Adding Stretcher and BLS to an NEMT Fleet: Rules and Rates

Short answer: stretcher service is a second crew member, a cot and a fastener, a different license in some states, and a rate that can be generous or barely higher than wheelchair, depending on where you operate. BLS is not a bigger version of stretcher. It is ambulance service under your state's EMS law and Medicare's ambulance rules, with an EMT on every truck. Before you buy anything, check two numbers: what your state pays for a stretcher trip over a wheelchair trip, and what the second person costs for the time that trip takes.

Below: how six states regulate stretcher transport, what four current Medicaid fee schedules pay, what the equipment lists for, and a hypothetical break-even you can rerun. Our gurney and stretcher explainer covers terminology and cot types; this is the business case.

Three levels of service that get confused

Wheelchair van. One driver, a seated rider secured in a wheelchair.
Stretcher van (also called a gurney van, litter van or stretcher ambulette). A rider who cannot sit, carried lying down on a cot locked into a floor fastener, with no medical care en route. Medicaid usually bills it with HCPCS T2005 for the trip and T2049 for mileage. See our stretcher van glossary entry.
BLS ambulance. Basic life support ambulance service. Non-emergency BLS bills as A0428 plus A0425 mileage. Under 42 CFR 414.605, the ambulance must be staffed by at least two people, and at least one must be certified at least as an EMT-Basic.

The line between the second and third is medical care. Colorado's NEMT billing manual defines a stretcher van as a vehicle that can legally carry a client "in a prone or supine position when the client does not require medical attention en route." The moment the rider needs monitoring, oxygen your crew gives, suctioning or an IV, the trip belongs to an ambulance.

How states regulate stretcher transport

There is no national rule for stretcher vans. States handle them in roughly three ways, and some use more than one at once: as a Medicaid level of service, through a separate license, or by putting stretcher-bound riders inside the ambulance definition. Six examples, from primary sources:

State	How stretcher is handled	Crew and rider rules
Illinois	Separate stretcher van provider license under the Department of Public Health's EMS rules. Per 77 Ill. Adm. Code 515.835: $25 per vehicle, a four-year license with annual inspection, and proof of liability insurance per vehicle.	Section 515.845: no stretcher van may run with fewer than two trained attendants, one of whom stays with the passenger. Attendants need CPR certification and stretcher training. No riders needing monitoring, oxygen they cannot self-administer, suctioning or IV fluids (amended Nov. 1, 2024).
Arizona	Set by statute in the state's EMS law, A.R.S. 36-2223.	Stretcher vans may carry convalescent or nonambulatory riders who need no medical monitoring en route. They may not carry medical equipment or markings that imply ambulance care, or answer a public dispatch call. Violations can be treated as running an unregistered ambulance.
California	A Medi-Cal level of service called litter van. Under 22 CCR 51323, it is covered when the rider must lie prone or supine, needs equipment beyond a regular vehicle, and is stable without constant observation.	22 CCR 51231.1: a certified driver and an attendant, each 18 or older with current Red Cross Standard First Aid or equivalent and a current DL-51 medical exam. Gurney fasteners must hold in a rollover.
New York	A Medicaid category, stretcher ambulette, under the eMedNY transportation policy manual (effective Aug. 25, 2023).	Bed-confined riders who cannot sit in a wheelchair and need no medical attention. At least two employees, who must get the stretcher over curbs and steps. No oxygen on board or given by crew. The broker may require vendor certification.
Pennsylvania	Public Utility Commission paratransit authority. The PUC's paratransit application lists transportation "of people in wheelchair and stretcher vans" as a paratransit service; the filing fee is $350.	Medicaid and broker rules apply on top of the PUC certificate.
Ohio	Points to ambulance licensing. Ohio Rev. Code 4766.01 defines an ambulette around riders who need a wheelchair or other mobility aid, and excludes from "ambulance" only vehicles used solely for nonstretcher-bound people.	Read together, those definitions leave no ambulette category for a stretcher-bound rider. Confirm with the state EMS board (EMFTS) before planning stretcher service in Ohio.

Two patterns hold. Every state that allows non-ambulance stretcher transport draws the line at medical care en route, and Illinois, California and New York write the two-person crew into the rules. Get your state's classification in writing from the EMS office and Medicaid transportation unit before you spend money, and treat a second state as a new application.

What Medicaid pays for stretcher, and how it compares with wheelchair and BLS

Here is a 12-mile one-way trip (the distance our NEMT earnings model uses) on four current fee-for-service schedules. Brokers and managed care plans set their own, often unpublished, rates.

Schedule (date)	Wheelchair, 12 miles	Stretcher (T2005 + T2049), 12 miles	Non-emergency BLS (A0428 + A0425), 12 miles
Health First Colorado (Medicaid), rates effective July 1, 2026 (HCPF NEMT fee schedule)	$67.02 ($34.14 + $2.74 a mile)	$71.74 ($49.42 + $1.86 a mile)	$249.83 ($174.47 + $6.28 a mile)
Minnesota state-administered NEMT, mileage effective July 1, 2026 (Minnesota DHS)	$41.40 ($19.80 + $1.80 a mile)	$90.48 ($60.00 + $2.54 a mile)	Not on this schedule
North Dakota Medicaid, data updated Sept. 27, 2026 (NEMT schedule, ambulance schedule)	$18.05 to $48.89 ($18.05 + $2.57 a mile; see note)	$128.21 ($97.37 + $2.57 a mile)	$456.71 ($329.75 + $10.58 a mile)
South Dakota Medicaid, effective July 1, 2026 (transportation fee schedule)	$43.39 in town (secure van)	$109.66 in town	$388.09 ($280.09 + $9.00 a mile)

Notes on reading the table:

South Dakota pays secure van and stretcher van mileage only outside city limits, so an in-town trip pays the base alone. Ambulance mileage has no such limit.
North Dakota's July 2025 schedule paid wheelchair mileage only past 15 miles and listed stretcher mileage with no threshold. If that still applies, the 12-mile wheelchair trip pays $18.05.
Colorado pays stretcher mileage at $1.86, below its $2.74 wheelchair mileage, so the stretcher premium shrinks as trips get longer. Past about 17 loaded miles, Colorado pays less for a stretcher trip than for a wheelchair trip. Its new XL/bariatric wheelchair base ($63.70, two attendants required) pays more than its stretcher base.
Minnesota lists a $9.00 T2001 attendant or escort payment that applies to stretcher (Mode 7) trips only. Confirm with DHS whether your crew qualifies before counting it.

The spread is the story. On a 12-mile trip the stretcher premium over wheelchair runs from $4.72 in Colorado to about $79 in North Dakota. The same crew and cot can be a margin line in one state and a loss in the next. (Our loaded mile entry explains how mileage is counted.)

Equipment and vehicle: what the listings show

Stretcher pricing is less transparent than wheelchair van pricing, and much of it is quoted by phone. These are public listings checked Oct. 1, 2026: reference points, not quotes.

Item	Listed price	Source
2026 Ford Transit 350, 148-inch wheelbase, mid roof, gurney van with 34-inch side-entry lift	Starting at $79,900 plus tax, registration and delivery	National Fleet Sales. The same page lists the rear-lift wheelchair version at $78,900 and says it can be built for stretcher transport. The listing does not say whether a cot is included.
Ferno 35-X manual ambulance cot	$1,953 certified refurbished (plus $495 shipping) to $9,950 factory new	MFI Medical listing, four configurations
Ferno Model 175-3 cot fastener kit	$1,144	Dixie EMS listing. Installation into structural floor is extra.

So the cot and fastener alone run about $3,100 to $11,100 before installation, a stair chair, a powered loader or a bariatric cot. Vehicle pricing for wheelchair builds is in our guide to what a medical transport van costs.

A van that carries both wheelchair and stretcher riders keeps earning on days when discharge planners do not call. Our guide to running a mixed fleet covers dispatching across levels of service.

Crew labor: the cost that decides it

The cot is bought once. The second crew member is paid on every trip, so the rate differential, not the stretcher rate, is the number to watch.

For wages, the BLS May 2025 median for shuttle drivers and chauffeurs (SOC 53-3053) is $17.93 an hour, the same figure our earnings model uses. A stretcher attendant without EMS certification is usually hired from that labor pool. The BLS puts the median annual wage for EMTs at $44,470 in May 2025, about $21.38 an hour on a 2,080-hour year. That is what BLS service puts on every truck, at a minimum.

You can staff the second seat with a full-shift attendant (simple, but you pay idle hours), a trip-based or on-call attendant (cheaper, harder to fill for same-day discharges), or a driver pulled off a wheelchair route. That last one looks free and isn't: the cost is the wheelchair trips that driver no longer runs.

Hypothetical break-even: rate differential compared with the second person's time

This is a hypothetical example, not a forecast. Every input below is an assumption except the published rates. Replace them with your payroll and your contracts.

Assumptions: a 12-mile one-way trip; the attendant earns $18.00 an hour plus 28% payroll burden ($23.04 loaded, the same as our earnings model); the attendant is paid for 90 minutes per stretcher trip, including stairs, hallways and facility handoff; the driver's time equals the wheelchair trip it replaces. Equipment and insurance come after.

State	Stretcher premium over wheelchair	Attendant cost, 90 minutes	Left per trip	Stretcher trips a day to cover a 9-hour attendant ($207.36)
Colorado	$4.72	$34.56	-$29.84	About 44: not achievable
Minnesota	$49.08	$34.56	$14.52	About 4.2
South Dakota	$66.27	$34.56	$31.71	About 3.1
North Dakota	$79.32 (up to $110.16 if wheelchair mileage starts at mile 15)	$34.56	$44.76	About 2.6

How to read it:

Where the premium is thin, Medicaid stretcher loses money once a second person is paid. In Colorado, a 12-mile stretcher trip pays $4.72 more than wheelchair and costs about $35 more in labor.
Where the premium is wide, the question is volume. A full-shift attendant needs roughly three to four stretcher trips a day in the Dakotas and Minnesota to cover their own pay. Below that, pay by the trip.
Time is the hidden input. At 120 paid minutes, the attendant costs $46.08 a trip and Minnesota's margin falls to about $3. Time your first 20 stretcher trips door to door.

Then add the fixed costs. Spread over 36 months, $3,100 to $11,100 of cot and fastener is about $86 to $308 a month. At 4 stretcher trips a day for 21 days, that adds about $1 to $3.70 a trip. The insurance change is the line you cannot estimate from here: get it quoted.

To run the vehicle side, open the vehicle break-even calculator. Enter your blended revenue per trip, put both crew members' paid time in driver cost per trip, add the cot and fastener to setup costs and your insurance quote to insurance per year. Check deadhead in the cost per trip calculator too; discharge trips rarely chain into the next pickup.

Private-pay and facility contracts change the math more than any Medicaid schedule because you set the rate. Price them from your own labor cost per trip.

BLS: a separate business, not an upgrade

The BLS column in the rate table is tempting: on a 12-mile trip, non-emergency BLS pays about 2.8 to 3.6 times the stretcher rate in Colorado, North Dakota and South Dakota (South Dakota's low end assumes the stretcher trip runs outside city limits, where its mileage is paid). What it takes is a different company.

The vehicle. Under 42 CFR 410.41, a Medicare ambulance must be specially designed for emergencies or acute care, with warning lights, sirens and two-way communication as state or local law requires, plus emergency medical supplies and oxygen equipment. An Arizona stretcher van may not carry medical equipment at all.
The crew. Two people, at least one certified at least as an EMT-Basic and authorized to operate the equipment on board.
The license. Ambulance service is licensed under state EMS law (Illinois's IDPH rules, Ohio's Chapter 4766, Arizona's ambulance registration). Requirements and timelines differ by state.
Medical necessity. Medicare covers non-emergency ambulance for bed-confined beneficiaries when other transport is contraindicated, or when the condition requires an ambulance regardless. Under 42 CFR 410.40, bed-confined means all three: unable to get up from bed without help, unable to walk, and unable to sit in a chair or wheelchair. The same rules require claims to indicate that a physician or non-physician certification statement is on file.

The routes into BLS are to start, buy or partner with a licensed ambulance service. For most NEMT fleets the realistic step is stretcher service where the state allows it, plus a referral relationship with a local ambulance company. Some ambulance services run stretcher vans too (Arizona's statute addresses them), so expect them as competitors as well as partners.

Insurance implications

Call your carriers before you buy the cot, not after. Three things to ask:

Commercial auto. Whether stretcher work changes your vehicle class, rating or underwriter. Illinois requires proof of liability insurance for each vehicle on the stretcher van license application.
Workers' compensation. Stretcher work is lifting work. In a NIOSH study of EMS workers treated in emergency departments, career workers had 8.6 injuries per 100 full-time workers, more than four times the rate for all workers treated in emergency departments. Most respondents were transferring, carrying or lifting a patient when hurt. Your stretcher crew does the same lifting.
General and professional liability. How the policy treats patient handling and falls during transfer.

Premiums vary by state, carrier and loss history, so we publish no stretcher surcharge figure. Our NEMT insurance guide covers the coverage stack.

Training

The state rules above set the floor:

Illinois: CPR certification and training on stretcher operation for every attendant.
California: Red Cross Standard First Aid or equivalent, a DL-51 medical exam within two years, and a minimum age of 18 for driver and attendant.
New York: enough trained staff to move the stretcher over curbs, through doorways and up and down steps, and no help with oxygen.
BLS: EMT-Basic certification from the state for at least one crew member.

Above the floor, train every crew on the cot and fastener you bought, two-person lifts, stair chairs, and rider screening: who your license lets you carry, and what to do when a rider's condition changes. Pair it with wheelchair securement training, since a dual-use van carries chairs too.

What to do in the next 30 days

Pull your state's current NEMT and ambulance fee schedules, and your broker or MCO contract rates for T2005 and T2049. Calculate the stretcher premium over wheelchair at your average loaded miles, then check whether mileage is paid only past a threshold or outside city limits.
Email your state EMS office and Medicaid transportation unit. Describe the service (bed-confined, stable, no monitoring, no oxygen given by staff) and ask which license and enrollment apply. Keep the reply.
Count the stretcher requests you turned down last quarter, and ask your three most active facilities and discharge planners how many a week they would send. Our client relationship guide covers working those referral sources.
Get quotes from your commercial auto and workers' comp carriers for adding stretcher, and two installed quotes for a cot and fastener.
Rerun the hypothetical with your wage and paid minutes, then the vehicle break-even calculator with both crew members in driver cost. Pick full-shift or trip-based staffing from the result.
If BLS is on the table, plan it as a separate company and talk to a local ambulance service about a partnership first.

This is not legal, tax or investment advice. Rules and rates vary by state and change often; confirm with counsel, a CPA or your state Medicaid agency before you act.

FAQ

Do I need an ambulance license to run stretcher trips?

It depends on the state. Illinois licenses stretcher vans separately, California and New York treat stretcher as a Medicaid level of service, Pennsylvania covers it under PUC paratransit authority, and Ohio's statute points stretcher-bound riders to ambulance licensing. Get your state's answer in writing.

How much more does Medicaid pay for a stretcher trip than a wheelchair trip?

On a 12-mile trip under current schedules, the premium runs from $4.72 in Colorado to $49.08 in Minnesota, $66.27 in South Dakota and about $79 in North Dakota. Broker and MCO rates differ, so check your own contracts.

Does a stretcher van need two people?

In Illinois, California and New York, the rules require two. Where a state is silent, safely loading a bed-confined adult still takes two people.

Can an NEMT company bill BLS ambulance codes?

Only as a licensed ambulance service: an ambulance-spec vehicle, an EMT-Basic on a two-person crew, a state EMS license and, for Medicare, documented medical necessity.

How many stretcher trips a day make an attendant pay for themselves?

In our hypothetical, a full-shift attendant at $18 an hour plus 28% burden needs about 2.6 to 4.2 stretcher trips a day in North Dakota, South Dakota and Minnesota. In Colorado the 12-mile premium is too thin at any realistic volume.

Adding Stretcher and BLS: What It Takes and What It Pays

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