Drivers with seizures, diabetes, or sleep apnea: medical standards for NEMT drivers

Which rulebook decides for each driver

Whether a condition keeps someone off your schedule depends first on what they drive and where. Three sets of rules can apply, and many NEMT drivers fall under only the last one.

• Interstate commercial vehicles. The federal medical standards in 49 CFR 391.41 apply to drivers of commercial motor vehicles on interstate trips. For NEMT, that means a paid van designed or used for more than 8 people counting the driver, or anything with a weight rating of 10,001 pounds or more. A medical examiner on FMCSA’s National Registry makes the call, guided by FMCSA’s Medical Advisory Criteria, which were updated on January 19, 2024 and are advisory, not binding.
• State rules. States set the medical rules for in-state commercial driving within limits FMCSA allows, and they may run variance programs for in-state drivers with conditions that would otherwise disqualify them, if the program rests on sound medical judgment and performance standards (49 CFR 350.305). FMCSA’s own exemptions cover interstate driving only. Some states also require exams for specific NEMT drivers, covered in our guide to pre-employment physicals for NEMT drivers.
• Everyone else. A driver in a sedan or minivan on local trips needs a valid license, which the state grants under its own medical review, plus whatever your contracts and your own hiring process require.

Broker contracts sit on top of all three. In MTM’s standard provider agreement, submitting a driver for credentialing means you represent that the driver has said they know of no condition, physical or mental, that would interfere with the work or with carrying members safely.

Insulin-treated diabetes

Insulin no longer bars interstate commercial driving. Under 49 CFR 391.46, adopted in 2018, a driver treated with insulin can be certified when these steps line up:

1. The treating clinician evaluates the driver and completes the Insulin-Treated Diabetes Mellitus Assessment Form, MCSA-5870. The treating clinician is the professional who manages the diabetes and prescribes the insulin.
2. The medical examiner sees the driver within 45 days of the clinician’s signature, and at least once a year after that.
3. The driver gives the treating clinician three months of glucose records from an electronic meter that stores every reading with the date and time. With them, the certificate can run up to 12 months. Without them, it runs no longer than three months.

Two findings end the process. Severe non-proliferative or proliferative diabetic retinopathy disqualifies a driver permanently, and a driver who is not keeping a stable insulin regimen and proper control is not qualified until that changes. After certification, a severe low blood sugar episode, meaning one where the driver needed help from others or had a loss of consciousness, seizure, or coma, stops the driver from operating a commercial vehicle. The stop lasts until a treating clinician finds the cause addressed, confirms stable control, and completes a new MCSA-5870.

Diabetes managed without insulin has no specific federal standard, and FMCSA leaves it to the examiner’s judgment. New York’s Article 19-A adds its own cycle for ambulette and other bus drivers: a diabetic driver’s personal healthcare provider completes form DS-704 every six months.

On the schedule, a request you may see is time to eat or check blood sugar. The EEOC’s own example of an accommodation request is a 15-minute break every two hours to eat a snack, and it says the employer may ask for documentation when the need is not obvious. A short gap between trips on that driver’s manifest can cover it.

Seizures and epilepsy

The federal standard bars interstate commercial driving for anyone with an established history or diagnosis of epilepsy or another condition likely to cause loss of consciousness or loss of control. The January 2024 Medical Advisory Criteria explain when an examiner may still certify:

• Epilepsy or a seizure disorder in the past. Off antiseizure medication and seizure-free for 10 years or more.
• A single unprovoked seizure that was not epileptic. Off medication and seizure-free for 5 years or more.
• A single provoked seizure or blackout with a clear, avoidable trigger such as a drug reaction, dehydration, or high temperature. Fully recovered, no lasting complications, off antiseizure medication, and recurrence unlikely.
• A single unexplained loss of consciousness that was not a seizure. The examiner decides case by case with the treating provider, and the criteria recommend waiting 6 months from the episode.

A driver currently taking antiseizure medication to prevent seizures is not qualified under the criteria, which is where the federal exemption program comes in. FMCSA has granted seizure exemptions case by case since January 15, 2013, weighing the 2007 recommendations of its medical expert panel: 8 years seizure-free for a driver with epilepsy, or 4 years after a single unprovoked seizure, on or off medication, with any medication plan stable for 2 years. FMCSA says it decides within 180 days of a complete application, and drivers with a regular class D license apply as well; a September 9, 2026 notice lists class D license holders from Arizona, New Jersey, New York and Vermont among the applicants.

An exemption lasts two years and can be renewed. Its terms, as published on September 10, 2026, require the driver to stay seizure-free on stable treatment, report any seizure or treatment change to FMCSA within 24 hours, send annual reports from the treating physician, pass a yearly exam by a certified medical examiner, give the employer a copy of the medical certificate for the driver file, and report any crash within 7 days.

For a regular license, each state sets the rule. Two examples:

• Pennsylvania. Under the rule as amended effective March 28, 2026, a person with a seizure disorder qualifies to drive once a licensed physician reports at least 3 months without a seizure, and the physician can add another 3 months when the condition calls for it (67 Pa. Code 83.4). Every provider who treats a person after a single seizure must report it to PennDOT.
• California. Physicians must report patients 14 and older diagnosed with a disorder characterized by lapses of consciousness to the local health officer, who passes the report to the DMV. The DMV may refuse or decline to renew a license after a lapse within the last three years unless it has medical information that the person can drive safely.

Sleep apnea

FMCSA has no regulation on sleep apnea screening, testing, or treatment. Federal law (Public Law 113-45) lets the agency impose such requirements only through a rulemaking, and FMCSA withdrew its advance notice of proposed rulemaking on moderate-to-severe sleep apnea in August 2017. What exists is guidance. The Medical Advisory Criteria list obstructive sleep apnea among the respiratory conditions that can affect safe driving, and they tell examiners who suspect an undiagnosed or poorly treated condition to confer with the treating provider or refer the driver to a specialist.

The 2024 Medical Examiner’s Handbook adds that untreated moderate-to-severe sleep apnea is associated with heart and stroke-related illness, metabolic disease, and death. It suggests looking at several risk factors together rather than any single one, and it leaves to the examiner whether a driver’s treatment is working. For drivers outside federal rules, the practical issue is daytime sleepiness on long manifests, which our guide to NEMT driver fatigue covers.

High blood pressure

Federal guidance says high blood pressure alone is unlikely to interfere with safe driving. It calls for confirming a high reading with at least two more measurements, then sets the certificate length by stage:

FMCSA kept this guidance in 2024, after removing from the draft handbook a 2013 expert panel table that commenters found confusing. In New York, Article 19-A carriers file blood pressure follow-up exams on form DS-703.

Vision, hearing, and medications

The federal vision standard calls for 20/40 in each eye and in both together, with or without glasses, a 70-degree horizontal field in each eye, and the ability to tell red, green, and amber signals apart. Since March 22, 2022, a driver who misses that standard in one eye can qualify under 49 CFR 391.44 if the better eye meets 20/40 and 70 degrees and the condition is stable:

• An ophthalmologist or optometrist completes the Vision Evaluation Report, form MCSA-5871, and the medical exam starts within 45 days of that signature.
• The certificate lasts up to 12 months.
• A driver qualifying this way for the first time needs a road test from the motor carrier before driving, unless the carrier confirms 3 years of in-state or excepted commercial driving with the same vision deficiency and puts a written statement in the driver file.

For hearing, the driver must perceive a forced whisper at 5 feet in the better ear or show an average loss of no more than 40 decibels at 500, 1,000, and 2,000 Hz, with a hearing aid if needed. FMCSA runs a hearing exemption program for drivers who cannot meet it.

Medications follow 391.41(b)(12). A commercial driver may not use Schedule I drugs, amphetamines, narcotics, or other habit-forming drugs, and may use other scheduled drugs only when prescribed by a practitioner who knows the driver’s medical history and has advised that the drug will not affect safe driving. MTM’s agreement applies a similar rule to every driver, whatever the vehicle. A driver on prescribed or over-the-counter medication that may hinder driving tells a supervisor and stops carrying members. A prescribed drug is allowed once you hold a note from the driver’s medical provider saying the drug will not impair them at the wheel. Our guide to marijuana laws for NEMT drivers covers the cannabis questions.

Drivers outside the federal rules: the ADA’s individual look

For a sedan or minivan driver on local trips, no federal medical standard applies, and the ADA governs any decision you make at a company with 15 or more employees. The EEOC says an employer is not liable for following a federal law that bars a person from a job, but it must be sure that compliance is actually required, not voluntary. If you apply DOT medical standards to drivers the federal rules do not cover, that defense is gone: the standard is your own choice and has to be job related and consistent with business necessity.

To exclude a driver for safety reasons, the EEOC requires a direct threat: a significant risk of substantial harm that a reasonable accommodation cannot remove or reduce enough. The judgment must rest on objective, current medical evidence and on this person’s present ability to do the job. The employer weighs how long the risk lasts, how severe the harm could be, how likely it is, and how soon it could happen. The EEOC’s example of a lawful exclusion is a worker who repeatedly skipped prescribed medication and had several seizures at work, applying for a job where a seizure would be dangerous.

When a current driver has an episode

1. Take the driver off the road for the day and reassign their trips before anything else.
2. For interstate commercial drivers, require a new exam. Federal rules require a fresh medical exam for any driver whose ability to do the job has been impaired by an injury or disease (49 CFR 391.45). Insulin-treated drivers stop after a severe low, as described above, and exemption holders report a seizure to FMCSA within 24 hours.
3. For other drivers, ask only for what you need. The EEOC allows a request for medical information when you reasonably believe the employee cannot do the job or poses a direct threat, limited to what is needed to judge present ability. Periodic doctor’s notes are allowed only when you reasonably believe the employee would pose a direct threat without regular care.
4. File it separately. Keep doctor’s notes and your decision in the confidential medical file, apart from the personnel file.

Shorter certificates in HealthRide

Many of the drivers on this page carry certificates that run 12 months, 6 months, or even 3 months instead of the usual 24. Add each one to HealthRide as a credential with its own expiration date, and a reminder goes out before it lapses. If it expires anyway, the dispatcher sees a warning when assigning that driver a trip. Each driver’s credentials sit with their record in fleet management.