Quick answer: Before you sign your first Medicaid or broker contract, you need four coverages in place: commercial auto for livery (typically $1M combined single limit, sometimes $1.5M), general liability, sexual abuse & molestation (SAM), and workers' compensation, with your broker named as additional insured. You will also need any required Form E / PUC / DOT filing and a certificate of insurance ready to submit for credentialing.
New NEMT operators often discover, too late, that insurance is not the last box to check before launch, it is the gate. Brokers will not assign trips, and Medicaid will not credential you, without proof of the right coverage. Here is the exact checklist to get in place first, so your first contract closes instead of stalling.
NEMT is a for-hire livery operation. The instant you carry a Medicaid member for compensation, standard personal and business-use auto policies exclude you. You cannot start an NEMT business on a repurposed contractor or delivery policy; you need commercial auto written specifically for livery/for-hire passenger transportation. Building on the wrong policy is the most common, and most expensive, first mistake.
| Coverage | Typical starting requirement | Why brokers require it |
|---|---|---|
| Commercial auto (livery) | $1M CSL floor; $1.5M sometimes | Accident bodily injury & property damage |
| General liability | $1M / $2M aggregate | Slips, falls, non-auto injuries |
| Sexual abuse & molestation | Commonly $1M | Abuse allegations involving vulnerable riders |
| Workers' compensation | State statutory | Injuries to your drivers |
Every major broker, Modivcare, MTM, Verida, SafeRide, and Access2Care, requires this full stack and requires to be named as an additional insured, often with primary/non-contributory wording and a waiver of subrogation.
Many states regulate for-hire passenger carriers through a PUC, DOT, or transportation authority and require your insurer to file proof of coverage, commonly a Form E, before you can legally operate. This filing is made by your insurance carrier, not by you. Confirm your carrier can file in your state before you bind, and know that if coverage lapses, the insurer files a cancellation notice and your authority can be suspended automatically.
Your insurance requirements ultimately come from whoever assigns your trips. Some states use a single statewide broker, for example, Georgia moved to Verida as its single statewide NEMT broker effective April 1, 2026, while others use several brokers under different managed-care plans. Pull the provider agreement for your broker and market and match your policy limits and endorsements to it exactly.
Your COI is the document that unlocks your first contract. Make sure it shows:
As a planning figure, a fully-insured NEMT vehicle commonly costs roughly $6,000 to $15,000+ per year all-in, with commercial auto the largest piece. Your actual number depends on your state, vehicle type, limits, driver records, and (as a startup) your lack of loss history. Build this into your business plan from day one so your margins survive contact with reality. These are illustrative industry ranges, not quotes.
From your very first policy, treat continuous coverage as sacred. A lapse does not just expose you to a claim, it suspends your Medicaid enrollment and broker credentialing, halting trips until you re-credential, which can take weeks. New operators with thin cash reserves are the least able to survive that interruption, so build the discipline before you launch.
The operators who launch smoothly are the ones who treat insurance as step one, not step ten. Line up the four coverages, the endorsements, and the filings, then walk into credentialing with a clean COI. A specialist who places NEMT programs every day can assemble the whole stack, matched to your broker's exact requirements, faster than you can piece it together alone.
• Medicaid.gov — Non-Emergency Medical Transportation (NEMT) overview
• FMCSA — Insurance and Form E filing requirements for passenger carriers
• Georgia Medicaid — Non-Emergency Medical Transportation
NEMT Insurance Pros builds the full startup insurance stack, commercial auto, general liability, abuse & molestation, and workers' comp, matched to your state filings and broker requirements, so your first contract clears.
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This article is general information, not legal or insurance advice. Requirements vary by state, broker, and health plan; verify current rules before contracting. Cost figures are illustrative industry ranges, not quotes. NEMT Insurance Pros is the national non-emergency medical transportation insurance practice of Thrive Risk Management.