Value-based care transportation: selling rides to ACOs under the safe harbors that let them pay

Why accountable care organizations pay for rides

An accountable care organization (ACO) is a group of doctors, hospitals, and other providers that coordinates care for a set of Medicare patients and answers for both its cost and its quality. When an ACO delivers high-quality care and spends less, it can share in the savings it achieves for Medicare, and ACOs that take two-sided risk also share in losses. CMS says this kind of coordinated care can spare patients costly emergency department visits and repeated tests. Avoided costs like those are where an ACO’s savings come from, so an ACO has a reason to pay for rides that a fee-for-service practice usually would not.

The market is large. CMS’s figures for 2026:

• Medicare Shared Savings Program. 511 ACOs serving 12.6 million people in Traditional Medicare. In 2024, the most recent year settled, these ACOs earned $4.1 billion in shared savings and saved Medicare $2.5 billion.
• ACO REACH. 74 ACOs serving about 1.7 million people. The model ends with 2026, and the LEAD Model takes over from January 1, 2027.
• Kidney Care Choices. 74 kidney contracting entities serving 237,000 people with chronic kidney disease or end-stage renal disease, a group that includes people on dialysis (see dialysis transportation contracts).

A ride paid by an ACO is still a payment that touches Medicare patients, so it has to fit a federal rule. The full list of conditions for each anti-kickback safe harbor is in the Anti-Kickback Statute guide. This guide covers what is different when the buyer is an ACO or another value-based group. If the ACO includes a hospital, the readmission angle in hospital readmission transportation applies as well.

Three rules that let a value-based group pay for rides

An ACO can fund rides under the local transportation safe harbor, the patient engagement and support safe harbor, or, inside the Shared Savings Program, CMS’s in-kind incentive rule. Each one sets a different limit, so the contract changes with the rule the ACO picks.

Local transportation: the ACO needs no patients of its own

The local transportation safe harbor protects free or discounted rides offered by an “eligible entity”, which is anyone except individuals and entities that primarily supply health care items. In its 2016 rule, OIG listed health plans, Medicare Advantage organizations, ACOs, clinically integrated networks, and charities as eligible.

The established-patient test works differently for them. A provider that offers rides must limit them to its own established patients. OIG explained that ACOs, health plans, and health systems do not have established patients of their own, so they are always treated as providing transportation to another provider, and the rider must be an established patient of that doctor or clinic. A patient counts as established once they have booked an appointment.

This route has no dollar cap, but it keeps the distance limits and bans paying drivers or arrangers per patient carried. Bill these rides by the mile, by the hour, or at a fixed rate.

Patient engagement and support: the $623 cap

This safe harbor, added in the 2020 rule, protects tools and supports that a value-based enterprise participant gives patients in its target population. A value-based enterprise is two or more participants working toward a value-based purpose under a governing document and an accountable body or person. OIG said in 2020 that an existing ACO could qualify, but only by meeting every part of that definition; nothing is automatic. The conditions that matter for rides:

• In-kind only. A ride qualifies; cash and cash equivalents do not. OIG’s own examples of in-kind transportation are “transit vouchers or rideshares organized by the VBE participant.”
• Recommended by the patient’s clinician. The ride must be recommended by the patient’s licensed health care professional and advance a goal such as sticking to a treatment plan or a follow-up care plan.
• Capped per patient. The total retail value of all tools and supports one participant gives one patient in a year may not exceed $623 in 2026.
• Open regardless of coverage. Whether a patient gets the support cannot depend on the type of insurance they have.
• No recruiting. The rides cannot be used to market other services or to recruit patients.
• Six years of records. The participant must be able to show the Secretary how each support was given.

The participant can hand the ride to an “eligible agent”, which means anyone not on the safe harbor’s ineligible list (drug makers, pharmacy benefit managers, laboratory companies, and medical equipment suppliers, among others). A transportation company can be that agent.

Shared Savings Program in-kind incentives

ACOs in the Shared Savings Program have a third route written into the program rules. Under 42 CFR 425.304(b), the ACO, its participants, and its providers may give Medicare patients in-kind items or services when there is a reasonable connection to the patient’s medical care, the item advances a clinical goal such as adherence to a follow-up care plan or management of a chronic condition, and Medicare does not cover it for that patient on that date. The ACO may use its shared savings to pay for it. CMS models such as ACO REACH and Kidney Care Choices follow their own participation documents, and the CMS-sponsored model safe harbor at 1001.952(ii) protects patient incentives where CMS has made it available for the model.

Pricing rides under the $623 cap: a worked example

Under the patient engagement route, the cap counts retail value, so the ACO needs to know what each ride is worth to the public. Quote your normal private-pay rates and put the value of each trip on every invoice line.

As an example, take a rider whose one-way trip is valued at $45:

1. One round trip to the clinic is worth $90.
2. Six round trips in 2026 come to $540, under the $623 cap.
3. A seventh round trip brings the total to $630, which is over the cap.

The cap covers every tool and support from that participant, not only rides. If the ACO also gave the same patient a blood pressure cuff or a scale, its value comes out of the same $623. Ask the ACO how it tracks the running total for each patient and send ride values in the format it uses. The cap moves every calendar year with the CPI-U change for the year to September 30: $500 in 2021, $605 in 2025, and $623 in 2026. OIG announces each new figure after that September number is out, so check for the 2027 cap before you renew prices.

When the ACO needs more rides per patient than the cap allows, the local transportation route has no dollar limit, as long as each trip stays inside its distance rules and you are paid by the mile, hour, or a fixed fee.

Where to find value-based buyers near you

CMS publishes the list. The Accountable Care Organizations file on data.cms.gov names all 511 Shared Savings Program ACOs for 2026, with each ACO’s service area by state, its executive contact, public contact, compliance contact, medical director, and public reporting website. A companion file lists the practices and hospitals that participate in each ACO.

Work the list in this order:

1. Filter by state. Keep the ACOs whose service area covers your counties.
2. Read the public reporting web page. Under 42 CFR 425.308, every Shared Savings Program ACO must keep one listing its participants, governing body, key clinical and administrative leaders, committees, shared savings received and how they were used, and quality results. It shows which clinics and hospitals are inside the ACO and who runs care management.
3. Match to riders you already carry. Clinics you already drive to, dialysis units in a Kidney Care Choices entity, and hospitals with readmission problems are the warm leads.
4. Watch the 2027 change. ACO REACH ends with 2026, and LEAD’s first year starts January 1, 2027, with a stated focus on high-needs patients, people with both Medicare and Medicaid, and people who are homebound or home limited.

Health plans that run their own value-based programs are a separate buyer. Medicare Advantage transportation benefits are covered in Medicare Advantage NEMT.

What to put in front of an ACO

Start by asking which rule the ACO will use, because it decides your contract. A local transportation program needs a set eligibility policy that staff apply the same way every time, no advertising, and mileage or fixed pricing. A patient engagement program needs a clinician’s recommendation for each rider and a running retail value per patient. An in-kind incentive under the Shared Savings Program needs a clinical goal on file.

Then bring a short proposal:

• The patients. A value-based arrangement must define its target patient population in writing before it starts. Ask for that definition and build the program around it, for example patients with heart failure who have missed specialist visits.
• The trips. Clinic visits, dialysis schedules, pharmacy pickups the clinician recommends, and rides home after a hospital stay.
• The measures. Completed rides, missed rides with reasons, and on-time pickups, reported by clinic and month. ACOs care about avoided emergency visits and admissions, but they will measure those themselves.
• Privacy. Patient details shared for booking should be covered by a business associate agreement where the ACO asks for one. The HIPAA guide for NEMT covers what that commits you to.
• A pilot. One practice or one patient group for 90 days is easier for an ACO to approve than a network-wide program.

Keeping ACO rides organized in HealthRide

In HealthRide, ACO and clinic staff book rides from their own portal. Completed trips keep GPS-verified miles, timestamps, and signatures captured on screen, which backs up billing by the mile and the ride records an ACO program keeps. HealthRide’s reports break out trips by payer, so an ACO program stays separate from Medicaid and private-pay work, and completed rides roll into the ACO’s invoice.