# What Is Network Adequacy in Medicaid? Why Plans and Brokers Must Keep Enough Ride Companies

Canonical URL: https://nemtguide.com/glossary/network-adequacy/ · Updated 2026-10-04

Network adequacy is the Medicaid managed care requirement that a health plan keep enough contracted providers, of the right kinds and close enough to members, to deliver every covered service on time. Federal rules in 42 CFR 438.68, 438.206, and 438.207 set the floor, and states write ride standards into plan and broker contracts. A gap in a network is a ride company's opening.

- Every Medicaid health plan must keep a network big enough to deliver all covered services, including rides when it covers them, and pay for care out of network when it cannot.
- Federal rules set no ratio for ride companies. Each state writes its own, such as Wisconsin's one transportation provider per 150 Family Care members.
- A broker the state pays per member to run only rides answers to its state contract. The federal standards in 438.68 and 438.207 do not apply to it.
- States must post their network standards online, and from rating periods starting on or after July 9, 2025, their yearly network reports too.
- A plan may turn you away when its network is big enough, but it must tell you why in writing.

When a broker tells you its network is full, it is making a network adequacy call. When it is short of wheelchair vans in your county, it may be falling below a network adequacy standard. The rules below tell you which one you are looking at.

## What network adequacy means in Medicaid

Three federal rules work together for Medicaid health plans:

- **The state sets the standards.** [42 CFR 438.68](https://www.ecfr.gov/current/title-42/section-438.68) makes each state that contracts with health plans develop and enforce network adequacy standards. It names the provider types that need a numeric standard, such as primary care, hospitals, and pharmacies, plus long-term care providers when plans cover long-term care. Ride companies are not on that list. When a state sets its standards, it must weigh distance, travel time, and the means of transportation members usually use, and it must publish the standards on its Medicaid website.
- **The plan keeps the network.** Under [42 CFR 438.206(b)](https://www.ecfr.gov/current/title-42/section-438.206), each plan maintains and monitors a network of providers, under written agreements, big enough to give all members adequate access to every covered service. That includes members with disabilities or limited English. When the network cannot provide a covered service to a member, the plan must cover it out of network, adequately and on time, for as long as the gap lasts.
- **The plan proves it.** Under [42 CFR 438.207](https://www.ecfr.gov/current/title-42/section-438.207), each plan shows the state that its network is sufficient in number, mix, and geographic spread. It does so when it signs the contract, every year, and after any significant change, such as a new service area, a new group of members, or a change in who is in its network or what it pays them. The state then certifies the plan to CMS.

Two newer pieces of 438.207 matter to providers. For rating periods starting on or after July 9, 2025, the state must post its network adequacy report on each plan on its website within 30 days of sending it to CMS. For rating periods starting on or after July 9, 2028, a state that finds an access problem must send CMS a remedy plan within 90 days and fix the problem within 12 months. The rule lists raising provider pay and cutting credentialing barriers among the ways to fix it.

## Which rules reach your broker

How your state hired the company that runs rides decides which of these rules apply. [Prepaid ambulatory health plan](https://nemtguide.com/glossary/prepaid-ambulatory-health-plan/) explains the models in full.

- **A health plan that covers rides.** All three rules apply, along with any ride standards the state adds. North Carolina's managed care plans provide NEMT for their members this way, and when a plan hands its ride network to a broker, the state's policy makes the broker carry the plan's duties.
- **A broker the state pays per member to run only rides,** called a NEMT PAHP. Under [42 CFR 438.9](https://www.ecfr.gov/current/title-42/section-438.9), it must keep a network sufficient for adequate access under 438.206(b)(1) and give written reasons when it turns providers away. The state standards in 438.68, the yearly proof in 438.207, and the out-of-network duty do not apply. The state contract sets the real bar.
- **A broker under the state plan's brokerage option, paid at state plan rates.** The managed care rules do not apply. Under [42 CFR 440.170(a)(4)](https://www.ecfr.gov/current/title-42/section-440.170), the broker must monitor member access and complaints, and the state must audit it regularly for timely rides and adequate access to care. See [federal rules for NEMT brokers](https://nemtguide.com/guides/federal-rules-for-nemt-brokers/).

## How states write ride standards

Each state puts its own ride standards into its contracts and policies. Four show the range:

- **Wisconsin Family Care.** Standard P-02542 (April 2024) asks each MCO for one transportation provider per 150 members for Medicaid medical rides, excluding ambulance, and the same ratio for the waiver's specialized transportation. DHS reviews each MCO's network when the contract starts, every year, and after a 25 percent swing in members or a 5 percent drop in providers. If the network falls short, the MCO must contract with more providers or cover the rides out of network. See [Wisconsin Family Care transportation](https://nemtguide.com/guides/wisconsin-family-care-transportation/).
- **North Carolina.** The state's managed care NEMT policy (amended January 1, 2025) says each plan's ride network must get members to appointments on time but no more than one hour early, with no more than a one-hour wait after treatment. For shared, long-distance, or coordinated trips, both limits are two hours. Urgent trips, such as hospital discharges, need no advance notice. Plans may not deny a trip because they lack resources, and neither plans nor their brokers may put exclusivity or non-compete terms in a ride company's contract.
- **Georgia.** DCH pays its broker a monthly rate for each eligible member, and Verida has been the broker in all five regions since April 1, 2026. DCH's NEMT manual (October 1, 2026 version) requires a network with enough vehicles, drivers, and attendants, of the right types, that the failure of any one provider will not keep the broker from providing rides. The broker sends DCH each signed provider agreement within five business days and a monthly report of late trips.
- **New Jersey long-term care.** The NJ FamilyCare contract (January 2026) requires each plan to contract with at least two providers of each MLTSS home and community-based service in every county, including non-medical rides. See [MLTSS](https://nemtguide.com/glossary/mltss/).

## Network adequacy in practice

A North Carolina health plan member needs a wheelchair van to a 9 a.m. appointment, and none of the plan's in-network ride companies can take the trip. The plan cannot deny the ride for lack of resources. Under 438.206(b)(4), it must cover the trip out of network for as long as its network cannot. That is how a company outside the network ends up with a one-time trip, sometimes under a [single case agreement](https://nemtguide.com/glossary/single-case-agreement/). A run of those trips in one county is a gap you can name.

Use the rules to find and prove a gap:

1. **Read your state's posted standards and network reports** on the Medicaid agency's managed care pages. Look for ride, wheelchair, or stretcher standards and any county the state flagged.
2. **Ask the broker or plan which counties, service levels, and hours are short,** and offer the one you can cover. "A stretcher van for the north end of the county on weekends" names a gap; "we have vans" does not.
3. **Keep a record of missed and late rides** that clinics and dialysis centers tell you about, with dates.
4. **Get any refusal in writing.** Under [42 CFR 438.12](https://www.ecfr.gov/current/title-42/section-438.12), a plan must give you its reason when it declines you.
5. **Take a real access problem to the state Medicaid agency.** CMS says the state agency stays responsible for members' rides under fee-for-service or managed care, even when it hands the work to vendors or health plans.

When the answer is still no, [what to do when a broker network is full](https://nemtguide.com/guides/broker-network-full/) covers the other ways in, and [NEMT broker RFPs](https://nemtguide.com/guides/nemt-broker-rfp/) shows when the next contract, and its network terms, will be written.

## Frequently asked questions

### Do network adequacy rules apply to NEMT brokers?

It depends on how the state hired the broker. For a health plan that covers rides, all of 42 CFR 438.68, 438.206, and 438.207 apply. A broker paid per member to provide only rides, a NEMT PAHP, must keep a sufficient network under 438.206(b)(1), but 438.9 leaves out the state standards and yearly proof in 438.68 and 438.207. A broker the state runs under its state plan brokerage option, paid at state plan rates, is audited by the state for access instead.

### Can a broker or plan refuse me if its network is already big enough?

Yes. Under 42 CFR 438.12, a plan does not have to contract with more providers than its members need. It may not turn you away only because of the license you hold, and it must give you written notice of the reason when it declines you. The rule also covers a broker paid per member to run only rides.

### Where do I find my state's network adequacy standards?

On your state Medicaid agency's managed care website. 42 CFR 438.68(g) requires states to publish their standards there. For rating periods starting on or after July 9, 2025, 438.207(d) also requires the state to post its network adequacy report for each plan within 30 days of sending it to CMS.

### What happens when a plan's ride network is too small?

The plan must cover the ride out of network, adequately and on time, for as long as its network cannot (42 CFR 438.206(b)(4)). The state can require more contracts: Wisconsin makes a Family Care MCO add providers or pay out-of-network ones. From rating periods starting on or after July 9, 2028, a state that finds an access problem must send CMS a remedy plan within 90 days.

## Official resources

- [eCFR: 42 CFR 438.68, Network adequacy standards](https://www.ecfr.gov/current/title-42/section-438.68)
- [eCFR: 42 CFR 438.206, Availability of services](https://www.ecfr.gov/current/title-42/section-438.206)
- [NC Medicaid: NEMT managed care policy](https://medicaid.ncdhhs.gov/NEMT-policy)
- [Wisconsin DHS: MCO Provider Network Adequacy, P-02542](https://www.dhs.wisconsin.gov/publications/p02542.pdf)