Texas: High-Growth Market for Non-Emergency Transportation

Texas is one of the most attractive states in the nation to start a Non-Emergency Medical Transportation (NEMT) business. With over 30 million residents and rapidly growing metro areas such as Houston, Dallas-Fort Worth, San Antonio, and Austin, the state provides an enormous and expanding customer base. Texas also has one of the largest senior populations in the U.S., along with a significant number of Medicaid recipients, veterans, and individuals with disabilities, each group heavily dependent on reliable transportation for medical care. 

Texas has more than 5 million Medicaid enrollees, and between 3–4 million use NEMT annually. Approximately 60–70% of Medicaid NEMT users are seniors or disabled individuals, and 42% are “dual eligibles” who qualify for both Medicare and Medicaid. Since Medicare generally does not cover non-emergency transportation, Medicaid and facility contracts become the primary payer sources.

The state uses a broker-based Medicaid system, with ride coordination handled by MTM and Access2Care. Medicaid-funded rides provide steady volume but often low reimbursement rates and strict documentation requirements. For providers following Joel’s strategies, the path to higher margins is clear: build direct-pay and facility contracts with hospitals, nursing homes, dialysis centers, and rehab facilities. These relationships bring faster payments, more control over pricing, and stronger ROI.

Hospitals across Texas face growing discharge challenges due to the shortage of reliable wheelchair transport. When patients are medically cleared but cannot secure transportation, discharges are delayed for hours or even days, creating:

• Bed shortages in inpatient units.
   
• ER backups that block new admissions.
   
• Financial penalties under value-based reimbursement models.
   
• Increased staff strain, as nurses and case managers must hold patients awaiting transport.
   

Ambulances rarely handle wheelchair trips, and rideshare services like Uber and Lyft lack ADA-compliant vehicles. As a result, hospitals are actively seeking dependable NEMT partners who can provide consistent, on-time wheelchair and stretcher transport. Providers who meet this need can secure long-term, premium-rate contracts and position themselves as essential hospital partners.

Texas offers major advantages for NEMT startups:

• No Certificate of Need (CON): Unlike New York or New Jersey, Texas does not require operators to prove service demand before launching.
   
• Manageable requirements: ADA-compliant vehicles, insurance, and basic safety compliance are required, but the process is far less restrictive than in heavily regulated states.
   
• Low-cost operations: Texas has no state income tax, lower insurance and labor costs than coastal states, and affordable fuel.
   

This regulatory freedom reduces startup costs and accelerates time-to-market, making Texas one of the easiest large states for entrepreneurs to enter.

•  Urban Markets: Metro areas like Houston and Dallas generate dense, high-volume trips, especially for dialysis and hospital discharges. Providers can complete more trips per day per vehicle, maximizing fleet utilization.
   
• Rural Markets: In underserved counties, patients often travel 30–100+ miles for specialty care. These longer trips yield higher reimbursements and offer strong profit margins for providers willing to serve beyond the urban core.
   

This dual-market structure allows providers to scale strategically, balancing high-volume city routes with high-margin rural transports.

•  Skilled Nursing Facilities (SNFs): ~1,183 licensed nursing homes and ~1,313 certified SNFs, plus 2,008 assisted living facilities.
   
• Hospitals: 600–650 statewide, including large academic medical centers and small critical access hospitals.
   
• Dialysis Centers: ~559–600 Medicare-certified facilities, serving thousands of ESRD patients requiring treatment three times weekly.
   

This healthcare network ensures steady demand for ambulatory, wheelchair, and stretcher transport services every day of the year.

Texas combines huge demand, Medicaid scale, business-friendly regulation, and diverse markets to create one of the most lucrative states for NEMT. While Medicaid provides volume, the real profitability comes from direct contracts with hospitals, SNFs, dialysis centers, and private-pay clients, particularly in wheelchair and stretcher transport, where hospitals urgently need reliable partners.

Entrepreneurs who follow Joel’s strategies, investing in compliance, fleet reliability, and facility relationships, can scale quickly in Texas and secure a strong foothold in one of the fastest-growing healthcare markets in the country.