Maysville non-emergency medical transportation operator holding both Kentucky and Ohio Medicaid broker contracts, serving Meadowview's Brown County and Adams County cross-river catchment.

Meadowview discharge volume sets the return-to-home pool. The hospital runs about 100 acute-care beds with emergency, ICU, cardiac, orthopedic, OB, and outpatient diagnostics. We estimate 700 to 900 FTE, based on bed count and regional LifePoint comparables; LifePoint has not published a Maysville figure. The annual flow lands at about 3,500 to 5,500 inpatient discharges, 15,000 to 22,000 emergency-and-observation dispositions, and 28,000 to 42,000 outpatient-clinic visits. Medicaid and dual-eligible share at a Northeastern Kentucky single-acute investor-owned hospital plausibly runs 24 to 34 percent. Net Medicaid-billable return-to-home discharges plus recurring outpatient-appointment trips originating Meadowview-side plausibly aggregate 7,500 to 14,000 trips a year.

Brown County, Ohio sets the cross-river slice. Of Meadowview's roughly 85,000-to-100,000-person catchment, the Brown County share — Aberdeen, Ripley, Russellville, and Higginsport, all within 10 to 20 miles of the bridges — plausibly runs 15 to 25 percent of inpatient discharges and emergency dispositions, because those residents are closer to Meadowview than to Adams County Regional, Mercy Anderson, or Cincinnati hospitals. The Brown County Ohio-Medicaid-billable trip pool plausibly runs 1,200 to 3,200 trips a year. Adams County, Lewis County, and Bracken County add adjacent trip pools.

Recurring dialysis is the largest single recurring trip type. Dialysis-center placement in Maysville and Aberdeen is not yet confirmed against Fresenius, DaVita, and U.S. Renal Care location records. Each enrolled patient generates six one-way trips a week. A working range of 70 to 130 Medicaid-or-Medicare-Advantage-covered dialysis patients across both states generates 22,000 to 40,000 one-way trips a year. Behavioral-health recurring at Comprehend Inc. adds 1,800 to 4,500 bilateral trips a year. Senior-residential standing orders, Kentucky 1915(c), and Ohio HCBS waivers add 3,500 to 8,500 combined. Medicare Advantage supplemental benefits add 2,800 to 6,500. VA Community Care Network adds 400 to 1,100. The composite bilateral addressable pool runs 38,000 to 78,000 trips a year. Realistic captured share at maturity with a four-to-six-van fleet is 8,500 to 18,000 trips a year.

Bilateral broker contracting is the operational moat. A Maysville-based operator becomes bilaterally operational only by securing parallel subcontracted-provider service agreements on both sides of the river. Interior-Kentucky-only operators do not carry Ohio-side broker credentialing; interior-Ohio-only operators do not carry Kentucky-side credentialing. The compliance posture compounds against any single-state operator entering cold. It includes KY Public Service Commission for-hire passenger certification under KRS 281; Ohio PUCO Transportation Department for-hire certification; FMCSA USDOT and MC authority; commercial-auto, general-liability, workers'-comp, and umbrella coverage at the NEMT specialty band on bilateral underwriting; broker-required surety bonding in both states; and dispatch-and-billing platform integration with both states' broker portals.

The lane is operations, not clinical staffing. Brown County, Ohio is structurally without acute care, so the work is vehicles, drivers, dispatch, and dual-state broker contracts on a zero-acute-Ohio demand surface. Kentucky and Ohio share a long-standing individual-income-tax reciprocal agreement, so there is no income-tax arbitrage embedded in the bilateral lane. The structure differs materially from intra-state-only operators whose work runs to a single hospital network inside one state.

Per-trip pricing for rural Kentucky and Ohio Medicaid non-emergency medical transportation; rate-card specifics are not yet confirmed against current broker fee schedules. Ambulatory: base $14-24 plus $1.90-3.50 per loaded mile; a 15-mile Maysville-Aberdeen ambulatory round-trip lands at $58-115. Wheelchair: base $28-48 plus $2.40-4.20 per loaded mile; a 15-mile wheelchair round-trip lands at $95-175. Stretcher: base $80-160 plus $4.60-7.80 per loaded mile. Long-haul specialty over 75 miles (Cincinnati VAMC, Lexington UK HealthCare, Huntington VAMC): ambulatory round-trip $700-1,250; wheelchair $1,000-1,900. Recurring dialysis runs $30-62 ambulatory or $44-88 wheelchair per trip. Trip mix at maturity is roughly 52 percent ambulatory, 30 percent wheelchair, 5 percent stretcher, and 13 percent long-haul. Blended per-trip net revenue at the working midpoint is $58-74.

Year 1 (founder plus 2-3 vans and 4-6 drivers; building Kentucky and Ohio service agreements; one Maysville base): 2,500-4,000 trips at blended $52-66 yields $130K-$264K revenue. Founder take-home $50,000-$100,000 with heavy reinvestment.

Year 2 (3-5 vans and 6-9 drivers; bilateral service agreements active; recurring dialysis and standing-order accounts online): 5,000-8,500 trips at blended $56-70 yields $280K-$595K. Founder take-home $90,000-$140,000.

Year 3 (4-6 vans and 9-13 drivers; stabilized bilateral cadence): 7,500-12,000 trips at blended $60-74 yields $450K-$888K. Sustained founder take-home $130,000-$200,000. Above $200,000 requires expansion into prime master-vendor scope at Meadowview, hospital-system fleet contracting, or multi-county fleet operations, outside this lane.

Cost structure at mature scale. Driver wages 42-55 percent of revenue. Fleet operating 11-16 percent. Insurance 10-16 percent (the NEMT market has hardened since 2021). Dispatch software and billing 1-3 percent. Compliance, bonding, and dual-state renewals 0.5-1.3 percent. Office and general and administrative 4-7 percent.

Founder-side capital $200,000-$700,000. Year 1 fleet (3-5 vans): 2-3 used ambulatory passenger vans at $20,000-$35,000 each, plus 1-2 lift-equipped wheelchair-accessible vans at $48,000-$78,000 used or $60,000-$98,000 new with lift conversion. Total Year 1 fleet capital $110,000-$230,000. Lift conversion and securement retrofit on an owner-acquired chassis: $15,000-$28,000 per unit. USDOT and MC authority registration, Kentucky PSC and Ohio PUCO for-hire applications, and attorney support: $5,000-$14,000. Broker onboarding (Verida, Modivcare, Access2Care, MTM): $4,000-$9,000 per broker for fingerprinting, background checks, vehicle inspections, broker-portal integration, and insurance-certificate filing. Commercial-auto, general-liability, workers'-comp, and umbrella Year 1 premium $38,000-$82,000. Broker surety bonding $400-$1,800. Driver recruiting, training, drug-and-alcohol-testing registration, and DOT physicals for the initial pool $5,000-$12,000. Dispatch and billing platform with broker-portal integration (Tobi Cloud, RouteGenie, NEMT Cloud Dispatch, MediRoutes) $7,000-$18,000. Office and secured fleet parking 1,400-2,600 square feet at $1,300-$2,600 a month, Year 1 lease and fit-out $20,000-$38,000. Working capital and payroll float reserve (Kentucky and Ohio broker payment cycles run 30-60 days) $35,000-$95,000.

No certificate-of-need gate and no acquisition multiple required. The capital range sits inside the owner-operator NEMT-fleet envelope. Family-capital deployment plus SBA 7(a) lending plus equipment-finance overlay on the lift-conversion units is realistic.

• Meadowview Regional Medical Center

  Acute-care hospital under LifePoint Health (Brentwood, Tennessee)

  Active in market

  989 Medical Park Drive, Maysville. About 100 beds. LifePoint, not ScionHealth. The only acute-care hospital within roughly 30 miles, serving Brown County and Adams County, Ohio cross-river catchment. Discharge planning, occupational health, and transport-vendor relationships are not yet public.
• Comprehend Inc.

  Regional community mental health center, Maysville-resident

  Active in market

  611 Forest Avenue, Maysville. Serves the five-county Buffalo Trace catchment plus Brown County, Ohio residents accessing Maysville services.
• Kentucky Department for Medicaid Services

  State Medicaid agency; non-emergency medical transportation policy and Kentucky-side broker oversight

  Out-of-county

  Frankfort. The 2026 Kentucky MCO portfolio and MCO-to-broker assignments are not confirmed as of May 2026.
• Ohio Department of Medicaid

  State Medicaid agency; non-emergency medical transportation policy and Ohio-side MCO oversight

  Out-of-county

  Columbus. The 2026 Ohio MCO portfolio and broker assignments are not confirmed as of May 2026.
• Verida and Modivcare (Kentucky-side brokers)

  Statewide Kentucky Medicaid non-emergency medical transportation broker channel; subcontracted-provider service agreements are the entry gate

  Out-of-county

  Kentucky MCO-to-broker assignments and 2026 onboarding windows for new entrants are not yet confirmed.
• Access2Care and MTM (Ohio-side brokers)

  Ohio Medicaid non-emergency medical transportation broker channel; Anthem, Buckeye, and CareSource MCO sub-contractor surface

  Out-of-county

  Each broker's posture on out-of-state-provider enrollment for a Kentucky-based operator is a binary gate: some require an Ohio physical base; others accept Kentucky operators serving Ohio residents under PUCO authority.
• Kentucky Public Service Commission Motor Carriers Division

  Kentucky for-hire passenger motor-carrier authority under KRS 281

  Out-of-county

  The 2026 application, posting, and protest cycle is not yet confirmed.
• Public Utilities Commission of Ohio Transportation Department

  Ohio for-hire passenger motor-carrier authority

  Out-of-county

  The 2026 certification process and any 2025-2026 Ohio legislative amendments affecting cross-state-line NEMT operations are not yet confirmed.
• FMCSA Kentucky Division and FMCSA Ohio Division

  Federal Motor Carrier Safety Administration; USDOT and motor-carrier authority

  Out-of-county

  Frankfort and Columbus divisional offices. USDOT and MC authority issuance and renewal for bilateral operations.
• Kentucky Department for Aging and Independent Living

  1915(c) Home and Community-Based Services waiver; Kentucky senior and disability transport

  Out-of-county

  Waiver participant counts in Mason, Bracken, Lewis, Fleming, and Robertson are not yet confirmed. The Buffalo Trace Aging-Services pass-through is the regional entry point.
• Ohio HCBS waiver administrator

  Ohio Home and Community-Based Services waiver; Brown County and Adams County senior and disability transport

  Out-of-county

  Brown County and Adams County waiver participant counts are not yet confirmed.
• Buffalo Trace Area Development District

  Regional planning and DAIL Aging-Services pass-through; Maysville-resident headquarters

  Institution

  201 Government Street, Maysville. Executive Director Kevin Cornette returned November 1, 2024 after Amy Kennedy retired. Five-county catchment: Bracken, Fleming, Lewis, Mason, and Robertson.
• Senior-residential bench (Kentucky assisted-living facilities and skilled-nursing facilities; Ohio senior-housing operators)

  Standing-order recurring transport; Kentucky OIG and Ohio Department of Health licensure

  Out-of-county

  Maysville-resident ALFs and SNFs plus Brown County, Ohio senior-housing operators run standing-order routes for medical appointments and scheduled outpatient diagnostics.
• Maysville Community and Technical College

  Two-year KCTCS member; commercial-driver and passenger-transport training-pipeline overflow

  Active in market

  Four-campus footprint covering Maysville, Cynthiana, Mount Sterling, and Morehead. Driver-pipeline coordination plus BTADD WIOA referrals.
• VA Community Care Network third-party administrator

  Optum Public Sector Solutions or TriWest in 2026; VA scheduled-appointment transport routing for Mason and Brown County veterans

  Out-of-county

  The 2026 regional administrator is not yet confirmed. Smaller trip count, materially higher per-trip revenue on long-haul routing to Cincinnati VAMC, Huntington VAMC, and Lexington VAMC.
• NEMT-specialty insurance bench (Lancer, Markel, Berkshire Hathaway GUARD, National Casualty, AXA XL)

  Commercial-auto, general-liability, workers'-comp, and umbrella underwriting; bilateral Kentucky-Ohio band

  Out-of-county

  Bilateral underwriting runs higher than single-state premium. Surety markets for Kentucky and Ohio broker-required service-agreement bonding stack in parallel.

The founder is mid-career with one of two profiles. Either prior NEMT or paratransit operations-manager tenure with passenger-transport-fleet supervision, dispatch-and-billing-platform fluency, and willingness to add bilateral Kentucky-Ohio regulatory and broker onboarding in the first 6 to 9 months. Or prior healthcare-facility transport-coordinator tenure — hospital case management, discharge planning, and payer-side NEMT vendor management — with willingness to add commercial fleet operations and driver recruitment through a hired-foreman partnership. Mason, Bracken, Fleming, Lewis, Brown County, or Adams County residence plus recruiting reach into the Maysville commuter pool materially lowers driver-recruitment friction in a tight rural NEMT labor market.

Relationship-portfolio target at launch. Meadowview Regional Medical Center CEO, Director of Case Management, Discharge Planning Coordinator, and Patient Access. Comprehend Inc. Director of Clinical Services and Transportation Coordinator. The Kentucky Department for Medicaid Services and Ohio Department of Medicaid NEMT Program Managers. Verida and Modivcare regional operations and provider relations leads on the Kentucky side. Access2Care and MTM regional operations and provider relations leads on the Ohio side. Kentucky PSC Motor Carriers Division and Ohio PUCO Transportation Department certificate-application coordinators. FMCSA Kentucky and Ohio division contacts. The DAIL Aging-Services regional coordinator and the Ohio HCBS waiver administrator. The Buffalo Trace ADD executive director and Aging-Services coordinator. The Kentucky assisted-living facility and skilled-nursing facility roster plus the Brown County, Ohio senior-housing roster. The MCTC commercial-driver pipeline coordinator. The NEMT-specialty insurance broker bench. Twelve to twenty named contacts by the end of Year 1.

Entity and credentialing posture. Kentucky USDOT and MC authority registration, Kentucky PSC KRS 281 for-hire passenger certificate, Ohio PUCO for-hire passenger certificate, FMCSA Kentucky and Ohio division registrations, commercial-auto and general-liability and workers'-comp and umbrella stack at the NEMT specialty band on bilateral underwriting, surety bonding parallel to both states, a driver pool with DOT physicals and drug-and-alcohol-testing program registration, and dispatch-and-billing platform integration with both states' broker portals. A broker-of-record relationship with a Lancer, Markel, Berkshire Hathaway GUARD, National Casualty, and AXA XL bench structures the bilateral underwriting.

The practice operates as an owner-operator bilateral fleet with paired billing-and-compliance overlay. No rollup arithmetic, no add-on EBITDA multiple. National NEMT operators — Modivcare-owned and MTM-owned fleets and others — compete at the prime broker-aggregator scope and metropolitan dense-urban fleet scope where engagement scopes absorb their cost structure. The rural bilateral Kentucky-Ohio dual-bridge dual-broker sub-flow sits below the national pricing floor and outside the same-day mobilization radius national firms reach from out-of-region depots. A Maysville-based operator of record carrying parallel Kentucky and Ohio service agreements, the Meadowview discharge-planning relationship, the Comprehend behavioral-health recurring routing, and the DAIL and Ohio HCBS standing-order accounts is the shape national platforms cannot replicate without the same time investment in the bilateral relationship portfolio.

• — The 2026 Kentucky DMS MCO portfolio and MCO-to-broker assignment matrix. Highest priority.
• — The 2026 Ohio Department of Medicaid MCO portfolio and MCO-to-broker assignment matrix. Highest priority.
• — Kentucky and Ohio broker onboarding windows for new 3-to-5-van entrants. A closed-network freeze on either side reduces the bilateral lane to single-state until the freeze lifts.
• — Meadowview's NEMT referral volume and LifePoint preferred-provider status — whether Meadowview runs an in-house transport function, holds a sole-source contract, or routes through broker-mediated assignment open to any qualified service-agreement holder. Plus any LifePoint corporate-level preferred-vendor program.
• — Brown County, Ohio resident patient volume to Meadowview (emergency, inpatient, and outpatient counts of Ohio-residence patients). Sizes the Ohio-side billing exposure.
• — Adams County, Lewis County, and Bracken County shares of Meadowview catchment. Sizes adjacent trip pools.
• — The competing NEMT bench at Maysville, Vanceburg, and Augusta — Kentucky PSC and Ohio PUCO for-hire passenger-certificate holders within 25 miles of Maysville, fleet sizes, and service-agreement coverage.
• — Ohio NEMT broker out-of-state-provider enrollment posture for a Kentucky-based operator — some brokers require an Ohio physical base.
• — Ohio PUCO for-hire passenger motor-carrier certification process 2026 — application, posting, and protest cycle, plus any 2025-2026 Ohio legislative amendments affecting cross-state-line NEMT.
• — Kentucky PSC KRS 281 for-hire passenger certification process 2026.
• — VA Community Care Network third-party-administrator contracting 2026 — Optum Public Sector Solutions or TriWest as regional administrator.
• — Medicare Advantage supplemental-transportation benefit plan-design currency 2026 for Western and Northeastern Kentucky plus Brown County and Adams County — Humana, Anthem, Aetna, UnitedHealthcare, and WellCare specifics.
• — DAIL 1915(c) waiver participant counts in Mason, Bracken, Lewis, Fleming, and Robertson; Ohio HCBS waiver participant counts in Brown County and Adams County.
• — NEMT commercial-auto, general-liability, workers'-comp, and umbrella underwriting 2026 for bilateral Kentucky-Ohio small operators — Lancer, Markel, GUARD, AXA XL, and National Casualty current rates and limits.
• — Whether Nurse Licensure Compact reciprocity extends to non-driver-only NEMT models requiring on-board clinical staff, or whether pure driver-only NEMT operations require no NLC layer.
• — Dialysis-center placement in Maysville and Aberdeen against Fresenius, DaVita, and U.S. Renal Care location records.
• — Simon Kenton and Harsha bridge inspection cadence 2026-2028 — extended single-bridge closures route all crossings through the remaining bridge. Coordination with KYTC District 9 in Flemingsburg under Director Steve Gunnell.

Tonight, this week, this month — in that order. Each step produces a yes/no or a number, not a deeper understanding.