Taking NEMT riders across state lines: approvals, authority, and billing
An out-of-state NEMT trip needs payer approval before you drive, and payers usually approve the out-of-state care first. Carrying a paid rider over a state line also takes a USDOT number, interstate operating authority from FMCSA, and a federal insurance filing of at least $1.5 million on any vehicle with 15 or fewer seats, unless an exemption applies. Then bill only the loaded miles the payer authorized.
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Three approvals stand behind every out-of-state trip
An out-of-state ride clears three separate checks, and each one belongs to a different party. The payer decides whether the trip is covered. Federal rules decide whether your company may carry a paid passenger across the line. Your insurer and your paperwork decide whether you get paid and stay protected if something goes wrong.
| Check | Who decides | What to have in hand before you drive |
|---|---|---|
| Coverage for the ride | The state Medicaid agency, health plan, or broker | A trip authorization number for this date, destination, and level of service |
| Permission to carry a paid rider across the line | FMCSA, under federal law | A USDOT number plus active operating authority, or a clear exemption |
| Protection and payment | Your insurer and the payer’s billing rules | Liability coverage on file at the federal minimum or higher, and the approved miles in writing |
Most problems on these trips come from treating the first check as the only one. A broker can approve a ride that your company is not yet allowed to drive.
When Medicaid pays for care in another state
Medicaid covers care across state lines only in defined situations. Federal rule 42 CFR 431.52 requires each state to pay for services a resident receives in another state, to the same extent as at home, when one of four conditions is met:
- The care is needed because of a medical emergency.
- The rider’s health would be endangered by traveling back to the home state for it.
- The state finds, based on medical advice, that the care or the resources behind it are more readily available in the other state.
- People in that locality customarily use medical resources in the other state.
The ride follows the care. CMS’s September 28, 2023 guidance to states (SMD 23-006) says a state generally must make sure transportation is available to the nearest qualified provider. Going farther generally takes a medical reason. It also warns that holding too tightly to that rule can violate the rider’s free choice of provider, for example when a farther provider costs the same to reach or has capabilities the rider’s care depends on.
States turn those principles into different procedures. Here is how six programs handle it:
| Program | Out-of-state rule |
|---|---|
| Colorado | Medical services must be provided in Colorado unless not available in-state. The Department prior authorizes out-of-state NEMT. The request goes in online no later than five business days ahead of travel, with recent clinical notes and a letter of medical necessity. |
| Montana | Riders use the nearest in-state provider. Out-of-state trips may be approved if total out-of-state costs are shown to be lower than in-state costs. Every transport needs prior authorization from the state’s Transportation Center. |
| South Dakota | Services received more than 50 miles outside the state, except in Bismarck, North Dakota, require prior authorization before travel costs are approved. |
| Louisiana (health plans) | Members may use care in another state when it is the nearest option. The plan must prior approve all non-emergency out-of-state transportation, and only after the member is approved for out-of-state treatment. |
| New York (Modivcare, for the plans and counties it serves) | Trips beyond the county or into a neighboring state are approved pending authorization from the member’s health plan or local Medicaid office. Some plans do not cover out-of-state transportation at all. |
| Indiana | Medical providers in listed counties of neighboring metro areas, including Cook County in Illinois, Hamilton County in Ohio, and Jefferson County in Kentucky, count as in-state for prior authorization. |
Border areas are the common exception. Colorado applies all of its in-state NEMT rules to routine care in the border towns listed in its billing manual’s Appendix F. Indiana treats providers in the listed counties around Chicago, Cincinnati, Louisville, Evansville, and South Bend as in-state for prior authorization, so the care itself needs no extra approval. A ride over the line to one of these places can be an ordinary trip in the payer’s eyes, so check the list before you assume extra paperwork.
The trip authorization is the approval you drive on
As the transportation provider, you rarely request the medical approval yourself. The rider, the facility, or the broker handles that. What you need is the approved trip, with its authorization number, before you accept it.
Montana shows how literal this gets. Its Transportation Center confirms eligibility, the appointment, the least expensive appropriate mode, and the closest site of service, then sends the provider a list with the pickup, destination, procedure code, and prior authorization number. If a provider transports a member without that confirmation, Medicaid may not pay. Montana also asks for diagnosis code Z75.3 on out-of-town trips and Z02.9 on in-town trips. New York pays a transportation claim only when its details agree with the prior authorization on file.
Before you accept a long trip, confirm these details with whoever authorized it:
- Destination. The exact facility and address on the approval, not a nearby campus.
- Dates and legs. Whether the return is the same day, a later date, or open.
- Level of service. Ambulatory, wheelchair, or stretcher, and any escort.
- Miles. The approved loaded miles and how the payer measures them.
- Extras. Whether tolls, parking, meals, lodging, or wait time are approved, and who pays them.
Keep the written approval with the trip record. It is the first thing an auditor asks for on an unusual trip, and prior authorization records are part of the documentation every payer expects.
Federal operating authority for paid interstate trips
Once a paid passenger crosses a state line, federal registration rules can apply to vehicles as small as a sedan. FMCSA says companies that transport passengers in interstate commerce for a fee or other compensation, whether direct or indirect, generally need interstate operating authority in addition to a USDOT number. Its November 15, 2022 interpretive rule (87 FR 68367) explains that this registration applies to for-hire passenger carriers regardless of vehicle characteristics, and that a nonprofit is still for-hire when it receives compensation for the ride.
Interstate commerce is broader than it sounds. FMCSA’s definition includes trips between two places in one state that pass through another state, and an in-state leg that is part of a trip starting or ending outside the state.
| Your situation | Operating authority | Federal safety rules |
|---|---|---|
| Paid trip over a state line in a car or minivan | Required unless exempt | Not a commercial motor vehicle, so most safety rules do not apply |
| Paid per ride, over a state line, in a van seating 9 to 15, counting the driver | Required unless exempt | Part 385 and parts 390 to 396 cover you: driver qualification, medical exams, driving time limits, and maintenance records |
| Any vehicle rated at 10,001 pounds GVWR or above, on an interstate trip | Required unless exempt | The same federal safety parts cover you |
| Every trip stays in your state | Not required federally | Your state’s rules apply, and many states require a USDOT number from in-state commercial vehicle operators |
Two exemptions matter for NEMT. By statute, most taxicab service needs no operating authority. Neither does a carrier whose trips all stay inside a federally designated commercial zone, a territory around a major city that spans state lines. Operating authority costs $300 for each type, and FMCSA estimates 20 to 25 business days for a new applicant, longer if the application gets extra review. You also file Form BOC-3, which names your process agents, when you apply (49 CFR 366.2). The USDOT number guide walks through registration step by step.
Insurance that follows the van
The federal minimum for interstate passenger carriers depends on seating. Under 49 CFR 387.33T, a for-hire carrier needs $1.5 million of public liability coverage on any vehicle with 15 or fewer seats, driver’s seat included, and $5 million on any vehicle with 16 or more. Proof goes to FMCSA from your insurer on a BMC-91 or BMC-91X filing, or from a surety company as a BMC-82 bond.
A policy bought for in-state work can fall well short of that. Louisiana health plans, for example, accept traditional NEMT providers with a $300,000 combined single limit, a fifth of the federal interstate minimum. Get written confirmation from your agent that the policy meets the federal filing, extends to the destination state, and covers the distance you plan to drive, and send brokers a current certificate when they ask. The NEMT insurance cost guide covers typical policies and what drives premiums.
Billing a long trip cleanly
Long trips pay well only if every line of the claim agrees with the approval. Four rules decide most of it.
Bill loaded miles, not empty ones. CMS policy generally bars paying for empty-van miles as a service of their own, though a state can reflect them in its rate structure. SMD 23-006 also lets a state cover unloaded mileage separately in narrow situations, once it amends its state plan. Montana’s manual states it plainly: bill member loaded miles only, up to the number authorized.
Travel expenses are part of transportation. Under 42 CFR 440.170, transportation includes a rider’s food and a place to sleep, both on the road to care and during it, along with an attendant’s own travel, food, and lodging, plus pay when the attendant is not a relative. SMD 23-006 makes that coverage mandatory when a long trip runs overnight. Colorado pays actual meal and lodging charges up to its daily per diem for authorized out-of-state treatment, one unit of each per day. Louisiana plans cover them when total travel time, appointment included, exceeds 12 hours, capped at federal GSA per diem rates.
Use the codes your payer lists. The CMS HCPCS file describes the codes you are most likely to bill on a long run:
| Code | What it covers |
|---|---|
| A0170 | Tolls, parking fees, and other ancillary costs |
| A0180 and A0190 | Lodging and meals for the rider |
| A0200 and A0210 | Lodging and meals for an escort |
| T2001 | A patient attendant or escort |
| T2007 | Waiting time, in half-hour units |
Each state picks which of these it covers and sets its own price for each, so match them to your fee schedule or contract terms. The ancillary codes glossary entry has state examples, and the long-distance pricing guide covers private-pay quotes for trips no payer covers.
Keep receipts and a clean trip log. Hold toll and lodging receipts, record the odometer or GPS miles for each leg, capture times and signatures, and note why the van left the direct route. The documentation requirements guide lists what most payers expect on every trip.
A pre-trip checklist for crossing state lines
- Confirm the payer approved the out-of-state care, or that the destination sits in a listed border area.
- Get the trip authorization number, approved destination, dates, and loaded miles in writing.
- Check that your operating authority is active, or that the trip fits an exemption, before you accept.
- Confirm the vehicle’s seating and weight rating, since they decide which federal safety rules apply.
- Confirm your insurance covers the destination state and meets the federal minimum on file.
- Ask which travel expenses are approved: tolls, meals, lodging, escort, and wait time.
- Plan the driver’s day so the return is safe and legal, including an overnight stop if needed.
- Record miles, times, receipts, and signatures, and file them with the approval.
Long out-of-state runs also stretch your schedule for the rest of the day. For scheduling around long loaded miles and empty returns, see the guide to rural operations.
Where HealthRide helps
HealthRide saves GPS miles and the route driven on every trip, along with signatures and on-time records, and the trip log prints ready for a broker review. On a long out-of-state run, that record backs up every mile you bill. Riders and facilities can follow the van from a text link, and the office watches each trip’s progress on the live map.
Frequently asked questions
- When is care in another state covered, and does the ride follow?
- Care in another state is covered in four situations under 42 CFR 431.52: a medical emergency, a health risk in traveling home for the care, a state finding that the care is more readily available there, or a local habit of using providers across the line. The ride follows the care approval, so a trip to an out-of-state provider the payer never approved is not covered.
- Is an MC number required for one paid trip into another state?
- Usually, yes. FMCSA expects a company paid to carry passengers between states, directly or indirectly, to hold interstate operating authority on top of its USDOT number. Most taxicab service is exempt, and so are trips that stay inside a federally designated commercial zone. Each type of authority costs $300, and a first application takes 20 to 25 business days or longer, so hand back the trip until your authority is active.
- Are trips to a hospital just across the state line treated as out-of-state?
- Often not. Colorado applies its in-state NEMT rules to routine care in listed border towns across the line. Indiana treats medical providers in named counties around Chicago, Cincinnati, Louisville, Evansville, and South Bend as in-state for prior authorization. South Dakota requires prior authorization only for services more than 50 miles outside the state, and it exempts Bismarck, North Dakota.
- Does Medicaid cover the rider's hotel and meals on an overnight trip out of state?
- Yes, if the payer approves them. Lodging and meals for the rider, and for an attendant the rider needs, count as travel expenses under 42 CFR 440.170, and CMS requires states to pay them when a long trip keeps the rider away overnight. Colorado reimburses what the rider is actually charged, capped at its daily per diem. Louisiana health plans pay once the trip, appointment included, runs past 12 hours.
- Can I bill the empty miles home after an out-of-state drop-off?
- Usually not. In most cases CMS does not let a state pay for the empty drive home as a separate service, although the state may account for that cost when it sets rates. A 2023 CMS option lets a state pay empty miles separately when they would be prohibitive for the most economical provider, but the state must first amend its Medicaid plan. Check with your state or broker on whether it has done so, and look for a return rider where your contract allows it.
- What happens if I run the trip before the authorization arrives?
- You risk not being paid. Montana's transportation manual warns that Medicaid may not pay for a trip run without confirmation from its Transportation Center. In New York, a claim whose details differ from the prior authorization on file does not get paid. Get the authorization number, the approved destination, and the approved miles in writing before the van leaves.
