Network Adequacy Requirements: What Health Plans Must Know in 2026

Network adequacy requirements ensure health plans maintain sufficient numbers and types of providers to deliver promised benefits with reasonable access and without unreasonable delay. Starting January 1, 2026, sweeping changes will impact how State-Based Marketplaces evaluate and enforce these standards. If you operate in these markets, these changes affect you directly.

The 2025 final rule (CMS-9895-F) established that beginning January 1, 2026, State Marketplaces and State-Based Marketplaces on the Federal platform must implement quantitative time and distance standards comparable to federally-facilitated exchanges. For many of you, this represents the most significant shift in network adequacy oversight in years.

What's Changing in 2026: Key Network Adequacy Updates

State marketplaces now face federal-level standards

If you operate in state-based marketplaces and haven't been held to federal time and distance standards before, you have less than three months to ensure compliance.

Effective January 1, 2026, State Marketplaces and SBM-FPs must implement time and distance standards determined at the county level. State Marketplaces must also conduct independent network adequacy reviews before certifying any plan as a QHP.

Here's why this matters to you: 243 out of 375 plan issuers on federal exchanges didn't comply with 2023 standards. Now state plans face the same scrutiny. If your state marketplace has been lenient or inconsistent with network adequacy enforcement, that grace period ends in January.

Mandatory telehealth provider status tracking

For plan years beginning January 1, 2026, you must collect information on whether your network providers offer telehealth services. This isn't optional anymore. It's a mandatory reporting requirement.

The challenge? Collecting this data from providers can be difficult. Many providers don't proactively report their telehealth capabilities. Others change their telehealth offerings frequently based on demand, reimbursement, or technology adoption. You need processes to capture, validate, and continuously update telehealth status across potentially thousands of providers before your 2026 certification cycles begin.

Independent network adequacy reviews become mandatory

Starting January 1, 2026, State Marketplaces must conduct network adequacy reviews before QHP certification. You can't just attest to compliance anymore. External validation is coming.

This means regulators will scrutinize your provider directory accuracy and actual provider availability. When they conduct independent reviews, they'll verify that the providers you claim in your network are actually there, accepting new patients, and accessible to your members.

Exception request framework expands

HHS may grant exceptions to State Marketplaces from certain requirements if evidence-based data demonstrates alternate standards effectively ensure access comparable to federal standards.

You need documented justification and alternative access strategies. Telehealth options, extended hours, transportation assistance. Not just promises to try harder. The informal exception request process is becoming formalized and evidence-based.

Understanding the Full Network Adequacy Regulatory Landscape

Before we look at what's new, here's where you stand today. This is the foundation these 2026 changes build on.

Federal framework: ACA, CMS, and NAIC standards

The ACA mandates that QHPs in Marketplaces meet criteria including sufficient provider choice, essential community providers, and transparency. NAIC Model #74 introduced detailed network requirements and consumer protections.

The key reality you're dealing with: There is no single national standard. Requirements vary by coverage type and state. This patchwork creates complexity if you operate across multiple markets.

The three pillars of network adequacy measurement

Time and Distance Standards

Federal marketplace plans have met these since 2023. State plans join them in 2026. These standards are calculated county-by-county based on population density. Requirements differ for large metro versus rural counties.

For example, urban counties typically require primary care providers within 10 miles or 15 minutes. Rural counties may allow 60 miles or 75 minutes.

Appointment Wait Times

These began for federally-facilitated exchanges in plan year 2025. Currently, wait time standards cover only three types of routine care:

• Behavioral Health: 10 calendar days
• Primary Care (routine): 15 calendar days
• Specialty Care (non-urgent): Not specialized or urgent care

Provider-to-Enrollee Ratios

Provider ratios are not required for federal marketplace plans. However, 10 states have established minimums ranging from 1:500 to 1:2,500. Medicare Advantage uses minimum number standards. Medicaid varies by state.

If you operate in Michigan, you need 1:500 for primary care. California mandates 1:2,000. Tennessee sets 1:2,500.

Essential community provider requirements

CMS proposed increasing the threshold to 35% of available ECPs for 2023, up from 20%. This ensures your plans provide access for low-income and medically underserved populations. You must demonstrate good faith efforts to contract with these providers.

Why 2026 Standards Are Different: What's Actually Changing

The Data Accuracy Crisis Threatening Your 2026 Compliance

Even with clear standards, your compliance fails when underlying data is inaccurate. Regulators evaluate your plans against quantitative standards using network directory data. The problem? That data often contains errors.

The Government Accountability Office found that CMS does little to verify accuracy of provider information despite known directory inaccuracies. The result? The majority of plans failed to comply with 2023 standards.

The 90-day attestation requirement from the No Surprises Act compounds your challenge. Now, adding telehealth status tracking in 2026 creates another data point you must manage and keep current.

According to Atlas Systems' 2025 Member Experience Monitor research, 58% of provider directory users have encountered incorrect information. Even more concerning: 80% say these errors made them trust their health plan less. Only 15% of members who found directory errors reported it happened just once. The majority (78%) have found errors more than once.

The risk you face: Your plans may appear compliant on paper but fail independent reviews when regulators validate actual provider availability.

Medicare Advantage and Medicaid: What's Changing for You

Many of you manage multiple lines of business. Here's how 2026 affects you across programs:

Medicare Advantage network adequacy in 2026

CMS does not require MAOs to routinely submit updated network information. Instead, the agency relies on complaints and broader oversight. However, expect increased audit activity as CMS addresses GAO criticisms. Telehealth credit programs are continuing. The focus on behavioral health access is intensifying.

Medicaid managed care evolution

Your state-specific standards continue to develop. Expect cultural and linguistic competency requirements in directories. Also, appointment wait time standards for routine primary care and behavioral health.

Top 5 Challenges You May Face Meeting 2026 Requirements

1. Provider shortages in underserved areas

Provider shortages, especially in rural areas, make it difficult for you to maintain comprehensive networks that meet time and distance standards. Mental health providers and certain specialists simply don't exist in sufficient numbers in many counties.

You need alternative access strategies: telehealth, extended hours, travel assistance. But you must document these alternatives thoroughly for exception requests.

2. Delegated provider data chaos

Your IPAs, medical groups, and contracted networks don't update data in a timely manner. There's no standardized format or submission schedule.

As one Network Management Director at a large New York health plan told us, "Our single biggest problem with directory accuracy and provider data management is with our delegated provider contracts."

When providers join or leave delegated entities, change their accepting new patients status, or update their practice locations, you often don't find out until a member complains or an audit reveals the gap.

3. The telehealth tracking dilemma

This is a new 2026 requirement with no established best practice yet. Your providers may not know or accurately report their own telehealth capabilities. The data can change rapidly as providers add or drop telehealth services based on demand and reimbursement.

You need a systematic way to capture this information during initial credentialing, validate it periodically, and update it when changes occur.

4. Continuous monitoring versus point-in-time compliance

Your 90-day attestation cycles mean constant validation work. Annual certification reviews are insufficient. You need real-time monitoring systems that flag changes as they occur.

The old model of annual directory review and update cycles won't work anymore. CMS network adequacy compliance now requires ongoing verification.

5. Documentation for exception requests

Waivers require substantial justification and proof of your good faith contracting efforts. You must demonstrate alternative solutions you've implemented. The Texas Department of Insurance, for example, grants network adequacy waivers only when plans demonstrate thorough recruitment efforts and submit detailed justification for provider shortages.

Audit trail requirements are increasing. You need timestamped documentation of every recruitment contact, contract offer, provider response, and alternative access solution implemented.

How Leading Health Plans Are Preparing for 2026

Here's what the market is doing to get ready.

Automating provider data validation

Plans are moving beyond annual surveys to continuous verification. They're implementing multi-source validation. Primary source verification from provider websites. Public database checks against NPI Registry, state licensing boards, and CMS sources. Cross-directory consistency checks. Automated alerts when data changes or conflicts are detected.

Building telehealth data collection into existing workflows

Forward-thinking plans are adding telehealth questions to credentialing applications. They're launching periodic outreach campaigns to capture telehealth status. Some are partnering with provider data management platforms that include telehealth tracking as a standard data element.

Creating exception request playbooks

Plans preparing for 2026 are documenting provider recruitment efforts systematically. They're maintaining evidence of alternative access strategies. They're pre-building justification templates by county and specialty so exception requests can be submitted quickly when needed.

Implementing geo-analytics for time and distance

Leading organizations are using real-time mapping of provider locations against member distribution. They're identifying gaps before regulators do. They're using predictive analytics to anticipate network adequacy issues based on demographic shifts and provider changes.

Establishing audit-ready documentation systems

Smart plans are creating timestamped provider data updates. Source attribution for every data element. Automated compliance reporting dashboards that show current status at any moment. This preparation makes independent reviews far less stressful.

2026 Preparation Checklist: What You Need to Do Now

Q4 2025 (Now):

☐ Audit your current provider data accuracy rates
☐ Map your network against 2026 CMS network adequacy standards (if you're a state marketplace plan)
☐ Assess your current telehealth tracking capabilities
☐ Identify high-risk counties and specialties for exception requests

Q1 2026:

☐ Implement your telehealth data collection process
☐ Begin more accurate provider data aggregation for time and distance analytics
☐ Train your provider relations teams on new requirements
☐ Establish monitoring dashboards for continuous compliance

Q2-Q3 2026:

☐ Complete provider outreach for telehealth status
☐ Prepare exception request documentation
☐ Conduct internal mock audits before certification reviews
☐ Validate directory accuracy with sample phone surveys

Q4 2026:

☐ Review your first year of compliance under new standards
☐ Identify process improvements for 2027
☐ Assess ROI of any new tools or systems you implemented

Beyond 2026: The Future of Network Adequacy Regulation

Looking ahead, watch for these trends that will shape your operations.

Expansion of specialty types in time and distance standards. More granular appointment wait time requirements. Integration of social determinants of health. Transportation access, language capabilities, cultural competency. AI-powered auditing and validation by regulators. Real-time directory accuracy monitoring requirements. Potential federal preemption of inconsistent state standards.

The bigger shift you're seeing: From compliance-as-checkbox to compliance-as-continuous-improvement. Plans that invest in solid provider data infrastructure now will adapt faster to future regulatory changes.

How Modern Provider Data Management Supports Your 2026 Compliance

Given the complexity and continuous nature of 2026 requirements, many health plans are evaluating whether manual processes can keep pace.

The organizations preparing most effectively share common characteristics. They've implemented multi-layered validation approaches. They use real-time monitoring instead of periodic snapshots. They've built automated exception management workflows. They maintain bi-directional data exchange with providers. They have audit trails and compliance reporting built into their systems. They track telehealth status as a standard data element, not an afterthought.

PRIME® by Atlas Systems was built specifically for this reality. Our platform addresses the data accuracy crisis at the heart of provider network adequacy compliance. Here's how:

Six-layer validation framework

PRIME® verifies provider data through:

• Provider websites (the most current source)
• Public and government sources like NPI Registry and state licensing boards
• Background and sanction checks
• Network consistency analysis across multiple plan directories
• AI-powered outreach calls
• Human call center verification for exceptions

Automated monitoring for continuous compliance

Instead of periodic snapshots, PRIME® monitors your provider data continuously. Track provider license expirations, sanction list additions, and practice closures in real time. Discover issues before regulatory audits do.

Delegated provider data management

PRIME® Provider-Payer Connect solves delegated data exchange. No matter how messy the files, outdated the systems, or chaotic the workflows from your IPAs and medical groups. The platform ingests Excel, PDF, CSV, Word files, even screenshots. It auto-cleans and standardizes the data. Then it pushes updates in real time to your credentialing, directories, claims, and Salesforce systems.

Audit-ready documentation

Every data change is logged with timestamps, source attribution, and validation method. When independent reviews begin in 2026, you'll have complete audit trails showing exactly how you verified each provider's information and when.

Schedule a 20-minute demo to see how PRIME® addresses your specific 2026 network adequacy challenges.

Frequently Asked Questions

What are the new network adequacy requirements for 2026?

Starting January 1, 2026, State-Based Marketplaces must implement quantitative time and distance standards, conduct independent network adequacy reviews before QHP certification, and collect telehealth provider status information. These requirements bring state marketplaces in line with federal exchange standards that have applied to federally-facilitated exchanges since 2023.

Do 2026 network adequacy changes affect Medicare Advantage plans?

The major 2026 changes primarily impact State-Based Marketplace QHPs. However, if you manage Medicare Advantage plans, expect increased audit activity. CMS is focusing more on behavioral health access, telehealth options, and provider directory accuracy as it addresses ongoing GAO recommendations about network adequacy oversight.

How do I know if my health plan is ready for 2026 network adequacy reviews?

Assess three key areas. First, can you prove time and distance standards compliance at the county level with accurate provider data? Second, have you collected and validated telehealth status for your network providers? Third, do you have documented alternative access strategies for counties where standards can't be met? If you're failing any of these, you face compliance risk.

What happens if we can't meet 2026 network adequacy standards in certain counties?

State Marketplaces may grant exceptions if evidence-based data demonstrates your alternate quantitative standards effectively ensure provider access comparable to federal standards. Your exception requests require substantial justification, proof of your good faith contracting efforts, and implementation of alternative solutions like telehealth or extended office hours.

How often do we need to validate provider data for network adequacy compliance?

While your certification reviews are annual, the No Surprises Act requires 90-day provider attestation cycles. Best practice for 2026 and beyond is continuous monitoring. Not periodic snapshots. This is especially important as independent reviews increase and regulators validate actual provider availability rather than accepting your self-reported data.