Texas is one of the most attractive states in the country to start a non-emergency medical transportation (NEMT) company. With over 30 million residents and rapidly growing metropolitan areas like Houston, Dallas-Fort Worth, San Antonio, and Austin, the state offers an enormous and expanding market for transportation services. Texas also has one of the largest senior populations in the U.S., along with a significant number of Medicaid recipients, individuals with disabilities, and veterans - each of whom relies heavily on dependable medical transportation.
With more than 5 million Texans enrolled in Medicaid, many needing regular transportation to dialysis appointments, doctor's visits, physical therapy sessions, and more, Texas uses a broker-based model for Medicaid NEMT services, with companies like MTM and Access2Care managing ride coordination.
When it comes to seniors using non-emergency medical transportation (NEMT),between 3 to 4 million Texas Medicaid beneficiaries use NEMT services annually, accounting for approximately 4-5% of total Medicaid enrollees. Of these individuals, around 60-70% are either seniors aged 65 and older or people living with disabilities. This makes Medicaid a dominant payer source for NEMT services among the elderly population.
Further data shows that approximately 42% of Medicaid NEMT users are dually eligible for both Medicare and Medicaid. These "dual eligibles" are typically older adults or disabled individuals with low income who qualify for Medicaid benefits in addition to their Medicare coverage. Because Medicare generally does not cover non-emergency transportation, Medicaid and direct-pay contracts and agreements become primary funding sources for facility transportation.
For seniors who are not on Medicaid, either because their income exceeds eligibility limits or they are covered by private insurance, NEMT services are usually not covered at all. Most private health insurance plans and Medicare do not reimburse for non- emergency transportation, unless it is an emergency ambulance ride. As a result, seniors outside of Medicaid must rely on private and direct-pay options.
Hospitals and emergency rooms across the country are facing increasing challenges due to the lack of reliable wheelchair transportation services, which directly impacts their ability to operate efficiently. One of the biggest bottlenecks in healthcare delivery today is patient discharge. When patients are medically cleared to leave but have no dependable assisted transportation solutions, especially those requiring wheelchair- accessible transport, they often remain in their hospital bed hours or even days longer than necessary. These delayed discharges create a domino effect, leading to bed shortages, emergency room backups, and a strained clinical workforce.
Emergency rooms are designed for high patient turnover and rapid triage, not extended patient stays. Yet when a wheelchair-bound patient is ready to be discharged to a skilled nursing facility, assisted living community, or even home, the unavailability of proper transport can force ER staff to hold that patient in place. This extends length-of-stay metrics, blocks beds for incoming emergencies, and increases overall healthcare costs for the hospital. Moreover, hospitals are financially penalized for unnecessary extended stays and inefficient patient flow under many value-based care reimbursement models.
The issue is further complicated by the fact that most ambulance services do not handle wheelchair transports and rideshare platforms like Uber or Lyft lack the proper vehicles and training. Many hospitals, particularly in underserved or rural areas, do not have contracts in place with reliable non-emergency medical transportation (NEMT) providers, or they rely on a fragmented pool of underperforming vendors who cannot consistently meet demand. This creates frustration among case managers and discharge planners, who are under pressure to free up beds quickly but have limited transportation options for mobility-impaired patients.
Reliable wheelchair transportation services are not just a convenience, they are an essential part of the hospital ecosystem. When NEMT providers can offer consistent, on-time pickups for discharges, they help hospitals improve patient throughput, reduce ER crowding, and better allocate staff and resources. These improvements ultimately enhance patient satisfaction, reduce liability, and support the hospital's overall operational and financial health.
In short, dependable wheelchair transportation is no longer a luxury, it is a critical infrastructure component in Texas healthcare. Hospitals and emergency departments are actively seeking trustworthy partners who can help them solve this growing pain point, and providers who can deliver timely, safe, and professional wheelchair transport services are well-positioned to fill this urgent gap in the market.
Regulatory freedom is another major advantage. Unlike states such as New York or New Jersey, Texas does not have a Certificate of Need (CON) requirement for NEMT providers. That means entrepreneurs don't have to jump through complicated licensing hoops or prove the demand for their services before launching. This simplifies the startup process, reduces costs, and speeds up the time it takes to begin operations. Although wheelchair and stretcher transports require ADA-compliant vehicles, the requirements are straightforward and manageable for most new providers.
Texas also ranks high in terms of its business-friendly environment. With no state income tax, relatively low overhead costs, and strong legal protections for business owners, the state encourages entrepreneurship and scalability. Insurance premiums, wages, and fuel costs are often lower than in more heavily regulated states, giving NEMT companies a financial edge when trying to maintain profitability.
The state's size and diversity also present numerous service opportunities. Texas is home to over 700 hospitals and thousands of nursing homes, dialysis centers, and assisted living communities. Many of these facilities are actively seeking reliable transportation partners, especially for discharges and recurring appointments. This allows NEMT providers to diversify their revenue streams beyond Medicaid-such as contracting directly with hospitals or serving private-pay clients.
In rural and medically underserved parts of the state, the demand for long-distance transportation is especially high. Patients in these areas often travel 30 to 100 miles or more to reach specialized care facilities. These longer trips generate higher reimbursements and offer better margins, making them an attractive niche for NEMT providers who are willing to serve beyond the urban core.
Finally, Texas offers a tremendous opportunity for growth and specialization. New operators can enter the market with just one or two vehicles and scale quickly by tapping into both urban and rural demand. There's room to specialize in areas such as dialysis transport, wheelchair or stretcher service, or VA hospital partnerships. Many hospital systems in Texas also struggle to coordinate timely discharges due to a lack of reliable transportation providers-creating a critical service gap that NEMT companies are well-positioned to fill.
Texas Facts & Figures:
Texas is home to one of the largest long-term care networks in the United States, with a significant concentration of skilled nursing and rehabilitation facilities. As of early 2024, there are approximately 1,313 skilled nursing facilities (SNFs) operating across the state, making Texas the leading state in the nation for the number of certified SNFs. These facilities provide both short-term rehabilitative care and long-term custodial care, serving a wide range of patients recovering from hospital stays, surgeries, or chronic illnesses.
According to data from the Texas Health Care Association (THCA), there are currently 1,183 licensed nursing homes in the state, along with 2,008 assisted living facilities. This brings the total number of licensed long-term care facilities in Texas to 3,191. The variation between the 1,183 and 1,313 skilled nursing facility counts is likely due to differences in classification, some facilities may be licensed at the state level but not certified as skilled nursing facilities under federal Medicare or Medicaid programs, while others may have recently opened or changed designation.
For NEMT providers, the estimated 1,300 skilled nursing facilities represent a substantial market opportunity. These facilities frequently require dependable transportation for residents to attend dialysis treatments, medical appointments, therapy sessions, and hospital discharges. Given the state's aging population and the central role that skilled nursing and rehab facilities play in post-acute care, this sector remains one of the most consistent sources of demand for wheelchair transportation services throughout Texas.
Texas is home to one of the largest hospital networks in the country, with an estimated 600 to 650 hospitals operating statewide. While exact numbers vary depending on the classification criteria, the most comprehensive counts place the total number of hospitals between 525 and 649. This includes general acute-care hospitals, specialty facilities, critical access hospitals, and rural health centers. According to the Texas Department of State Health Services, there were 649 hospitals reported as of a past statewide survey, with more than 84,000 licensed beds, approximately 26% of which are located in rural areas. These facilities range in size from small regional providers to massive academic medical centers in metropolitan hubs like Houston, Dallas, San Antonio, and Austin.
The Texas Hospital Association (THA), which represents over 85% of the state's acute-care hospitals, includes more than 430 member hospitals in its network. These numbers reflect the vast scale of healthcare delivery across the state and highlight the critical need for support services, particularly non-emergency medical transportation, to ensure efficient patient flow. As hospitals face increasing pressure to discharge patients quickly and free up beds, the demand for dependable NEMT providers has grown considerably, especially for those capable of serving wheelchair-bound or mobility-impaired patients.
Texas is home to a large and growing number of dialysis centers, reflecting the state's high prevalence of chronic kidney disease and its sizable aging population. As of the most recent comprehensive report from the EndStage Renal Disease (ESRD) Network of Texas, there were approximately 559 Medicare-certified dialysis facilities operating across 121 of the state's 254 counties. This data, published in 2014, provides a reliable baseline for understanding the scope of dialysis care in Texas. However, given the state's continued population growth and the increasing incidence of conditions like diabetes and hypertension, which are leading causes of kidney failure, it is likely that the number of dialysis centers has grown since then, potentially exceeding 600 active facilities today.
These centers serve patients who typically require dialysis treatments three times per week, creating consistent and recurring demand for non-emergency medical transportation (NEMT). Many dialysis patients are elderly, mobility-impaired, or enrolled in Medicaid, making them ideal candidates for wheelchair-accessible transportation services. For NEMT providers, the dense network of dialysis centers throughout Texas presents a strong business opportunity, particularly in urban areas and underserved rural communities where access to reliable transportation remains a major barrier to consistent treatment.