Medicaid certification for network adequacy is entering a new era of regulation. Beginning in 2026, health plans face stricter federal standards, independent validation requirements, and continuous monitoring expectations that change how organizations demonstrate compliance.
This article explains what is changing in 2026, why network adequacy has become more complex, and how your organization can proactively meet network adequacy expectations with confidence.
What Is Changing in Network Adequacy Requirements for Medicaid Managed Care and Marketplace Certification
Recent rulemaking and regulatory guidance related to network adequacy are increasing oversight across both Medicaid managed care and marketplace plans.
CMS continues to refine network adequacy requirements through strengthened oversight, clearer quantitative standards, and expanded validation processes. In recent years, CMS has emphasized improved validation of care provider directories and strengthened external quality review. For 2026, that scrutiny becomes operationalized.
With over 70% of Medicaid and CHIP beneficiaries receiving some or all of their care through a managed care plan, these changes affect Medicaid managed care, Medicare Advantage plans, and marketplace programs alike.
Federal Time and Distance Standards Expand to State Marketplaces
Beginning January 1, 2026, state-based marketplaces must adopt quantitative time and distance standards mirroring those already required for federally-facilitated exchanges. This signals a broader CMS commitment to standardizing network adequacy across all health coverage programs, including Medicaid managed care.
A notable portion of federal exchange plan issuers failed to meet 2023 standards, with inaccurate provider directories identified as a primary cause. For Medicaid managed care plans, this underscores the critical role accurate provider data plays in meeting federal requirements.
Independent Network Adequacy Reviews
State marketplaces will now conduct independent network adequacy reviews before granting QHP certification, a meaningful departure from previous self-attestation approaches requiring external validation that providers are genuinely available to serve members.
Plans must demonstrate that their provider network meets established network adequacy requirements, including:
- Compliance with time and distance standards
- Accuracy of provider directories
- Access to covered services across the full service area
- Provider availability and appointment access
For Medicaid managed care, oversight is intensifying. CMS released updated EQR protocols in 2023 that added a mandatory network adequacy validation component for each managed care plan.
Results from Network Adequacy Validation activities must be included in EQR technical reports due April 30, 2025, meaning plans should anticipate increasingly rigorous examination of their network data submissions.
Telehealth Provider Status Becomes a Requirement
For plan year 2026, plans must report whether network providers offer telehealth services. This adds a new dimension to network adequacy and access reporting.
States vary in how telehealth services count toward network adequacy standards. Some allow telehealth credit toward time and distance standards. Others limit telehealth recognition to certain provider types.
Health plans must now integrate telehealth data into provider data governance processes to support certification and ongoing compliance.
Why Network Adequacy Compliance Is More Challenging in 2026
Network adequacy standards are becoming more data-driven, more transparent, and more enforceable.
Three core challenges are driving increased risk:
1. Inaccurate and Fragmented Provider Data
Network adequacy depends on accurate provider data.
Federal reviews in 2023 have found that more than half of the plans’ network providers in Medicare Advantage were inactive and did not provide a single service to enrollees over the course of a year. Research consistently shows that a majority of individuals who use provider directories encounter incorrect information, contributing to “ghost networks” where listed providers are not actually available.
Common provider data issues include:
- Incorrect specialty classification
- Outdated practice addresses
- Inaccurate provider type mapping
- Failure to reflect accepting new patients status
- Misaligned mental health and substance use disorder designation
When provider directories are inaccurate, network adequacy and access calculations become unreliable. Even minor data discrepancies measured at the centimeter level of geospatial analysis can impact time standard calculations.
Organizations seeking to address fragmented provider data often benefit from robust healthcare provider data management capabilities.
2. Point-in-Time Compliance Is No Longer Enough
The No Surprises Act established a 90-day provider attestation requirement. Combined with secret shopper surveys and EQRO validation, this creates demand for continuous data accuracy rather than periodic directory updates.
Research has shown that even after corrections, provider directories continued to have inaccurate information even after initial identification of errors, highlighting the challenge of maintaining ongoing accuracy. Managed care plans must transition from viewing certification as an annual submission event to maintaining certification readiness as an ongoing operational state.
Core Network Adequacy Standards Health Plans Must Address
While specific numeric thresholds vary by state, the categories of quantitative standards used to evaluate Medicaid managed care networks remain consistent.
A managed care plan must demonstrate a network that is sufficient in number and types of providers across its service area. Regulators expect plans to maintain a network that delivers timely access to covered health care services and supports quality health care for all enrolled members.
Time and Distance Access Requirements
Time and distance standards define the maximum travel time or driving distance members should experience when seeking care. Calculations occur at the county level, with different thresholds based on county classification and provider specialty.
County types typically include:
- Large metro
- Metro
- Micro
- Rural
- Counties with Extreme Access Considerations
In rural areas, standards may allow greater travel distances, but plans must still demonstrate reasonable access and document how members maintain timely access to services across the service area.
These access standards ensure covered services will be accessible to enrollees without unreasonable delay.
Appointment Wait Time Expectations
CMS has proposed appointment wait time standards for routine visits.
For example:
- Routine primary care: appointment wait within 15 business days
- Routine behavioral health: appointment wait within 10 business days
- Specialty care: defined time standard depending on urgency
Wait-time standards for routine visits are validated using secret shopper methodologies. Plans must demonstrate compliance with network adequacy standards through documented results.
Essential Community Provider (ECP) Access
Health plans must demonstrate good faith efforts to contract with essential community providers serving low-income populations and communities with limited access.
Network adequacy evaluations examine providers across multiple categories:
- Primary care for adults and children
- Specialty care services
- OB/GYN providers
- Behavioral health specialists
- Hospital facilities
- Pharmacy services
- Pediatric dental providers
- Long-term services and supports
States must also incorporate cultural and linguistic competency considerations into their standards.
Who and What Must Be Included in Network Adequacy Evaluations
Medicaid certification requires plans to demonstrate a provider network sufficient in both number and types of providers needed to deliver all covered services across the plan’s service area.
Providers Across Specialties and Care Settings
A health plan must demonstrate that its plan’s provider network is sufficient in number and types of providers across care settings and specialties. This includes:
- Primary and specialty care
- Mental health and substance use disorder treatment
- Acute care hospitals
- Skilled nursing facilities
- Diagnostic radiology
- Pharmacy
- Dental services
- Therapy services
At least ten states use provider-to-enrollee ratios to ensure sufficient provider capacity. These ratios vary considerably by state and provider type.
Delegated Entities and Managed Care Network Data Risk
Plans relying on independent practice associations, medical groups, or contracted vendor networks face distinct certification challenges. These delegated entities frequently do not update network data promptly or use consistent data formats.
When delegated provider data contains errors, such as outdated locations, incorrect accepting-new-patients status, or unreported provider departures, the plan’s documentation becomes compromised. The plan remains accountable for accuracy regardless of which entity supplied the information.
Risks of Falling Short of 2026 Network Adequacy Standards
States possess several enforcement mechanisms for network adequacy deficiencies:
- Corrective action plans
- Monetary penalties
- Enrollment freezes
- Contract termination
Independent reviews, secret shopper surveys, and heightened CMS oversight are expected to increase enforcement activity beyond the historical reliance on corrective action plans.
Beyond formal penalties, plans face reputational and operational consequences. Member complaints, lower performance scores, and weakened competitive positioning in state procurement all represent meaningful business risks.
How Health Plans Can Prepare for 2026 Now
To meet network adequacy requirements, health plans must shift from reactive correction to proactive governance.
Strengthen Provider Data Verification Processes
Effective verification requires drawing from multiple authoritative sources:
- Primary source verification from state licensing boards
- NPI Registry checks
- Sanctions and exclusions screening
- Automated alerts when data changes or conflicts arise
Verification must operate continuously. The 90-day attestation cycle and secret shopper surveys demand real-time accuracy, making ongoing monitoring essential for maintaining compliance.
Plans seeking rigorous provider data verification processes benefit from systems designed specifically for this purpose. For health plans building the verified provider data foundation that Medicaid network adequacy certification requires, healthcare payer solutions deliver continuously monitored data across all provider types and U.S. jurisdictions.
Integrate Telehealth Data Into Provider Workflows
Telehealth services must now be incorporated into network adequacy reporting.
Plans should:
- Update credentialing forms
- Track telehealth offerings by provider type
- Monitor changes continuously
Telehealth impacts network adequacy and access calculations and supports compliance with new network adequacy standards.
Use Analytics to Identify Risk Early
Geographic analytics tools can map provider locations against member distribution to identify counties and specialties where the plan’s network faces time and distance or ratio requirements at risk before certification deadlines.
Plans benefit from preparing exception request documentation in advance for known high-risk areas, enabling rapid submission when circumstances require an alternative access approach.
Managing Exceptions When Standards Cannot Be Met
When provider supply constraints prevent strict compliance with network adequacy standards, plans may request exceptions.
To secure approval, plans must demonstrate:
- Good faith contracting efforts
- Evidence of outreach
- Alternative access strategies
- Comparable reasonable access outcomes
Exception documentation must be structured, timestamped, and defensible.
Why Provider Data Accuracy Is the Foundation of Network Adequacy
Every certification element relies on accurate provider information:
- Time and distance calculations
- Provider ratio compliance
- Wait time validation
- Directory accuracy
- Exception documentation
Network adequacy standards for Medicaid and marketplace certification increasingly depend on validated, continuously monitored provider data.
Plans that ensure provider data accuracy will more reliably meet network adequacy and adapt to future regulatory shifts.
Preparing for 2026 and Beyond
When plans cannot meet numeric thresholds due to provider supply limitations, they may request formal exceptions.
To obtain approval, a managed care plan must demonstrate documented outreach efforts, recruitment activities, and alternative strategies to preserve access. Regulators evaluate whether alternative arrangements still support reasonable access and protect members’ availability and accessibility of services.
Exception review processes are governed by federal requirements and plan contract terms. Documentation must show that the plan attempted to establish network adequacy standards aligned with regulatory expectations, including network adequacy standards for Medicaid.
Structured documentation supports defensible network compliance and strengthens overall provider network adequacy validation during audits.
Sources
- Centers for Medicare & Medicaid Services (CMS). Medicaid and Children’s Health Insurance Program Managed Care Access, Finance, and Quality Final Rule (CMS-2439-F). https://www.cms.gov/newsroom/fact-sheets/medicaid-and-childrens-health-insurance-program-managed-care-access-finance-and-quality-final-rule
- Centers for Medicare & Medicaid Services (CMS). HHS Notice of Benefit and Payment Parameters for 2025 Final Rule. https://www.cms.gov/newsroom/fact-sheets/hhs-notice-benefit-and-payment-parameters-2025-final-rule
- Medicaid.gov (Centers for Medicare & Medicaid Services). Quality of Care External Quality Review. https://www.medicaid.gov/medicaid/quality-of-care/medicaid-managed-care-quality/quality-of-care-external-quality-review
- U.S. Department of Health and Human Services Office of Inspector General (HHS OIG). Many Medicare Advantage and Medicaid Managed Care Plans Have Limited Behavioral Health Provider Networks and Inactive Providers. https://oig.hhs.gov/documents/evaluation/11233/OEI-02-23-00540.pdf
- The American Journal of Managed Care (AJMC). Persistence of Provider Directory Inaccuracies After the No Surprises Act. https://www.ajmc.com/view/persistence-of-provider-directory-inaccuracies-after-the-no-surprises-act
