a PUC number unless an exemption applies (PUC FAQ, December 2024). If you hold PUC paratransit authority, change the tariff before you change the sheet.

Other states and cities license for-hire vehicles and may regulate what they charge. Ask your state health department and utility commission before you publish prices, and see NEMT license requirements.

Check your prices against Medicaid rates

A Medicaid fee schedule shows what one large payer pays for the same ride. It is a benchmark, not a price to copy.

Program and date	Service and codes	Per trip	Per mile
North Dakota, July 1, 2026	Wheelchair van, A0130 and S0209	$18.05	$2.57
North Dakota, July 1, 2026	Stretcher van, T2005 and T2049	$97.37	$2.57
Nebraska, July 1, 2026	Wheelchair van, A0130 and S0209	$46.12	$1.85
Ohio, rule 5160-15-28 appendix (enacted July 10, 2026)	Wheelchair van, A0130 and S0209, unchanged since January 1, 2024	$31.00	$1.30
Ohio, same appendix	Wheelchair van attendant, T2001	$15.00	None

North Dakota pays only miles with the member in the vehicle, measured in map miles from the pickup to the facility. A 12-mile wheelchair ride there pays $18.05 plus 12 × $2.57, or $48.89. Nebraska’s July 1, 2026 schedule notes that its rates did not rise for the state fiscal year that began that day, because no rate increase was funded. More states are in NEMT reimbursement rates.

Keep the sheet current

1. Watch fuel. The U.S. average price for regular gasoline was $4.478 a gallon for the week of September 21, 2026, up $1.305 from a year earlier (EIA). Write a fuel rule on the sheet: the gas price your mile rate assumes, and how much the rate moves for every 10 cents gas moves.
2. Use the IRS rate only as a check. The IRS business standard mileage rate is 76 cents a mile for July 1 through December 31, 2026, up from 72.5 cents for the first half of the year. It is a tax deduction rate that leaves out driver pay, and the IRS does not allow it for five or more cars operated at the same time (Topic 510).
3. Give receipts families can use. IRS Publication 502 (2025) counts amounts paid for transportation primarily for and essential to medical care, including taxi fares and ambulance service, as medical expenses. Leave health details off the receipt.
4. Review the sheet once a year. New insurance premiums, wage changes, and a new van all change line A. Rerun the worksheet with the new numbers and issue a new dated sheet.
5. Keep every old sheet. A dated sheet shows what your usual charge was on any date of service if a Medicaid program asks.