How does the Herfindahl-Hirschman Index work on a list of payers?

Square each payer's percentage share of your collected revenue and add the results. One payer scores 10,000, and the score drops as revenue spreads across more payers of similar size. For example, shares of 52, 18, 14, 9, and 7 percent score 3,354. The Justice Department treats markets above 1,800 as highly concentrated. A customer list is not a market, so use that line only as a sense of scale.

How do I know whether my largest payer is too big?

Compare two lengths of time. Runway is cash on hand divided by the monthly costs you would still owe with no trips running. Time to replace is the payer's notice period plus the months it would take to credential with another payer and start receiving trips. If the runway is shorter, that payer is too large for your reserve, and you need more cash, more payers, or both.

Why look at the programs behind a broker's trips?

Because each program can leave on its own schedule, even though your broker agreement does not change. One broker may carry trips for state fee-for-service members, several Medicaid health plans, and a Medicare Advantage plan. In Texas, for example, Blue Cross and Blue Shield switches its Medicaid members' rides to MTM Health from Modivcare effective October 1, 2026, standing rides included.

How can a rate change affect my payer mix?

When one payer sets most of your prices, one rate notice sets most of your margin. North Carolina Medicaid Direct paid NEMT at 97 percent of its September 30, 2025 rates for services from October 1, 2025, until a reversal the state announced on December 10, 2025 restored those rates and sent affected claims back for reprocessing. Track margin by payer, not only revenue, so a cut shows up in the next review.

Should I add private-pay riders to balance a Medicaid-heavy mix?

Yes, for riders without Medicaid, rides the Medicaid benefit does not cover, and families or facilities who choose to pay. Private pay also has no claim cycle when you charge a card. It cannot replace Medicaid billing for covered rides: under 42 CFR 447.15 the program's payment, plus allowed cost sharing, settles a covered service in full, and MTM's standard agreement bars charging its members.

Which payers balance a broker-heavy mix?

Payers you contract with directly. Dialysis centers bring repeat rides on fixed weekly schedules. Hospitals need same-day discharge rides. PACE organizations sign transportation contracts and stay responsible for vehicle upkeep, communication with the PACE center, and driver training under 42 CFR 460.76. Private-pay riders pay at booking. A second broker network also helps, where the agreements allow it.

NEMT Payer Mix: Spreading Revenue Risk (2026)

Payer mix is a risk measure. It shows how much of your company rides on decisions made somewhere else: a broker’s trip assignments, a state’s rebid, a health plan’s choice of vendor, a rate notice. One broker is a sensible way to fill a new schedule. The trouble starts when that broker is still most of the revenue years later. This guide covers how to measure concentration, what it exposes you to, and how to rebalance at each stage.

Two ways to split your revenue

Base payer mix on money that actually reached your account, net of denials and deductions. Look at the last 12 months for the trend and the last 3 months for recent shifts. Then split it two ways, because each view exposes a different risk.

View	What it shows	The risk it reveals
By payer: whoever deposits the money	How much revenue ends if one agreement ends	A broker gives notice or stops assigning trips
By program: whose members ride	How much moves if one program changes vendors	A health plan picks another broker, and your own broker contract never changes

Brokers often manage rides for several programs at once, such as the state’s fee-for-service members, one or more Medicaid health plans, and sometimes a Medicare Advantage plan. Each payer type is explained in who pays for NEMT, and the delivery model your state uses is in how states run NEMT.

Scoring concentration

Three numbers describe how concentrated your revenue is:

Largest payer’s share. The most important one.
Top three share. Whether you have a real second tier or one payer and some small accounts.
A concentration score. The Justice Department describes the Herfindahl-Hirschman Index, which squares each share and adds the results. A single payer scores 10,000, and the score falls as revenue spreads across more payers of similar size. Antitrust reviewers treat markets above 1,800 as highly concentrated. Your customer list is not a market, so treat that line as a sense of scale only.

Here is a hypothetical six-van company collecting $70,000 a month:

Payer	Collected per month	Share	Share squared
Broker X	$36,400	52%	2,704
Medicaid plan running its own ride network	$12,600	18%	324
Dialysis center group	$9,800	14%	196
Private-pay riders	$6,300	9%	81
PACE program	$4,900	7%	49
Total	$70,000	100%	3,354

The largest payer holds 52 percent, the top three hold 84 percent, and the score is 3,354. The program view adds a second problem. Say Broker X’s 52 percent breaks down into state fee-for-service members at 24 percent of total revenue, Medicaid plan A at 18 percent, and plan B at 10 percent. Plan A can choose a new ride vendor on its own, and 18 percent of this company’s revenue would go with it on the effective date, with no change at all to the Broker X agreement.

A year later, after adding a second broker and growing the facility work, the same company might look like this: Broker X at 38 percent, Broker Y at 17, the health plan at 15, dialysis at 14, private pay at 9, and PACE at 7. The score falls to 2,284, and no single agreement can take more than 38 percent of revenue when it ends.

What a concentrated mix is exposed to

Contract terms written for the broker

Broker agreements protect the broker’s flexibility. MTM’s standard provider agreement (the January 1, 2023 version, published by Pennsylvania) is a clear example:

Term	What the agreement says	Section
Volume	No minimum number of trips is guaranteed, and volume may vary at MTM’s sole discretion	2.K and 14.C
Reassignment	Any trip, recurring trips included, may be assigned or reassigned by MTM, and you have no right to any particular rider or facility	2.Q
Selection	Trips go to providers based on factors including quality, availability, and pricing compared with other local providers	2.A
Notice	Either side can walk away for convenience after giving 30 days’ notice in writing	14.A
Client events	MTM can terminate on the spot when its contract with the client is terminated or loses funding, or when the client wants the provider out	14.D

The Indiana agreement WellTrans revised on October 16, 2025 follows the same pattern. WellTrans does not owe you any particular number of trip requests, it may pull back a trip after assigning it, and either side can leave without giving a reason once 60 days’ written notice has run.

Vendor changes by states and plans

A state that runs a NEMT brokerage program must select the broker by competitive bid under 42 CFR 440.170, so each new contract period can bring a different broker. Health plans switch vendors as well. Two changes from 2026:

Georgia. As of April 1, 2026, Modivcare no longer serves Georgia Medicaid’s Central, Southwest, and East regions, and Verida handles the whole state.
Texas. Effective October 1, 2026, Blue Cross and Blue Shield of Texas hands NEMT for its Medicaid members to MTM Health, replacing Modivcare. Its provider notice says MTM Health will run the standing rides and the rides already scheduled after the switch date.

Recurring riders move with the program’s vendor. On the effective date, a provider credentialed only with the outgoing broker loses them, and one already in the incoming broker’s network is positioned to pick them up. Your state is switching NEMT brokers covers how to prepare.

Rate decisions

If one payer sets most of your prices, one rate notice sets most of your margin. For NEMT services from October 1, 2025, North Carolina Medicaid Direct paid 3 percent less than its September 30, 2025 rates. A December 10, 2025 announcement reversed the cut, the earlier rates came back, and affected claims were set for reprocessing. Rates can also differ between providers under the same program: Indiana’s transportation module lets Verida agree to higher or special rates provider by provider.

Money held upstream

A payer’s own cash problems reach you quickly. Under WellTrans’s agreement, your money can wait until WellTrans’s client, the state or a health plan, pays WellTrans. Under MTM’s agreement, liquidated damages and past overpayments can be subtracted from your payments. Brokers can also run into financial trouble themselves: Modivcare entered Chapter 11 on August 20, 2025 and came out of it on December 29, 2025, when its reorganization plan became effective. When one payer supplies most of the revenue, a single hold, offset, or dispute stalls nearly all incoming cash.

The replacement test

The useful question is whether your cash would last longer than it takes to replace your largest payer.

Runway. Divide cash on hand by monthly fixed costs: what you would still owe with every van parked, such as insurance, vehicle notes, rent, and office payroll.
Time to replace. Add the payer’s notice period to the months you would need to join another network and start receiving its trips. As one reference point, Indiana gives new providers 60 days after signing with Verida to finish credentialing.
Compare. A runway shorter than the time to replace means the largest payer is too big for your reserve.

In the example, $36,000 in the bank against $24,000 of monthly fixed costs is 1.5 months of runway. Thirty days of notice plus about two months to credential and see first trips is roughly three months. The company fails until it builds the reserve or shrinks Broker X’s share. Managing NEMT cash flow covers sizing and building a reserve.

A target mix for each stage

No Medicaid rule or broker contract sets a correct mix. These are planning targets that follow from the risks above. Adjust them for your market.

Stage	Typical situation	Planning target
First year	One broker or one facility contract carries the company	Start credentialing with a second payer before the year ends, and hold a reserve that covers the largest payer’s notice period
Established, roughly 5 to 15 vehicles	Three to five payers	Largest payer under half of collected revenue, plus at least one source that is not a broker, such as facilities, PACE, or private pay
Larger fleet	Several networks and direct contracts	Largest payer under a third of revenue, and no single health plan behind more than about a fifth of your trips

A better-looking mix is not automatically a better business. A payer whose rate sits below your cost per trip improves the spread and drains cash at the same time. Check each rate against your costs before chasing volume, using how to price NEMT trips or the profit per vehicle calculator.

What each payer type adds

Payers you contract with directly offset a broker-heavy mix, and each one brings something different.

Payer	What it adds to the mix	What to know first
Dialysis centers	Repeat rides on fixed weekly schedules, well suited to standing orders	Service levels, on-time expectations, and invoicing terms in writing. See dialysis transportation contracts.
Hospitals	Same-day discharge rides, often wheelchair or stretcher	Discharge planners need fast answers and reliable pickup times. See hospital discharge transportation.
PACE programs	A direct contract with a single organization	42 CFR 460.76 keeps the PACE organization accountable even when a contractor drives. Vans follow the manufacturer’s maintenance schedule and carry a way to reach the PACE center, and drivers learn to handle participants’ special needs and emergency situations. See PACE program transportation.
Other programs	Separate funding streams from veterans’ benefits, Medicare Advantage ride benefits, and aging agencies	Each buys rides its own way. See VA transportation contracts and Medicare Advantage NEMT.
Private-pay riders	The fastest cash, with no claim cycle when a card is charged	Only for riders without Medicaid, uncovered rides, or payers who choose to pay. Under 42 CFR 447.15 the program’s payment settles a covered ride in full, and MTM’s agreement bars charging its members. See private pay NEMT.
A second broker	Trips from a network that does not depend on your first broker’s clients	Check each agreement for exclusivity terms first. See broker network closed to new providers.

Price facility work by the ride and never pay for referrals. Our guide to NEMT facility contracts covers the pitch and the agreement, and the guide to anti-kickback rules for NEMT covers what to avoid.

On a second broker, MTM’s standard agreement says either side may sign with other parties for this kind of work (section 16). It does bar using MTM’s trade secrets or confidential information to start or support a competing business (section 21). Keep each broker’s member information separate.

A quarterly review

Check	Where the numbers come from	Act when
Largest share, top three share, concentration score	Money collected per payer and per program, for the last quarter and the last year	The largest share or the score rises two quarters in a row
Contract terms	Each agreement’s notice period, volume language, and offset rights	A renewal or amendment changes any of them
Replacement test	Current cash and fixed costs	Runway falls below the time to replace your largest payer
Vendor and rate news	Provider notices from your state Medicaid agency and every health plan whose members you drive	A broker change or rate update is announced
Next payer	Your own pipeline	Nothing new has started in the last quarter: pick one payer and begin its credentialing or sales work

Seeing the mix in one report

For any date range, HealthRide’s payer summary report shows each payer’s completed trips, cancellations, amount billed, and amount still unpaid, so the quarterly review starts from one screen. Because HealthRide connects with brokers like MTM, Alivi, and Sentry, their new trips show up on your board on their own, next to your facility and private-pay rides. See reports and broker connections.

NEMT payer mix: how to spread revenue so one contract cannot sink you