NEMT in big cities: slow miles, high-rise pickups, and short trips that eat the day

Why city trips run long on the clock

Big-city NEMT loses its time to traffic, not distance. It is the mirror image of rural NEMT, where long empty miles are the problem. INRIX’s 2025 Global Traffic Scorecard, released December 1, 2025, ranked Chicago first among US cities with 112 hours lost per driver. New York City followed at 102 hours, Philadelphia at 101, Los Angeles at 87 and Boston at 83. INRIX found congestion rose in 254 of the 290 US cities it analyzed.

The Texas A&M Transportation Institute’s 2025 Urban Mobility Report, which covers 2024 and came out October 22, 2025, adds two findings that matter for medical rides:

• Delay has left rush hour. The report says delays are spreading to midday, midweek and even weekends. Those are the hours medical appointments fill.
• The bad day got worse. Worst-day travel times, which the institute measures with its Planning Time Index, rose in regions of every size. On average, Americans lost 63 hours sitting in traffic in 2024, the highest level the institute has recorded.

For dispatch, the worst day matters more than the average. A broker scores you on the pickup that ran late, not the typical one. Set drive times between stops from your slow days, and check them against your own records by hour and by neighborhood. The on-time performance guide explains how pickup windows are usually measured.

More riders, and fewer of them own a car

Dense cities put more potential riders on every block, and many of those households have no car at all. The Census Bureau’s 2024 American Community Survey shows 56.7 percent of New York City households without a vehicle, against 8.5 percent nationally.

No car does not mean a van ride. CMS’s NEMT report to Congress shows how Medicaid members in different kinds of places rode in 2021. In large central metro counties, taxis carried 42.6 percent of NEMT ride days, vans 29.0 percent, public transit 5.5 percent and private vehicles 4.8 percent. Out in frontier and remote areas the van was the main ride, at 41.3 percent of ride days. The van share in big cities sits close to the national figure of 28.0 percent. The difference is who carries the riders who can sit in a car. In big cities that is mostly taxis, while private vehicles carry 17.1 percent of frontier ride days against 4.8 percent in the city.

Medicaid also expects the lowest-cost mode the rider can safely use, and in a city that is often the bus or train. Missouri’s NEMT manual (April 2026) shows where a state draws that line. Its broker may not put a rider on transit who is more than eight months pregnant, or who has a high-risk pregnancy, a high-risk heart condition or severe breathing problems. The same bar applies when the nearest stop is over half a mile away, or over four blocks if that distance is less. Riders who can manage the bus get a pass instead, as the Medicaid bus pass guide explains.

Door-to-door when the door is on the 14th floor

In a city, the rider’s door can be an apartment at the end of a hallway on the 14th floor. New York Medicaid spells out what that means for an ambulette company. Its transportation policy manual puts no cap on how many stairs or floors the crew must climb. The trip starts at the rider’s own door, which may be an apartment or a room in a nursing home, and ends at the practitioner’s door. The manual says this help comes at “no additional or enhanced charge,” and any escort the rider needs is included on the same terms.

Other payers word it differently, but the cost usually lands the same way. Time in lobbies, elevators and hallways is unpaid unless your contract or private-pay rate says otherwise. Collect building details once at intake and keep them on the rider’s profile:

• Floor, unit and entrance. Complexes with several towers, or a separate accessible entrance, send drivers to the wrong door. The pickup address guide covers unit numbers and entrances.
• Elevator. Whether there is one, whether a service elevator can be used, and whether the car takes a stretcher. The stretcher and elevator guide explains what to measure.
• Front desk. Doorman or concierge hours, the buzzer or intercom code, and whether staff will call up to the rider.
• Where to stop. A loading dock, a side street or a building driveway where the van can stand legally while the crew is inside.
• A number that reaches the rider. A call when the van is a few minutes out lets the rider wait in the lobby.

Plan for the day the elevator is out. A wheelchair rider on a high floor may then need a stair chair and two crew members, or a new appointment time. Flag buildings with repeat elevator trouble so dispatch calls ahead before sending a single driver.

The curb is part of the trip

While the crew is upstairs, the van is at a curb, and no one books that part of the trip. A driver working alone can’t leave one rider in a parked van to go up for the next. High-rise work therefore often calls for two people on the van, or a schedule that never leaves a rider waiting in the vehicle.

Facilities are easier than homes. Section 209.3 of the 2010 ADA Standards requires licensed medical and long-term care facilities where stays run past 24 hours to have at least one passenger loading zone, meeting the accessibility specs, at an accessible entrance. Garages are harder. The same standards require only 98 inches of clearance for van-accessible parking (section 502.5), so compare your van’s height with the posted clearance before you pull in. The hospital parking guide covers loading zones, placards and tickets.

Tolls and congestion charges

Some cities charge vehicles to enter their busiest districts. New York has two separate charges, plus ordinary bridge and tunnel tolls. INRIX’s 2025 scorecard found congestion in New York City held flat while it rose in most US cities, and it named the new toll a likely factor.

• The Manhattan toll. The Central Business District tolling program covers Manhattan south of and including 60th Street, leaving out the FDR Drive and the West Side Highway (Vehicle and Traffic Law section 1704). Section 1704-a says no qualifying authorized emergency vehicle, and no qualifying vehicle transporting a person with disabilities, shall be charged the toll. The law leaves the application process to the Triborough Bridge and Tunnel Authority. Apply before your vans start trips into the zone, and keep trip records that show who was aboard.
• The for-hire surcharge. Since January 1, 2019, a state surcharge has applied to for-hire rides that begin in, end in or drive into its zone: Manhattan south of 96th Street (Tax Law section 1299), a larger area than the toll zone. The charge is $2.75 when one rider is aboard ($2.50 in a medallion taxi), or 75 cents a head on a pooled ride. New York Medicaid’s policy manual applies it to Medicaid rideshare, taxi, livery, green car and black car trips. Ambulettes and ambulances are exempt. Any provider surcharged more than once in a calendar month registers with New York’s Department of Taxation and Finance ($1.50, good for three years). Each month’s return and payment are due 20 days after the month closes, and the provider bills fee-for-service Medicaid under A0170 with the TU modifier ($2.75) or TK ($0.75 per person). The rider can never be asked to pay it.
• Bridges and tunnels. New York Medicaid pays tolls per vehicle, one unit per charged crossing, however many riders are aboard. E-ZPass customers bill the actual toll, and a toll paid by mail is paid back at the E-ZPass rate and no more.

On private-pay work in any city, list tolls as their own line on the quote.

What mileage pay means on a short city trip

Per-mile pay rewards distance, and city trips have little of it. New York Medicaid’s fee-for-service schedule (April 5, 2026) shows the shape. In New York City, an ambulette trip (A0130) earns $52.90, and each mile (S0209) adds $3.60. A taxi or livery trip (A0100) earns $22.97, with $2.93 for each mile (S0215). New York’s manual makes the broker responsible for setting rates with its network providers, and those rates supersede the schedule, so your own rate sheet may differ.

Take two hypothetical ambulette trips at those rates:

• A 3-mile trip pays $52.90 + $10.80 = $63.70. The per-trip fee is 83 percent of the money.
• A 15-mile trip pays $52.90 + $54.00 = $106.90.

Say the short trip takes 45 minutes of crew time, from arrival at the building to drop-off. It earns about $85 an hour. If the long one takes 60 minutes on an open highway, it earns about $107 an hour. Cut the short trip to 30 minutes with tight zones and a rider waiting in the lobby, and two of them fill that hour for $127.40. Track revenue per vehicle hour, and start the clock when the crew arrives at the pickup, not when the rider sits down.

Rates also vary inside one state. The same New York schedule pays an ambulette $43.00 a trip and $3.00 a mile in Albany County, and $64.00 and $3.00 in Nassau County. Compare city and suburban rates before you decide where to base vans.

Building a city schedule

City scheduling comes down to keeping each van inside a small area and keeping crews out of lobbies. Habits that help:

1. Zone the day. Group pickups by neighborhood and hospital campus so vans shuttle short distances. The zone dispatching guide covers setting zones.
2. Budget building time on its own. Give every high-rise pickup a set number of minutes for the lobby and elevator, separate from drive time, and adjust it from your records.
3. Get riders downstairs on time. A call or text a few minutes out turns lobby waiting into loading.
4. Keep a floater van. One unassigned van near the busiest hospitals absorbs late returns and elevator failures.
5. Move the longest legs off peak. Where appointment times allow, schedule bridge, tunnel and cross-town trips outside commute hours.

Running city days in HealthRide

Ryder Go plans your whole day in one click, matching every trip to the right driver and van based on pickup times, appointments, where your drivers are and who needs a wheelchair van. On the live map you see where each van is, and riders and facilities can follow the driver live from a text link, so the rider can be waiting in the lobby. See Ryder Go for how the plan is built.