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Bulletin 487
Network Adequacy Guidance for Plan Year 2026
The Legislature has approved amendments to Bureau of Insurance Rule Chapter 850 that require the Bureau to establish new network adequacy standards effective for plan years beginning on or after January 1, 2026, and to publish those standards and an exception process in an annual Bureau of Insurance bulletin.1 The standards must equal or exceed the minimum requirements set by the Centers for Medicare and Medicaid Services (CMS) for qualified health plans offered on the Marketplace.2
For plan years beginning on or after January 1, 2026, the Superintendent hereby adopts the standards that CMS has adopted for Medicare Advantage plans in the State of Maine, as shown in the spreadsheet that is attached as Appendix 1, which sets forth maximum distance and driving time for primary care and for designated specialty and facility types, based on the enrollee’s county of residence. Insurers must contract with a sufficient number of providers and facilities to ensure that at least 90 percent of enrollees in each county can access care within the specified travel time and distance standards. Distance and estimated driving time must be measured according to a methodology CMS refers to as “geographic distance,”3 which uses an algorithm designed to identify the most likely driving route, considering various topographic factors that consumers experience when traveling to access care.
Insurers must also continue to meet Rule 850’s requirement to maintain a ratio of at least one full-time-equivalent primary care provider for every 2,000 enrollees.4 For purposes of this calculation, primary care providers include general and internal medicine, family practice, and pediatric providers.5
These standards are based on a nationwide set of baseline standards which classifies counties into five designations: Large Metro (not applicable in Maine), Metro, Micro, Rural, and Counties with Extreme Access Considerations (CEAC). CMS standards have been modified in Maine for certain provider/county combinations where CMS has determined that its baseline standards are not achievable due to provider shortages, topographical challenges, or other limitations outside a plan’s control. Cells where these modifications have been made are highlighted.
How to Submit Network Adequacy Plans and Exception Requests
The Bureau has contracted with Quest Analytics, LLC to perform network adequacy analyses of carrier plans. For plan year 2026, Quest will provide carriers with a template to complete and return within a specified time frame. In future years, the Bureau anticipates that carriers will be able to use the Systems for Electronic Rates and Form Filings (SERFF) to submit data on their networks. If different plans offered by a carrier use the same network of providers, carriers should not submit more than one network file.
The Network Adequacy Exception Request Form is attached to this bulletin as Appendix 2. Carriers will be required to submit this form to the Bureau in the event that they are notified that a particular provider category or county does not meet network adequacy standards.
To view Appendix 1 and Appendix 2, please open the PDF version of this bulletin at https://www.maine.gov/pfr/insurance/sites/maine.gov.pfr.insurance/files/inline-files/487.pdf .
October 23, 2025
Robert L. Carey
Superintendent of Insurance
NOTE: This Bulletin is intended solely for informational purposes. It is not intended to set forth legal rights, duties, or privileges, nor is it intended to provide legal advice. Readers should consult applicable statutes and rules and contact the Bureau of Insurance if additional information is needed.
1 02-031 C.M.R. Ch. 850, § 7(B)(2), effective August 8, 2025, as amended pursuant to P.L. 2025, Ch. 31.
2 Id.
3 CMS 2026 Final Letter to Issuers in the Federally-facilitated Exchanges, Page 14.
4 02-031 C.M.R. Ch. 850, § 7(B)(1).
5 Id.
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