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The same 12-mile wheelchair trip pays $17.70 if you run it under North Dakota Medicaid and $100.00 if you run it in Suffolk County, New York. Both are published, current fee schedules. Neither number tells you whether the trip is worth taking, because the fee schedule is not your pricing model — your cost stack is.
Most operators price backwards: look up what the broker pays, decide they can live with it, then discover the problem eighteen months later when the bank balance stops growing despite the fleet doubling. This is the arithmetic you should have run first — what a loaded mile actually costs you, what your deadhead ratio does to that number, and which channels clear it.
What the payers actually pay
Nearly every Medicaid transportation fee schedule uses the same skeleton: a base rate per one-way trip leg plus a per-loaded-mile rate, tiered by vehicle type — ambulatory (sedan, livery, minibus), wheelchair van, stretcher van. What varies is everything else: the dollar amounts, whether mileage starts at mile zero or after a threshold, whether extra passengers get paid, and whether the schedule has been touched this decade.
The spread is not a rounding error
Wheelchair-tier rates from published state schedules, priced for a single 12-mile loaded leg:
| State / schedule | Wheelchair base (A0130) | Loaded mile (S0209) | 12-mile trip pays | Effective |
|---|---|---|---|---|
| Wisconsin SMV max fee (ForwardHealth) | $11.99 | $1.26 (from mile 0) | $27.11 | 07/01/2008 |
| North Dakota Medicaid | $17.70 | $2.52, mileage only past 15 mi | $17.70 | 07/01/2025 |
| Louisiana Medicaid (standard) | $21.50 | $1.30 (from mile 0) | $37.10 | 01/01/2022 |
| Louisiana Medicaid (elevated level of care) | $31.50 | $1.30 (from mile 0) | $47.10 | 10/01/2025 |
| South Dakota Medicaid (secure van) | $43.39 | $2.61 | $74.71 | 07/01/2026 |
| New York FFS — Erie County (ambulette) | $41.00 | $3.00 | $77.00 | 08/01/2024 |
| New York FFS — Suffolk County (ambulette) | $64.00 | $3.00 | $100.00 | 05/20/2024 |
Three things there matter more than the headline range.
Mileage thresholds are a trap. North Dakota's wheelchair mileage code doesn't engage until past 15 miles, so short urban trips — the bread and butter of most fleets — pay a flat $17.70 regardless of how long they take. Montana runs the same logic: $15.30 base under 16 miles, $1.18 per mile beyond. Louisiana pays from mile zero. Model "base plus mileage" without reading the threshold language and you will overstate revenue on every short trip.
Rates go stale and stay stale. Wisconsin's specialized medical vehicle maximum fees carry a 07/01/2008 effective date. That is not a typo. And rates move down as well as up: North Carolina cut NEMT reimbursement 3% effective October 1, 2025, then reversed it that December.
Intrastate variation can exceed interstate variation. New York's ambulette base ranges from $40.00 in Onondaga County to $64.00 in Suffolk; stretcher (T2005) runs $101.00 in Erie and $280.00 in Onondaga. Same state, same code, same program. Price off the county, not the state average.
Price from the cost stack up
Here is a worked example for one wheelchair-accessible minivan in a three-to-five vehicle fleet, running one driver, five days a week, 21 days a month.
| Line item | Monthly | Basis |
|---|---|---|
| Driver wages | $3,402 | $18.00/hr × 9 hrs × 21 days. BLS median for shuttle drivers and chauffeurs: $17.63/hr. |
| Payroll burden | $953 | 28% — FICA, workers' comp, unemployment, PTO. BLS puts benefits at 29.9% of total private-industry compensation, so 28% is a floor if you offer health coverage. |
| Commercial auto insurance | $1,000 | $12,000/yr. Year-one quotes run $7,000–$21,000; established 4–5 vehicle fleets often reach $9,000–$11,000. |
| Fuel | $691 | 3,108 miles ÷ 18 mpg × $4.001/gal (EIA U.S. regular average, week ending 7/20/2026). |
| Maintenance, tires, ramp service | $497 | 16¢/mile. AAA's 2025 study puts a new passenger vehicle at 11.04¢; converted, high-mileage NEMT vans run higher. |
| Vehicle note | $934 | $45,000 used conversion, 60 months, 9%. |
| Dispatch software + telematics | $100 | Published per-vehicle software list prices sit around $49–$69/month, plus camera/telematics. |
| Allocated overhead | $1,100 | Dispatcher, biller, credentialing, drug testing, accounting, office — divided across the fleet. |
| Total per vehicle | $8,677 |
Turning the stack into a rate
Assume 8 completed one-way legs per day averaging 12 loaded miles — 96 loaded miles daily — and deadhead at 35% of total miles, mid-range for the industry. Total daily miles: 96 ÷ 0.65 = 148. Monthly: 3,108 total, 2,016 loaded.
- Cost per day: $8,677 ÷ 21 = $413.19
- Break-even per completed trip: $413.19 ÷ 8 = $51.65
- Break-even per loaded mile: $8,677 ÷ 2,016 = $4.30
- Rate needed for a 15% net margin: $51.65 ÷ 0.85 = $60.76 per trip, or $5.06 per loaded mile
That is the number to carry into every rate conversation. Not "what does the broker pay," but "does this clear $60.76."
Deadhead is the number nobody calculates
Empty miles run roughly 30–40% of total NEMT fleet mileage and almost no payer reimburses them. Wisconsin is a rare exception, paying $0.46 per unloaded mile under an S0209 modifier. Everywhere else deadhead is pure absorbed cost.
The damage isn't fuel. It's that a driver day is finite — every empty mile is a minute you cannot bill. Split the stack into a time-based fixed component ($356.62/day) and a mileage-based variable component ($0.382/mile), and watch throughput move:
| Deadhead ratio | Trips/day the shift supports | Loaded miles/day | Total miles/day | Cost/day | Break-even/trip | Break-even/loaded mile |
|---|---|---|---|---|---|---|
| 20% | 10 | 120 | 150 | $413.95 | $41.40 | $3.45 |
| 35% | 8 | 96 | 148 | $413.19 | $51.65 | $4.30 |
| 50% | 6 | 72 | 144 | $411.66 | $68.61 | $5.72 |
Your daily cost barely moves. Your cost per trip moves 66%. A fleet at 50% deadhead must charge two-thirds more than one at 20% to earn the same margin — identical trips, identical vehicles, identical driver pay. This is why two operators in the same market can look at the same broker rate and honestly disagree about whether it's profitable. Both are right about their own book.
Density is therefore a pricing input, not just an ops metric. Standing orders — dialysis three times a week, adult day five days a week — are the cheapest deadhead reduction available, because they let you build recurring runs instead of reacting to will-call trips. Pre-scheduled trip automation is worth more to your P&L than a rate increase you're unlikely to get.
Broker vs. private pay vs. facility contract
Every channel trades rate against reliability against cash conversion. Priced against the same $51.65 break-even and 12-mile wheelchair leg:
| Broker / Medicaid FFS | Facility contract | Private pay | |
|---|---|---|---|
| Typical rate, 12-mi wheelchair | $17.70–$100.00 by state and county; brokered rates often run 10–30% under state FFS | Negotiated flat rate, between broker and retail | $125–$155 published retail; $90–$200 cited across markets |
| Payment lag | ~36 days — Indiana's broker reported 18 days claim-to-adjudication plus 18 adjudication-to-payment | Net 30, occasionally net 45 | Card at service to net 30 |
| Volume reliability | High volume, low control. Assignment shifts, rates get cut, networks saturate | Highest. Standing orders create predictable density | Lowest. Episodic and seasonal |
| Denial / leakage risk | Real — Indiana's March 2025 report shows a 4.75% claim denial rate | Low; invoice disputes happen | Near zero if you collect at booking |
| Effective margin vs. $51.65 cost | −66% to +94% | Moderate, stable | +142% to +200%, but you fund your own demand generation |
Note what the payment lag does to a growing fleet: at a 36-day cycle you carry roughly a month and a half of operating cost as receivables before the first dollar lands. Growth on broker volume alone is a working-capital problem disguised as a sales success.
The arithmetic of losing money on broker volume
Louisiana's standard wheelchair rate is $21.50 base plus $1.30 from mile zero. A 12-mile leg pays $37.10 — against a $51.65 break-even, a $14.55 loss every trip. At 168 trips a month that vehicle burns $2,444 monthly, roughly $29,100 a year. Add a second van on the same contract and you have doubled the loss and called it growth.
The honest counterargument: a Louisiana cost stack isn't a national-average cost stack. Strip $1,000 a month out for cheaper wages and insurance and break-even falls to $45.70 — still $8.60 short. Actually breaking even at $37.10 requires a $296.80 day, a $6,233 monthly stack, 28% below the model above. Achievable for an owner-operator who drives, self-dispatches, owns the van outright and carries minimum limits. Not achievable for anyone with a payroll and a dispatcher.
Two things change the answer. Density: at 20% deadhead and 10 trips a day, break-even drops to $41.40 and Louisiana's elevated-level-of-care wheelchair rate ($31.50 base, effective 10/01/2025) clears at $47.10. Mix: the same fleet running two private-pay trips a day at $125 alongside six broker trips adds $250 of high-margin revenue to carry the low-margin volume. That is the entire case for a hybrid book — commonly 60–70% brokered base load, 30–40% private pay and facility contracts for margin.
The test is per-contract, not per-company. Run your break-even against each broker's actual paid rates at your actual average trip length — not the published fee schedule, not the state average — then accept, renegotiate, or narrow the geography you'll take assignments in. Auditing what you were paid against what you billed usually finds a few more points on top.
Accessorials: where recovered margin lives
Base-plus-mileage undercharges for the things that actually consume your day. Public schedules pay accessorials thinly or not at all; private-pay rate cards price them properly. The gap between those two columns is where most operators leave money on the table.
| Charge | What public schedules pay | Common private-pay pricing |
|---|---|---|
| Wait time | Usually nothing on the wheelchair tier | $85/hr in 15-minute increments ($21.25/quarter hour); $15–$30 per 30 minutes also common |
| No-show / late cancel | Generally unbilled | Full fare, $85 minimum, for no-show or under 2 hours' notice; 50% for 2–12 hours |
| Additional passenger | South Dakota 50% of base ($21.70 on a $43.39 secure van); Wisconsin $10.19 base + $1.07/mile | $25 flat per rider |
| Attendant / escort | South Dakota T2001 $2.60; Wisconsin T2001 $8.08; North Dakota A0210 $8.67/hr | $5–$15, more for a genuine second attendant |
| Oxygen / life-sustaining supplies | Colorado A0422 $14.44 per unit (FY2021–22 schedule) | Bundled or itemized; verify your state allows the code off the ambulance tier |
| Unloaded / deadhead miles | Almost never; Wisconsin's $0.46/mile is the exception | Zone surcharge outside a set radius, or a long-distance minimum |
| After-hours, weekend, holiday | No code on any schedule reviewed | 25–50% markup on full fare |
| Stair assist / bariatric | No code on any schedule reviewed | Quoted per job; needs a second attendant, price it as labor |
A driver sitting 40 minutes outside a dialysis center is $57 of unbilled cost at your fully loaded day rate. Ten of those a month exceeds your software bill for the year. Write the wait-time and no-show policy down, and apply it on every private-pay and facility trip.
What this actually means for your P&L
Published net margins for small NEMT fleets cluster in the 8–15% range. At $51.65 of cost per trip, a 10-point swing is about $5 a trip — roughly $10,300 per vehicle per year at 2,000 annual trips. That $5 comes from four places, in descending order of controllability:
- Deadhead ratio. Worth $10–$27 per trip between a well-clustered book and a scattered one. Nothing else on this list comes close.
- Channel mix. Moving 20% of volume from a marginal broker contract to facility contracts or private pay is worth more than any rate negotiation you'll win.
- Accessorial capture. Wait time, no-shows, and additional passengers, billed consistently.
- Cost lines. Insurance is the largest controllable fixed line after labor — quotes vary threefold for the same risk, and operating radius alone moves the premium. Use brokers who specialize in NEMT risk (SWAN Insurance, Southern States Insurance, Bridgeway and others) rather than a generalist commercial agent, and re-shop annually once you have loss history. Disciplined preventive maintenance keeps the 16¢/mile line from drifting toward 25¢.
Rate itself is fifth, because on brokered volume you mostly don't control it.
Do this in the next two weeks
- Pull your real deadhead ratio. One month of total odometer miles minus total billed loaded miles, divided by total miles. If your dispatch platform can't produce that, it's a finding. Published per-vehicle pricing runs roughly $49–$69 (Bambi $69, ZeitRide $49, RouteGenie's Growth tier $50 plus $100 per broker integration; NEMT Cloud Dispatch lists $149.99 for 1–5 vehicles). MediRoutes, Tobi Cloud, TripMaster and Ecolane quote rather than publish — get comparable numbers in writing before you switch.
- Rebuild the cost stack table with your own numbers. Your payroll, your insurance declaration page, your note, divided by your completed trips. Do not use the figures in this article as your figures.
- Price every active contract against that break-even at your true average loaded trip length, and rank them. Anything below break-even gets renegotiated, geographically narrowed, or exited.
- Read the mileage threshold language in your state's current fee schedule. Rates and thresholds change quietly — verify amounts with your state Medicaid agency or broker before signing anything.
- Publish a private-pay rate card: base by tier, per-mile or banded distance, wait time, no-show, additional passenger, after-hours. You cannot charge for accessorials you never disclosed. If you're still assembling the cost side of the business, build the rate card before the first trip, not after.
The operators who survive rate compression aren't the ones who found a better broker. They're the ones who knew their break-even to the dollar and had the discipline to say no below it.
