Key Points
• July 2028 enforcement creates a compliance obligation that most current Medicaid
programs cannot meet. CMS secret shopper surveys will measure actual
appointment availability, not directory listings. Results will be public.
• Provider recruitment cannot close rural access gaps where providers do not
exist. 31 of 35 physician specialties face shortages; 432 rural hospitals are
vulnerable to closure.
• Mobile health programs solve the provider distribution problem. One provider
serves rotating community sites, closing access gaps across multiple counties.
The Compliance Problem
Beginning July 1, 2028, CMS will enforce Medicaid managed care network adequacy through
independent secret shopper surveys (42 CFR 438.68, as amended by CMS2439-F). The rule
requires states to verify actual appointment availability: 15 business days for primary care;
10 business days for behavioral health. Results will be posted publicly by MCO and geography.
Virginia conducted secret shopper testing for prenatal care in 2023. MCOs reported full
directory compliance. Actual results: 13 of 1,844 calls (0.7%) resulted in appointments
within state standards. 46.3% of listed providers did not offer the services they were
listed for. This gap between reported compliance and actual access exists in managed
care networks nationwide.
The structural problem compounds the directory accuracy issue. The Chartis Center for
Rural Health reports 46% of rural hospitals operate at negative margins. 432 are
vulnerable to closure. 116 labor and delivery units have closed since 2020. In many rural
service areas, the provider workforce required for network adequacy simply does not
exist.
POLICY BRIEF
Alternative Access Standards will not provide relief under the new enforcement
framework. Under the 2024 rule, AAS requests become documented failures. When
MCOs request waivers for rural areas, and states grant them, but that documentation
becomes public evidence that managed care networks cannot meet federal access
standards.
Why Traditional Network Strategies Will Not Solve This
State-managed care contracts have relied on three primary approaches to address
network gaps: provider recruitment, telehealth expansion, and rate increases. Each has
structural limitations that prevent compliance in areas with workforce shortages.
Provider Recruitment
Recruitment assumes providers can be attracted to underserved areas. In markets with
structural workforce shortages, there is no provider pool from which to recruit. HRSA
designates 65 million Americans as living in primary care Health Professional Shortage Areas.
The shortage is not temporary; it reflects permanent features of rural healthcare economics.
Telehealth Expansion
Telehealth extends access for consultations but cannot perform physical examinations,
administer vaccines, draw blood, conduct screenings, or provide urgent care. For
services requiring in-person contact, telehealth documents access failure rather than
solving it.
Rate Increases
Higher rates incentivize existing providers to see more Medicaid patients, but do not
create providers where none practice. Rate increases in a county with two primary care
physicians cannot produce a third physician.
What Mobile Healthcare Infrastructure Solves
Mobile health programs operate on a different logic than facility-based care. Rather than
recruiting providers to underserved areas, a network of mobile clinics extends the
geographic reach of providers who already exist elsewhere.
A physician or advanced practice provider based at a regional FQHC or hospital can
serve rotating community sites across multiple counties via a mobile unit. This produces
appointment availability in locations that cannot independently sustain fixed
infrastructure. The same provider who is unavailable for recruitment becomes available
for extension.
For network adequacy purposes, the relevant question is whether a Medicaid enrollee in
a rural county can obtain an appointment within federal time standards. Mobile clinic
networks produce appointment availability without requiring a permanent provider
presence in every service area.
The Solution: MCO Contract Requirements
The most direct implementation pathway is through managed care contract
amendments. States can require MCOs to include mobile healthcare capacity as part of
network adequacy demonstrations for designated service areas without requiring a
State Plan Amendment. Consider adding the following language:
Network Adequacy: For service areas designated as Health Professional Shortage
Areas or Rural Health Priority Areas, the Contractor may demonstrate compliance with
appointment availability standards through one or more of the following mechanisms: (a)
contracted fixed-site providers meeting time and distance standards; (b) contracted
mobile clinic networks with published schedules providing service within the designated
area at intervals sufficient to meet appointment wait time standards; (c) telehealth
arrangements for services appropriate to virtual delivery.
Mobile Healthcare Provider Standards: Mobile health programs qualifying as a network
adequacy mechanisms must: (i) operate under the license of an enrolled Medicaid
provider; (ii) maintain published service schedules with community site locations and
hours; (iii) provide services consistent with the scope of the sponsoring provider;
(iv) submit encounter data using Place of Service code 15 (mobile unit); (v) meet all
applicable state licensure and vehicle safety requirements.
Documentation Requirements: Contractor shall report the mobile healthcare network
capacity annually, including: service area coverage maps; published schedules by
location; utilization data by site, and appointment availability testing results for mobile
sites using the same methodology applied to fixed sites.
Regulatory Pathway
What Requires CMS Approval
• State Plan Amendment: Required only if creating a distinct mobile provider type
with a different reimbursement methodology or if establishing a mobile-specific rate
enhancements.
• Directed Payment Preprint: Required if mandating MCOs pay enhanced rates to
mobile providers specifically. Must demonstrate value-based connection.
• Managed Care Contract Amendment: Requires CMS review if a material change to
network adequacy standards. Recognizing mobile clinics as a qualifying
mechanism is generally within state discretion under 42 CFR 438.68.
What Does Not Require CMS Approval
• Clarifying that mobile units operating under existing enrolled providers count
toward network adequacy (operational guidance)
• Requiring MCOs to include mobile healthcare in network development plans as a
condition of contract compliance
• Allocating RHTP infrastructure funds for mobile clinic capacity building
Timeline
Q1 - Q2 2026 Issue guidance to MCOs clarifying mobile clinic networks as
a qualifying network adequacy mechanism. Identify priority service
areas based on current access gaps and AAS request history.
Q3 - Q4 2026 Draft MCO contract amendments for 2027 renewal cycle.
Coordinate with RHTP implementation planning for infrastructure
funding.
2027 Execute MCO contract amendments effective with renewal. Mobile
healthcare infrastructure deployment begins. Establish
documentation and reporting requirements.
Q1 - Q2 2028 Verify mobile network capacity in advance of July enforcement.
Conduct internal secret shopper testing. Address gaps before
CMS surveys begin.
July 2028 CMS enforcement begins. States with established mobile
healthcare infrastructure demonstrates compliance.
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