Meeting network adequacy standards begins long before your data submission. As you work toward Qualified Health Plan (QHP) certification for plan year 2027, here’s what you need to know about the network adequacy requirements.
Health Policy Update: Final Notice of Benefit and Payment Parameters for 2027
Zach Snyder, VP of Government Affairs at Quest Analytics, breaks down the HHS Notice of Benefit and Payment Parameters for 2027. He explains the key changes to network adequacy and essential community provider standards, and what the updates mean for health issuers and states.
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 the 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.
PY2027 Network Adequacy for Marketplace Qualified Health Plans
Time and Distance Standards to Use Geographic Distance Methodology
As stated in the 2027 Final Letter to Issuers in the Federally-facilitated Exchanges (2027 Final Letter), 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.
Dive Deeper with Our Full Podcast Episode! Get the full scoop on recent regulation changes and updates on network adequacy and provider directory accuracy. Listen Now
Alternative Time & Distance Standards
CMS will continue with its 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 for PY2027 QHP submissions.
Addition of Three New Specialty Types
In PY2026, CMS expanded provider eligibility to include the following specialties, and that change remains in effect for PY2027. These specialty types continue to appear 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)
PY2027 Network Adequacy Provider Validations
Network adequacy provider validation checks remain a critical aspect of the QHP Application process. When you submit your PY2027 Network Adequacy Template, the data you submitted will undergo several provider validation checks in MPMS. If errors are detected during this process, you must correct them before resubmitting your data.
Get Your QHP Network Adequacy Template Right the First Time
QHP certification hinges on getting your Network Adequacy Template right. Our quick-reference guide walks you through what you need to know for submitting accurate, compliant data the first time—so you can avoid data validation errors and set your application up for success.
QHP Certification and Network Adequacy Review Timeline
QHP Data Submission and Certification Timeline for PY2027
Stay ahead of submission deadlines. View our full QHP certification and review timeline.
Initial Application Submission Deadline
June 10, 2026
The initial deadline for Issuers to submit QHP Applications to CMS, including Plan ID Crosswalk data.
Secondary Application Submission Deadline
July 15, 2026
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 12, 2026
Deadline for Issuers to submit changes to their QHP Applications.
Quest Enterprise Services® (QES®) for QHP Issuers
In a market that’s always evolving, it’s important to have a solution that keeps up. Backed by decades of industry leadership, Quest Enterprise Services® (QES®) offers QHP Issuers a proven approach to adapt and succeed in the Health Insurance Marketplace® and State Exchanges.
Our industry-renowned CCIIO QHP Network Adequacy Template and State-Based Exchange Network Adequacy Templates provide you with the necessary tools and insights needed to evaluate your network in line with regulatory standards and compliance requirements.
The CCIIO QHP Network Adequacy Template includes built-in capabilities such as:
- CCIIO Data Validation Report
- CCIIO Data Validations Summary Report
- CCIIO QHP Submission Report
- Geographic Distance Calculation Methodology
Discover how QES can simplify QHP Certification compliance, drive network improvements, and help your organization succeed. Talk with an expert today!
More QHP Certification and Network Adequacy Resources
Proven Solutions for Your Provider Network Management
Looking to simplify your workload? Let Quest Analytics take on the heavy lifting! Our solutions and dedicated team specialize in provider data accuracy and provider network adequacy for various lines of businesses, including Medicare Advantage, Medicaid and Commercial. Schedule a strategy session today and see how we can help you every step of the way.