Skilled nursing facility transportation: who pays, and how to become the SNF's provider

Who pays depends on the resident’s status that day

The payer for a nursing home resident’s ride depends on two things: what coverage the resident has that day, and what vehicle the ride needs. Get both right before you quote, because the same resident can be a facility-paid rider in March and a Medicaid rider in June.

There are about 14,700 nursing homes in the United States with 1.2 million residents, according to CDC figures for 2022. A nursing home can be certified by Medicare as a skilled nursing facility (SNF), by Medicaid as a nursing facility, or by both. Residents leave the building for dialysis, specialist visits, imaging, wound care, dental work, and hospital stays.

The rest of this guide explains each row.

How consolidated billing works

Consolidated billing is a Medicare payment rule for SNFs. During a covered Part A stay, the SNF receives one daily rate and must bill Medicare for almost everything the resident receives, including services from outside companies. CMS’s claims manual (Chapter 6) says the outside supplier “must look to the SNF” for payment, not to Medicare or to the beneficiary.

Three points matter for a transportation company:

1. Medicare does not set your price. CMS leaves the amount and timing of payment to direct negotiation between the SNF and its supplier. It asks SNFs to document these arrangements in writing, especially with suppliers that serve residents on an ongoing basis.
2. The SNF still owes you without a contract. CMS states that the lack of a valid arrangement does not cancel the SNF’s duty to pay for medically necessary services included in its daily rate. A facility with a pattern of refusing to pay its suppliers risks violating its Medicare provider agreement.
3. It covers a limited window. Consolidated billing for transportation applies only during a covered Part A stay. Once Part A coverage ends, only therapy services stay under the rule, so ambulance trips go back to normal Part B billing.

Original Medicare generally covers SNF care only after a medically necessary inpatient hospital stay of at least three days in a row, and for up to 100 days in each benefit period. In 2026 the resident pays $0 a day for days 1 to 20 once the $1,736 Part A deductible is met (a deductible already paid for the hospital stay in the same benefit period counts), $217 a day for days 21 to 100, and all costs after day 100.

Consolidated billing is an Original Medicare rule. For a resident in a Medicare Advantage plan, CMS tells SNFs to bill under their agreement with the plan, so ask the facility how the plan handles outside trips. Some plans also include a ride benefit of their own; see our Medicare Advantage guide.

Consolidated billing applies to Medicare-certified SNFs and to swing beds in hospitals other than critical access hospitals. CMS lists these as outside it: critical access hospital swing beds, nursing homes that take neither Medicare nor Medicaid, non-certified parts of a building with a certified SNF unit, and nursing homes that participate only in Medicaid.

The ambulance trips that stay outside the SNF’s rate

Medicare’s SNF benefit covers ambulance transportation only when it meets the general medical necessity rule in 42 CFR 409.27(c): the resident’s condition must make any other means of transport medically contraindicated. Within that, CMS’s Chapter 6 splits ambulance trips into two groups.

The supplier bills Medicare Part B for these trips:

• The trip to the SNF for admission, on the admission date.
• The trip from the SNF to the resident’s home at discharge, on the discharge date.
• Trips to or from a hospital-based or freestanding dialysis facility for dialysis.
• A trip from the SNF to a hospital or critical access hospital for an inpatient admission.
• A trip after a formal discharge or other departure to anywhere other than another SNF, when the resident does not return to a SNF before the following midnight.
• A round trip to a hospital for emergency services or certain intensive outpatient services that are excluded from consolidated billing. Both legs are billed separately.

The SNF pays for these trips out of its daily rate:

• A medically necessary transfer to a second SNF when the resident is admitted there before the following midnight.
• Trips to or from a diagnostic or treatment site that is not a hospital or dialysis facility, such as an independent diagnostic testing facility, a cancer or radiation therapy center, or a wound care center.
• A round trip to a physician’s office.

If you run ambulances, this list decides whether you invoice the facility or Medicare. Check the resident’s status and the destination before the trip, not after the claim comes back denied.

Wheelchair and stretcher vans are outside Medicare

CMS is blunt on this point: Medicare “simply does not provide any coverage at all” under Part A or Part B for non-ambulance transportation such as an ambulette, wheelchair van, or litter van. Its own example: if a resident can safely travel by wheelchair van, the van is not covered, and an ambulance is not covered either because it is not medically necessary.

So for a NEMT company, consolidated billing does not create a Medicare payment for van rides. What it creates is a customer. During a Part A stay, the facility is already paying for ambulance-level trips, and its staff have to get residents to appointments by some means. Whether the facility pays for van rides itself, sends them to Medicaid, or charges the resident is its decision within state rules.

Federal rules shape that decision in two ways:

• Facilities must help residents get to certain care. When a resident needs or asks for help, nursing homes must assist with making appointments and arrange transportation for dental services (42 CFR 483.55), for vision and hearing practitioners, and for foot care (42 CFR 483.25). “Arrange” does not mean “pay”, but it does mean someone at the facility calls a provider.
• Residents must be told about charges. Under 42 CFR 483.10(g)(18), the facility must inform residents, at admission and during the stay, of charges for services not covered by Medicare, Medicaid, or the daily rate. When the facility changes what it charges for other items and services, it must tell residents in writing at least 60 days ahead.

That 60-day rule affects you. If a facility passes your ride charges through to residents, give it at least 60 days’ written notice of any rate change so it can notify residents in time. Our guide to Medicare and NEMT covers ambulance medical necessity in more detail.

Long-stay residents on Medicaid: the state decides

Each state’s Medicaid plan has to spell out how the agency gets members to and from their providers (42 CFR 431.53). How a state meets that duty for nursing home residents varies widely. Two states show the range.

Indiana puts it on the facility. Since July 1, 2023, Indiana Medicaid has required nursing facilities to book and pay the transportation company for their Medicaid residents’ non-emergency rides. The exception is a medically necessary advanced or basic life support ambulance trip, which the ambulance provider bills to the state. The state treats the cost of the other rides as part of the facility’s daily rate, so they cannot be billed to Medicaid separately, and the statewide broker does not schedule them. If you serve Indiana nursing homes, the facility is your customer. See the Indiana guide.

New York keeps nursing homes off the pay-your-own list. New York’s Medicaid transportation manual requires certain residences for people with developmental disabilities to provide or pay for residents’ medical rides at no extra cost to Medicaid. Nursing homes are not on that list. Instead, the manual lets a nursing home order non-emergency ambulance transportation on behalf of the resident’s practitioner, subject to the state’s prior authorization rules. The same manual answers a question nursing home administrators have raised: when facility staff escort a resident to an outside appointment, the home cannot bill the resident or family for it, and it cannot order a higher level of transport to make room for the escort. See the New York guide.

Other states use other models. Before you pitch a facility, find out whether its Medicaid residents’ rides go through the state’s ride program or broker, through a managed care plan, or through the facility’s own budget.

Rules that shape a nursing facility contract

Three sets of rules affect what goes into the agreement.

Written arrangements. When an outside company provides a service the facility is responsible for, 42 CFR 483.70(f) requires a written arrangement in which the facility takes responsibility for two things: that the service meets professional standards, and that it is delivered on time. CMS’s billing manual separately asks SNFs to document supplier arrangements in writing. Expect the facility to hold you to on-time standards, because federal rules hold it to them.

No swapping. OIG’s November 2024 compliance guidance for nursing facilities warns against a supplier accepting a low price on services covered by the facility’s Part A rate in exchange for referrals of other federal program business it can bill directly, such as Part B work excluded from consolidated billing. Ambulance providers are one of the supplier types OIG singles out. Its examples of suspect deals:

• Prices below cost.
• Prices lower than the supplier gives other customers of similar size that send it no federal program business.
• Discounts paired with exclusive contracts or with spoken or unspoken promises to send other business.

Set facility rates from your own costs and write down how you set them. Our facility billing guide covers invoicing under those rates.

Emergency evacuation. Nursing homes must plan for safe evacuation, and the plan must consider transportation (42 CFR 483.73(b)(3)). OIG’s guidance adds that facilities contracting for emergency transportation should confirm the company can move residents safely and on time during disasters that affect a large area. An evacuation agreement can open the door to a facility, but only promise the vehicles and drivers you would really have when every facility in the county calls at once.

What to put in the agreement

The facility transportation agreement template lays these out as clauses. For the pickup itself, see our guide to nursing home pickups and returns.

Selling to the administrator

Several people at a facility touch transportation, and each cares about something different.

• The administrator signs. Federal rules have the governing body appoint the administrator, who is licensed by the state where licensing is required and manages the facility.
• Nursing staff and unit clerks often book rides and deal with late returns.
• Social services often helps residents with appointments and discharge. Facilities over 120 beds must have a full-time qualified social worker.
• The business office pays your invoices and needs the bill-to rules to be clear.

A practical approach:

1. Build your list. Use Medicare Care Compare to find nursing homes within easy reach of your garage.
2. Ask where rides break down. Listen for missed dialysis chair times, residents waiting hours for a return, and staff calling around for a stretcher van.
3. Bring the bill-to table. A one-page answer to “who pays for what” is more useful to an administrator than a brochure, because the payer question comes up on every trip.
4. Start with the hard trips. Offer to take standing dialysis runs or stretcher appointments, then run them on time every week.
5. Report monthly. Send completed trips, on-time pickups, and any incidents. Our guide to keeping facility accounts covers the review meeting.

Running nursing home work in HealthRide

Nursing home staff can book rides through their own HealthRide portal, watch the van on its way, and pay the monthly bill online. A standing dialysis schedule is entered once and keeps repeating. Each completed trip is priced from that facility’s rates and lands on its invoice, so the business office sees one bill for the month.