Staying on top of all the latest updates in the industry can be a real challenge. That’s why we’re here to break down everything you need to know about the Qualified Health Plan (QHP) certification and network adequacy compliance. Grab your favorite beverage and get ready to dive into the world of QHP certification and network adequacy.
QHP Application and Network Adequacy Requirements
Every year the Department of Health and Human Services (HHS) issues the Notice of Benefit and Payment Parameters (NBPP) rule, outlining the parameters for the health insurance marketplace. One of the crucial aspects covered in the rule is network adequacy standards, which health plans and stand-alone dental plans (SADPs) must meet to offer qualified plans through the Federally-facilitated Exchanges (FFEs) and State-based Exchanges on the Federal platform (SBE-FPs).
QHP Application and Network Adequacy Reviews
CMS reviews, and approves or denies, QHP applications from issuers that are applying to offer QHPs on the FFEs, except for FFEs in certain states.
CMS will not evaluate QHP network adequacy in FFE States performing plan management functions that elect to perform their reviews of Issuers seeking QHP certification in their state, as long as the state applies and enforces quantitative network adequacy standards that are as stringent as the Federal network adequacy standards and the network adequacy reviews are conducted before QHP certification. CMS will continue to coordinate with state authorities to address network adequacy compliance.
PY2026 Network Adequacy for Marketplace Qualified Health Plans
New Geographic Distance Methodology
As stated in the PY2026 Letter to Issuers, CMS will measure network adequacy time and distance standards using Geographic Distance Calculations instead of estimated driving times.
Understanding Geographic Distance Calculation
Under the previous methodology, CMS evaluated network adequacy standards based on estimated driving times, which doesn’t account for complex topographic realities. The newly introduced Geographic Distance Calculation moves beyond this limitation by integrating topographic factors such as:
- Infrastructure: Roads, bridges, highways, and other transportation systems.
- Geographic Barriers: Rivers, swamps, large bodies of water, and other physical impediments.
- Terrain Complexity: Mountainous areas and regions with challenging landscapes.
Using an advanced algorithm, this method determines the optimal route based on available infrastructure, representing the most likely path a consumer would take to reach an in-network provider. This approach aligns accessibility metrics with real-world geographical conditions, improving accuracy and fairness when measuring compliance.
New Way to Measure QHP Network Adequacy
Kate Deiters and Zach Snyder discuss the new Geographic Distance Methodology, which shifts away from relying solely on estimated driving time. Instead, this approach accounts for real-world factors such as the terrain, bodies of water, and infrastructure to give a better understanding of the landscape.
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Alternative Time & Distance Standards
CMS has introduced Alternative Time & Distance (T&D) Standards to address network adequacy challenges in areas where baseline standards cannot be met. These standards are intended for specific provider specialty and county combinations where factors like provider shortages, topographic challenges, or other limitations outside of a QHP issuer’s control make compliance with the baseline requirements unrealistic.
By applying Alternative T&D Standards, issuers can receive credit for in-network providers that fall outside traditional time and distance standards.
Updates to the Network Adequacy Justification Form
In light of the Alternative T&D Standards, CMS has updated the Network Adequacy Justification Form. Issuers are no longer able to select certain dropdown options to justify network deficiencies, including:
- No providers of this specialty type are currently practicing within time and distance.
- An insufficient number of providers/facilities within time and distance.
Instead of relying on these explanations, the Alternative T&D Standards offer a solution by expanding time and distance standards for areas with provider shortages. This change nullifies the above responses as acceptable reasons for unmet network adequacy conditions and aims to better align issuers with the new, more adaptable standards.
Addition of Three New Specialty Types
As part of the PY2026 updates, CMS has expanded provider eligibility to include the following specialties on the Network Adequacy Template:
- A006 Primary Care-Advanced Practice Registered Nurse (Adult)
- P006 Primary Care-Advanced Practice Registered Nurse (Pediatric)
- P201 Dental-General (Pediatric)
New & Updated Network Adequacy Provider Validations
CMS has introduced new and updated network adequacy provider validations. Validating provider data remains a critical aspect of the QHP Application process. When issuers submit their Network Adequacy Template, it undergoes initial provider validation checks. If errors are detected during this process, issuers must correct them before resubmitting their template.
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Network Adequacy Telehealth Requirements
Issuers must report if a provider offers telehealth services within the Telehealth Services column of the Network Adequacy Provider tab. For each provider, Issuers will indicate whether that provider offers telehealth by selecting one of the following responses:
- Yes
- No
- Requested information from the provider and awaiting their response
Issuers who do not already have data on whether their providers offer telehealth will need to collect this information prior to QHP certification. QHP Issuers that do not currently collect this information may do so using the same methods they already use to collect information from their network providers relevant to time and distance standards and provider directory information. Issuers that do not have the information available at the time of the QHP certification process will be able to respond that they have requested the information from the provider and are awaiting the provider’s response.
QHP Certification and Network Adequacy Review Timeline
QHP Data Submission and Certification Timeline for PY2026
QHP Application Window Opens
April 16, 2025 – June 6, 2025
CMS reviews QHP Application data as they are submitted and releases results for issuers and states to review.
Initial Application Submission Deadline
June 11, 2025
The initial deadline for Issuers to submit QHP Applications to CMS, including Machine-Readable Index URLs and Plan ID Crosswalk data.
Secondary Application Submission Deadline
July 16, 2025
Deadline for Issuers to submit their QHP Application Rates Table Templates to CMS.
Optional deadline for Issuers to submit corrected QHP Application data to CMS.
Final Application Deadline
August 13, 2025
Deadline for Issuers to submit changes to their QHP Applications and to submit marketing URL data.
More QHP Certification and Network Adequacy Resources
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