On August 31, 2008, during Hurricane Gustav, 225 patients from Louisiana hospitals were evacuated to 12 hospitals in the central region of Arkansas. The evacuation was a success for the National Disaster Medical System (NDMS) but left Arkansas NDMS hospitals on their own to repatriate patients and negotiate payments for care. This article examines repatriation and reimbursement issues of Arkansas hospitals that provided care for these NDMS patients. Consensus statements were obtained from key organization stakeholders focused on repatriation of NDMS patients and reimbursement to Arkansas NDMS hospitals. The stakeholders concurred with recommendations addressing changes in both federal and state agreements related to repatriation of NDMS patients and reimbursement for care. Surveys from 10 of 12 participating hospitals showed Medicare was the primary payer for 57% of NDMS patients, higher than the usual community average of 43%. Length of stay was 3 days longer for NDMS patients than for the patients usually served by the hospital. Thirty percent of hospitals reported that they would be unlikely to take NDMS patients in the future. Private sector hospitals were adversely affected by system difficulties in repatriation and reimbursement. The federal government should consider a new paradigm for reimbursement of hospitals and develop a single payer for all NDMS patients.