NEMT in Puerto Rico: No Medicaid Benefit, and What Operators Do Instead

This is the Puerto Rico edition of Bambi Knows Best, and it is going to read differently from the other fifty-one chapters. In every one of those, the answer to "who pays for the trip" is some version of Medicaid, usually through a broker you credential with. In Puerto Rico that answer does not exist.

Puerto Rico Medicaid does not cover non-emergency medical transportation. Not partially, not in a limited way. It is a written exclusion. We read all four Plan Vital beneficiary manuals to be sure, and every one of them carries the same line in the excluded-services list: "Travel expenses, even when ordered by the PCP, are excluded." Emergency ambulance is covered, with a copay. Getting a member to a dialysis appointment is not.

So if you came here looking for the Puerto Rico equivalent of Modivcare or MTM, there isn't one, and any article that tells you otherwise has not checked. We would rather lose the click than send you into a credentialing process that does not exist.

Here is why the page is still worth your time. The demand side in Puerto Rico is, by the numbers, more extreme than almost anywhere in the United States. Twenty-six percent of the population is 65 or older. Diabetes prevalence is the third highest of all fifty-five states and territories. Around 5,600 people need in-center dialysis three times a week. And the shared-ride system that used to move rural Puerto Ricans has collapsed by roughly 94 percent in fifteen years with nothing replacing it.

There is real work here. It just is not Medicaid work. This guide covers who actually pays, the licence category the government already built for exactly this business, and what the numbers look like.

Part 1: Why There Is No Medicaid NEMT in Puerto Rico
Part 2: Who Actually Pays for Trips
Part 3: Licensing, the PCTPC Franchise and Insurance
Part 4: Registering the Business
Part 5: The Demand Picture
Part 6: Building the Fleet and the Team
Part 7: Technology

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This is the Puerto Rico chapter of Bambi's complete guide to starting a NEMT business, covering the seven steps that apply everywhere plus a guide for all 50 states.

Part 1: Why There Is No Medicaid NEMT in Puerto Rico

The exclusion, in the program's own words

Puerto Rico's Medicaid program is called Plan Vital, administered by ASES, the Administración de Seguros de Salud. It runs entirely through four managed care organizations: First Medical, Menonita, MMM Multi Health and Triple-S.

Each of those four publishes a beneficiary manual listing covered and excluded services. The excluded list is numbered, and item 29 is identical across all four: "Travel expenses, even when ordered by the PCP, are excluded." There is no carve-out for dialysis, no exception for wheelchair users, no prior-authorisation path. It is simply not a benefit.

Two other exclusions matter for anyone modelling this market. Item 26 excludes services received outside Puerto Rico except emergencies, which means Plan Vital does not fund travel to the mainland for specialty care, a real problem for a population with high rates of complex chronic disease. And ambulance service is covered, with a copay, which is why you will occasionally see a source claim Puerto Rico "covers transportation." It covers emergency transportation. That is a different business.

This is a gap, not a legal exemption, and the distinction matters

You might reasonably assume territories are exempt from the federal rule requiring states to assure transportation to covered services. They are not, at least not Puerto Rico.

The federal regulation, 42 CFR 431.53, requires a state plan to assure necessary transportation. It contains no territorial carve-out.
Puerto Rico counts as a "State" for Medicaid purposes under Section 1101(a)(1) of the Social Security Act.
The waiver that actually lets a territory opt out of Medicaid requirements, Section 1902(j), is available only to American Samoa and the Northern Mariana Islands. Puerto Rico cannot use it.

So the honest description is that Puerto Rico's non-coverage is a long-standing gap that has been tolerated rather than authorised. The reason is money. Puerto Rico's Medicaid funding is a capped block grant set in statute in 1968, growing only with medical inflation, rather than the open-ended federal match states receive. When the money runs out, the territory pays. Something had to give, and transportation was one of the things that gave. MACPAC has reported that Puerto Rico provides only 10 of Medicaid's 17 mandatory benefits.

What members are actually told to do

The manuals do not leave members with nothing. They point them somewhere: "If you do not have a way to get to your health care appointments, [your plan] and your Municipality may be able to help with transportation. Each municipality has some ways to help you get to your appointments."

Read the verbs. "May be able to." "Some ways." This is a phone number and a municipal favour, not an entitlement. There is no defined network, no appeal right, and no published reimbursement. Which brings us to the part of this market nobody has properly mapped.

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Part 2: Who Actually Pays for Trips

Somebody in Puerto Rico is already moving 5,600 dialysis patients to clinic three times a week. They are getting paid by someone. Here is who, ranked roughly by how much we could verify.

1 | The municipios, and this is the big unknown worth your first phone calls

Puerto Rico has 78 municipalities, and the Plan Vital manuals explicitly direct members to them for transportation help. Several run their own programmes for elderly and disabled residents. What nobody has published, including us, is an inventory of what each municipio actually operates, whether it runs vehicles in-house or buys service, and what it pays.

We are flagging this as the single largest gap in our research rather than papering over it. If there is a repeatable revenue stream in Puerto Rico, the municipios are the most likely place to find it, and the work of finding out is a series of phone calls to oficinas de programas federales and offices of the elderly. That is unglamorous, and it is also why the opportunity is still open.

2 | Dialysis chains

There are 50 Medicare-certified dialysis facilities in Puerto Rico with 1,461 stations. Fresenius operates 29 of them, Atlantis Healthcare Group 17, with four independents. Dialysis operators everywhere have a structural interest in patients arriving on time, because a missed session is a clinical problem and an empty chair is a revenue problem. Facility-level transport arrangements are a normal part of that world.

3 | Medicare Advantage

Puerto Rico has unusually high Medicare Advantage penetration, and MA plans may offer transportation as a supplemental benefit. That is plan-by-plan and year-by-year, so it needs checking against current plan documents rather than assumed. We did not verify which Puerto Rico MA plans currently include it, and you should not take a blog's word for it, including ours.

4 | Private pay and families

With no Medicaid benefit and a large elderly population, a meaningful share of this market is simply families paying out of pocket. That sets a real price ceiling, and it is worth understanding what households can actually bear before you build a rate card.

5 | Hospitals and discharge

Discharge transport is a universal hospital pain point. Puerto Rico has 60 hospitals and no critical access hospital programme, and discharge delays cost bed-days everywhere.

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Part 3: Licensing, the PCTPC Franchise and Insurance

This section is the reason we think the page is worth publishing. Puerto Rico's regulator has already built a licence category for exactly this business, and the terms are more favourable than most states.

1 | Get the agency right, because most guides do not

For-hire passenger transport in Puerto Rico is regulated by the Negociado de Transporte y otros Servicios Públicos (NTSP), which replaced the old Comisión de Servicio Público. Its parent body is the Junta Reglamentadora de Servicio Público (JRSP), not DTOP. That is a common error and it will send you to the wrong building. The governing document is Reglamento Núm. 9358, the NTSP's Código de Reglamentos.

One more thing that surprises people: NTSP licenses ambulances too, not the Department of Health. Health retains personnel licensing for EMTs and paramedics, but the vehicle and service authority sits with NTSP.

2 | The PCTPC franchise, which exists for this exact business

The category you want is PCTPC, Porteador por Contrato para el Transporte de Pasajeros y Carga. It matters that this category was formed by consolidating two predecessors: PCVTE, the elderly transport franchise, and PCVTI, the disability transport franchise. In other words, the regulator did not have to be persuaded that medical and mobility transport is a distinct thing. It already built the category.

Franchise term: three years.
Cost: $750 for a new franchise, $300 to renew. Vehicles are $150 per year new, $25 to renew. There are separate published fee lines for stretcher vehicles and for hydraulic wheelchair-lift vehicles.
Vehicles may operate on private plates rather than requiring public-service plates.

3 | The driver credential that names dialysis in its own text

Puerto Rico has a purpose-built licence endorsement for medical transport drivers: the Autorización de Operador para Cuidado Médico. The regulation describes it as covering drivers carrying passengers "hacia citas médicas, hospitales y centros de diálisis", to medical appointments, hospitals and dialysis centers. It costs $50.

Requirements are substantive:

A DTOP chofer-class licence, category 4 or above. Minimum age 18.
A negative criminal record certificate issued within the last 30 days.
A negative sex offender registry certification under Ley 266-2004.
DTOP driving history.
Current first aid and CPR certification on the national DOT First Responder curriculum.
Passing NTSP's Transporte de Emergencias course and exam.

Disqualifiers include any felony, any motor-vehicle-related misdemeanour, more than three misdemeanours, or appearing on the federal sex offender registry.

4 | The stretcher rule that will decide your business model

This is the most consequential operational fact on the page. Under Reglamento 9358, a stretcher vehicle must be operated by two people, one of whom must be an EMT or a paramedic, even though a PCTPC stretcher service is explicitly not an ambulance service and may not be used as one.

There is no mainland analogue to that. In most states a stretcher van runs with a driver and an attendant who does not hold a clinical licence. In Puerto Rico the crew cost on stretcher work is structurally higher. Model ambulatory and wheelchair service separately from stretcher service, because they are different businesses with different unit economics.

5 | Wheelchair and accessibility standards

The regulation incorporates 49 CFR Part 37 by reference. For any vehicle retrofitted with a stretcher or a hydraulic wheelchair lift, you need either an installer certification against ADAAG for Transportation Vehicles and FMVSS, or certification by a licensed Professional Engineer, plus a physical label on the vehicle showing the engineer's ID number. Budget for that at conversion time, not after.

6 | Insurance, and this one is genuinely low

PCTPC minimums are $50,000 per person, $100,000 per accident, $25,000 property damage. Policies must carry an endorsement in favour of NTSP and the Government of Puerto Rico, filed at the start and at each renewal.

For context, we just published a Washington DC guide where the floor is $1.5 million combined single limit. Puerto Rico's statutory minimum is a fraction of that. Two things follow. Your insurance line is cheaper than almost anywhere in this series. And a statutory minimum is a floor, not a recommendation. If you are carrying medically fragile passengers, the number that protects your business is probably well above $50,000, and your commercial customers may require more regardless of what the regulation says.

7 | No certificate of need, which is rarer than it sounds

Ley 109-1962 makes NTSP authorisation "uno de licenciamiento, no adjudicativo", a licensing process rather than an adjudicative one, and it expressly does not admit intervention by third parties. In plain terms: no public necessity hearing, and incumbents cannot protest your application. Several US states let existing operators fight new entrants. Puerto Rico does not.

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Part 4: Registering the Business

Sequence matters here, because one registration is a prerequisite for another.

1 | Hacienda first

Register as a merchant with the Departamento de Hacienda through the SURI system. This is required at least 30 days before you begin operations under Section 4060.01 of Ley 1-2011, and the certificate must be publicly displayed.

Do this first, because a current Registro de Comerciante certificate is a mandatory attachment to the NTSP franchise application. Get the order wrong and you will wait.

2 | Departamento de Estado

Register the entity with the Departamento de Estado. A for-profit corporation costs $150. LLCs file no annual report but pay $150 per year by April 15.

3 | Municipal patente

Under the Código Municipal, Ley 107-2020, municipalities levy a volume-of-business tax capped at 0.50% of gross receipts for services. Two things worth knowing: the statute sets a maximum, so actual rates vary by municipio and you should confirm locally, and new businesses get a payment-exempt provisional patente for their first semester, provided you notify the municipal Director de Finanzas within 30 days.

4 | Then NTSP

With Hacienda in hand, apply for the PCTPC franchise and the operator authorisations. There is no incumbent-protest step to plan around.

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Part 5: The Demand Picture

This is the strongest demand data in the entire series, and it is worth sitting with.

An old population, getting older fast

26.0% of Puerto Ricans are 65 or older, 828,673 people, against 18.9% for the United States. Median age is 45.4 versus 39.2.
The 85-plus group grew from 86,576 to 116,102 in five years.
Six municipios are above 30% aged 65 and over, led by Hormigueros at 33.5%.
Population is 3,184,835 as of July 2025, down 16.8% from the 2004 peak. Deaths now run about 1.8 times births, so this is natural decrease, not just out-migration.

Dialysis, which is the single biggest NEMT demand driver anywhere

6,263 dialysis patients as of the end of 2024, across 50 certified facilities.
Prevalence runs 1.29 times the national rate.
Only 10.5% are on home dialysis, against 16.3% nationally. So roughly 5,600 people physically travel to a clinic three times a week.
Diabetes prevalence is 17.8% of adults, third highest of 55 states and territories, against a 12.3% median. That is the pipeline.
The dialysis population is flat while total population falls, so the per-capita burden is rising.

For scale, 5,600 in-center patients at three sessions a week is on the order of 1.75 million one-way trips a year. That is our arithmetic, not a published figure, but the inputs are real.

And almost no transport to serve it

The público system collapsed. Puerto Rico's shared-ride network carried 39.5 million trips in 2010 and 2.4 million in 2023, a fall of about 94%. For rural Puerto Rico this was the closest thing to demand-responsive transport, and nothing replaced it.
ADA paratransit is tiny. AMA's Llame y Viaje serves the San Juan metro with 43 active vehicles and about 200 trips a day, on a 21-business-day eligibility process.
12.3% of households have no vehicle, against 8.5% nationally.
14.1% of bridges are in poor condition against 6.7% nationally, and the figure got worse between 2024 and 2025.

Put plainly: a large, old, poor, high-acuity population with unusually low car ownership and a collapsed shared-ride network. The demand is not in question. The payer is.

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Part 6: Building the Fleet and the Team

Split your model before you buy anything

The two-person, EMT-crewed stretcher rule means stretcher work carries a fundamentally different cost base than ambulatory or wheelchair work. Decide which business you are in. Plenty of viable Puerto Rico operations will never own a stretcher vehicle, and that is a legitimate strategy rather than a limitation.

Build around recurring trips

A dialysis patient is roughly 156 round trips a year at a predictable time on a predictable day. In a market with no broker feeding you volume, recurring standing orders are how you get to a stable schedule. Wheelchair-accessible capacity matters disproportionately here given the age profile and the diabetes-related mobility burden.

Plan for the roads and the weather

Poor bridge condition and mountainous interior routes mean maintenance is not a nice-to-have. Build a real inspection cadence, and plan for hurricane season as an operational reality with backup power, fuel and communications, not as a footnote.

Hiring

Your drivers need the Autorización de Operador para Cuidado Médico, which means first aid, CPR and an NTSP course before they can carry a passenger. That is a longer onboarding runway than most states. Recruit earlier than feels necessary, and expect to pay for certification if you want to fill seats. Bilingual capability is table stakes given mainland-facing insurers, health systems and family members.

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Part 7: Technology

With no broker feeding you trips, everything the broker would normally do falls to you. Scheduling, standing orders, eligibility checks, proof of pickup, invoicing multiple different payer types. That is more administrative surface, not less.

The recurring nature of dialysis work rewards software that handles standing orders properly, and the mixed-payer reality rewards clean documentation, because you may be invoicing a municipio, a dialysis clinic and a family in the same week under three different arrangements.

Get started with Bambi

Our aiNEMT software handles scheduling, dispatching, care coordination and real-time tracking. Get in touch for a demo and we will walk through what a Puerto Rico operation actually needs.

One last honest note

We would rather this page told you the truth than told you what you hoped to hear. There is no Medicaid NEMT contract to win in Puerto Rico. There is an aging, high-acuity population with collapsed transport options, a licence category built for this exact work, low insurance minimums and no incumbent protection. Whether that adds up to a business depends on finding the payer, and the most likely place to look is your municipio. Start there.

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