Network Adequacy Guidance for Plan Year 2026

STATE OF MAINE DEPARTMENT OF PROFESSIONAL & FINANCIAL REGULATION BUREAU OF INSURANCE Office Location: 76 Northern Avenue, Gardiner, Maine 04345 Mailing Address: 34 State House Station, Augusta, Maine 04333 www.maine.gov/pfr/insurance Phone: (207) 624-8475 TTY: Please Call Maine Relay 711 Consumer Assistance: (800) 300-5000 Fax: (207) 624-8599 Janet T. Mills Governor Robert L. Carey Superintendent Joan F. Cohen Commissioner 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 fulltime-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. 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. Page 2 of 2 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. 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. CountySSA County FIPS County Name State PY26 County Class Name 20000 23001 Androscoggin ME Metro 20010 23003 Aroostook ME Micro 20020 23005 Cumberland ME Metro 20030 23007 Franklin ME Rural 20040 23009 Hancock ME Micro 20050 23011 Kennebec ME Metro 20060 23013 Knox ME Micro 20070 23015 Lincoln ME Micro 20080 23017 Oxford ME Micro 20090 23019 Penobscot ME Micro 20100 23021 Piscataquis ME CEAC 20110 23023 Sagadahoc ME Micro 20120 23025 Somerset ME Micro 20130 23027 Waldo ME Micro 20140 23029 Washington ME Rural 20150 23031 York ME Metro PY2026 Maine Network Adequacy Time and Distance Standards Appendix 1 The salmon-shaded cells on the following pages represent provider type / county combinations where Maine uses alternative standards rather than the baseline standards. CountyName 007 Distance (Miles) 007 Time (Minutes) 008 Distance (Miles) 008 Time (Minutes) 035 Distance (Miles) 035 Time (Minutes) Androscoggin 30 45 20 30 40 60 Aroostook 240 240 60 90 240 240 Cumberland 35 55 20 30 40 60 Franklin 75 105 60 75 90 110 Hancock 60 85 35 50 75 100 Kennebec 30 45 20 30 40 60 Knox 65 175 35 85 75 175 Lincoln 60 80 35 50 75 100 Oxford 60 80 35 50 75 100 Penobscot 70 80 70 75 75 100 Piscataquis 110 125 85 95 130 145 Sagadahoc 60 80 35 50 75 100 Somerset 60 90 35 50 75 100 Waldo 60 80 35 50 75 100 Washington 115 155 60 105 115 155 York 30 45 20 30 40 60 CountyName 010 Distance (Miles) 010 Time (Minutes) DEN Distance (Miles) DEN Time (Minutes) 011 Distance (Miles) 011 Time (Minutes) Androscoggin 30 45 30 45 30 45 Aroostook 60 80 60 80 240 240 Cumberland 30 45 30 45 30 45 Franklin 75 90 75 90 70 105 Hancock 60 80 60 80 45 75 Kennebec 30 45 30 45 30 45 Knox 60 80 60 80 45 80 Lincoln 60 80 60 80 45 60 Oxford 60 80 60 80 45 65 Penobscot 60 80 60 80 65 75 Piscataquis 110 125 110 125 100 120 Sagadahoc 60 80 60 80 45 60 Somerset 60 80 60 80 45 70 Waldo 60 80 60 80 45 60 Washington 75 90 75 90 105 145 York 30 45 30 45 30 45 CountyName 037 Distance (Miles) 037 Time (Minutes) 012 Distance (Miles) 012 Time (Minutes) 013 Distance (Miles) 013 Time (Minutes) Androscoggin 30 45 40 60 30 45 Aroostook 60 80 240 240 70 100 Cumberland 30 45 40 60 30 45 Franklin 60 75 90 110 75 90 Hancock 60 80 75 100 60 80 Kennebec 30 45 40 60 30 45 Knox 60 80 75 110 60 85 Lincoln 60 80 75 100 60 80 Oxford 60 80 75 100 60 80 Penobscot 60 80 75 100 70 80 Piscataquis 100 110 130 145 110 125 Sagadahoc 60 80 75 100 60 80 Somerset 60 80 75 100 60 80 Waldo 60 80 75 100 60 80 Washington 60 75 115 155 105 155 York 30 45 40 60 30 45 Individual Provider Specialty Types Allergy and Immunology Cardiology Cardiothoracic Surgery Emergency Medicine Endocrinology ENT/Otolaryngology Dermatology Dental Chiropractor CountyName 014 Distance (Miles) 014 Time (Minutes) 015 Distance (Miles) 015 Time (Minutes) 016 Distance (Miles) 016 Time (Minutes) Androscoggin 30 45 20 30 20 30 Aroostook 240 240 35 50 30 55 Cumberland 30 45 20 30 20 30 Franklin 65 95 60 75 40 65 Hancock 60 95 40 70 30 50 Kennebec 30 45 20 30 20 30 Knox 45 85 35 80 25 105 Lincoln 45 60 35 50 20 30 Oxford 45 65 35 50 25 50 Penobscot 70 75 35 50 70 95 Piscataquis 100 110 85 95 60 70 Sagadahoc 45 60 35 50 20 30 Somerset 45 60 35 50 30 50 Waldo 45 60 35 50 25 40 Washington 65 95 60 75 50 80 York 30 45 20 30 20 30 CountyName 017 Distance (Miles) 017 Time (Minutes) 018 Distance (Miles) 018 Time (Minutes) 019 Distance (Miles) 019 Time (Minutes) Androscoggin 40 60 30 45 30 45 Aroostook 75 100 240 240 240 240 Cumberland 40 60 30 50 30 45 Franklin 90 110 75 90 65 95 Hancock 75 100 60 80 45 75 Kennebec 40 60 30 45 30 45 Knox 75 100 60 85 45 85 Lincoln 75 100 60 80 45 60 Oxford 75 100 60 80 45 65 Penobscot 75 100 70 80 65 75 Piscataquis 130 145 110 125 100 110 Sagadahoc 75 100 60 80 45 60 Somerset 75 100 60 80 45 60 Waldo 75 100 60 80 45 60 Washington 90 125 110 150 105 145 York 40 60 30 45 30 45 CountyName 020 Distance (Miles) 020 Time (Minutes) 050 Distance (Miles) 050 Time (Minutes) 021 Distance (Miles) 021 Time (Minutes) Androscoggin 40 60 30 45 30 45 Aroostook 240 240 60 80 70 95 Cumberland 40 60 30 45 30 45 Franklin 90 120 60 75 60 75 Hancock 75 100 60 80 45 70 Kennebec 40 60 30 45 30 45 Knox 75 175 60 85 45 85 Lincoln 75 100 60 80 45 60 Oxford 75 100 60 80 45 60 Penobscot 75 100 60 80 45 60 Piscataquis 130 145 100 110 100 110 Sagadahoc 75 100 60 80 45 60 Somerset 75 100 60 80 45 65 Waldo 75 100 60 80 45 60 Washington 115 155 60 75 100 145 York 40 60 30 45 30 45 Individual Provider Specialty Types Gynecology (OB/GYN) General Surgery Gastroenterology Infectious Diseases Nephrology Neurology Oncology - Medical & Surgical Occupational Therapy Neurosurgery CountyName 022 Distance (Miles) 022 Time (Minutes) 023 Distance (Miles) 023 Time (Minutes) 025 Distance (Miles) 025 Time (Minutes) Androscoggin 40 60 20 30 20 30 Aroostook 75 100 50 80 75 95 Cumberland 40 60 30 40 20 30 Franklin 90 115 60 75 60 75 Hancock 75 100 40 65 35 50 Kennebec 40 60 20 30 20 30 Knox 75 175 35 80 35 100 Lincoln 75 100 35 50 35 50 Oxford 75 100 35 50 35 50 Penobscot 75 100 40 50 45 50 Piscataquis 130 145 85 95 85 95 Sagadahoc 75 100 35 50 35 50 Somerset 75 100 35 50 35 50 Waldo 75 100 35 50 35 50 Washington 115 155 100 145 60 75 York 40 60 20 30 20 30 CountyName OPBH Distance (Miles) OPBH Time (Minutes) 026 Distance (Miles) 026 Time (Minutes) 049 Distance (Miles) 049 Time (Minutes) Androscoggin 10 15 30 45 30 45 Aroostook 20 30 65 95 60 80 Cumberland 10 15 30 45 30 45 Franklin 30 40 75 90 60 75 Hancock 20 30 60 80 60 80 Kennebec 10 15 30 45 30 45 Knox 20 30 60 105 60 80 Lincoln 20 30 60 80 60 80 Oxford 20 30 60 80 60 80 Penobscot 20 30 60 80 60 80 Piscataquis 60 70 110 125 100 110 Sagadahoc 20 30 60 80 60 80 Somerset 20 30 60 80 60 80 Waldo 20 30 60 80 60 80 Washington 30 40 75 100 60 75 York 10 15 30 45 30 45 CountyName 027 Distance (Miles) 027 Time (Minutes) 028 Distance (Miles) 028 Time (Minutes) PCX Distance (Miles) PCX Time (Minutes) Androscoggin 40 60 30 45 10 15 Aroostook 240 240 55 80 20 30 Cumberland 40 60 30 45 10 15 Franklin 90 110 60 75 30 40 Hancock 75 100 45 60 20 30 Kennebec 40 60 30 45 10 15 Knox 75 100 45 85 20 30 Lincoln 75 100 45 60 20 30 Oxford 75 100 45 60 20 30 Penobscot 75 100 45 60 20 30 Piscataquis 130 145 100 110 60 70 Sagadahoc 75 100 45 60 20 30 Somerset 75 100 45 60 20 30 Waldo 75 100 45 60 20 30 Washington 115 155 60 75 30 40 York 40 60 30 45 10 15 Individual Provider Specialty Types Oncology - Radiation Ophthalmology Orthopedic Surgery Physical Therapy Physical Medicine & Rehabilitation Outpatient Clinical Behavioral Health Plastic Surgery Podiatry Primary Care - Adult CountyName 101 Distance (Miles) 101 Time (Minutes) 029 Distance (Miles) 029 Time (Minutes) 030 Distance (Miles) 030 Time (Minutes) Androscoggin 10 15 30 45 30 45 Aroostook 20 30 45 60 60 90 Cumberland 10 15 30 45 30 45 Franklin 30 40 60 75 60 75 Hancock 20 30 45 60 45 60 Kennebec 10 15 30 45 30 45 Knox 20 30 45 60 45 80 Lincoln 20 30 45 60 45 60 Oxford 20 30 45 60 45 60 Penobscot 20 30 50 85 70 80 Piscataquis 60 70 100 110 100 120 Sagadahoc 20 30 45 60 45 60 Somerset 20 30 45 60 45 75 Waldo 20 30 45 60 45 60 Washington 30 40 60 80 110 150 York 10 15 30 45 30 45 CountyName 031 Distance (Miles) 031 Time (Minutes) 051 Distance (Miles) 051 Time (Minutes) 033 Distance (Miles) 033 Time (Minutes) Androscoggin 40 60 30 45 30 45 Aroostook 75 100 60 80 45 60 Cumberland 40 60 30 45 30 50 Franklin 90 110 60 75 60 75 Hancock 75 100 60 80 45 60 Kennebec 40 60 30 45 30 45 Knox 75 100 60 80 45 85 Lincoln 75 100 60 80 45 60 Oxford 75 100 60 80 45 60 Penobscot 75 100 60 80 70 95 Piscataquis 130 145 100 110 100 110 Sagadahoc 75 100 60 80 45 60 Somerset 75 100 60 80 45 60 Waldo 75 100 60 80 45 60 Washington 100 145 60 75 60 90 York 40 60 30 45 30 45 CountyName 034 Distance (Miles) 034 Time (Minutes) Androscoggin 40 60 Aroostook 75 100 Cumberland 40 60 Franklin 90 110 Hancock 75 100 Kennebec 40 60 Knox 75 100 Lincoln 75 100 Oxford 75 100 Penobscot 75 100 Piscataquis 130 145 Sagadahoc 75 100 Somerset 75 100 Waldo 75 100 Washington 115 155 York 40 60 Pulmonology Psychiatry Primary Care - Pediatric Individual Provider Specialty Types The salmon-shaded cells represent the alternative times and distances for the respective individual provider specialty type / county combinations. Rheumatology Speech Therapy Urology Vascular Surgery County Name 040 Distance (Miles) 040 Time (Minutes) 042 Distance (Miles) 042 Time (Minutes) 041 Distance (Miles) 041 Time (Minutes) Androscoggin 30 45 40 60 40 60 Aroostook 60 80 240 240 120 160 Cumberland 30 45 40 60 40 60 Franklin 60 75 120 145 120 145 Hancock 60 80 120 160 120 160 Kennebec 30 45 40 60 40 60 Knox 60 80 120 160 120 180 Lincoln 60 80 120 160 120 160 Oxford 60 80 120 160 120 160 Penobscot 60 80 120 160 120 160 Piscataquis 100 110 140 155 140 155 Sagadahoc 60 80 120 160 120 160 Somerset 60 80 120 160 120 160 Waldo 60 80 120 160 120 160 Washington 80 90 120 150 120 155 York 30 45 40 60 40 60 County Name 043 Distance (Miles) 043 Time (Minutes) 047 Distance (Miles) 047 Time (Minutes) MHF Distance (Miles) MHF Time (Minutes) Androscoggin 30 45 30 45 45 70 Aroostook 120 160 65 95 75 100 Cumberland 30 45 35 50 45 70 Franklin 120 145 80 120 75 90 Hancock 120 160 60 85 75 100 Kennebec 30 45 60 65 45 70 Knox 120 160 90 210 75 100 Lincoln 120 160 65 90 75 100 Oxford 120 160 60 80 75 100 Penobscot 120 160 65 95 75 100 Piscataquis 140 155 100 120 140 155 Sagadahoc 120 160 60 80 75 100 Somerset 120 160 95 125 75 100 Waldo 120 160 60 85 75 100 Washington 120 145 105 155 75 90 York 30 45 30 45 45 70 County Name 048 Distance (Miles) 048 Time (Minutes) 057 Distance (Miles) 057 Time (Minutes) 046 Distance (Miles) 046 Time (Minutes) Androscoggin 45 70 30 45 30 45 Aroostook 60 80 240 240 60 80 Cumberland 30 45 30 45 30 45 Franklin 60 75 70 105 60 75 Hancock 60 90 60 85 60 80 Kennebec 50 65 30 45 30 45 Knox 60 155 65 180 60 120 Lincoln 60 80 60 80 60 80 Oxford 60 80 60 80 60 80 Penobscot 60 80 70 80 60 80 Piscataquis 100 110 100 120 85 95 Sagadahoc 60 80 60 80 60 80 Somerset 60 80 60 90 60 80 Waldo 60 85 60 80 60 80 Washington 60 75 90 135 60 75 York 30 45 30 45 30 45 Acute Inpatient Hospitals (Must have emergency services available 24/7) Cardiac Catheterization Services Cardiac Surgery Program Facility Provider Specialty Types Critical Care Services - Intensive Care Units (ICU) Diagnostic Radiology (Free-standing; hospital outpatient; ambulatory health facilities with Dx Radiology) Inpatient or Residential Behavioral Health Facility Services Mammography Outpatient Infusion/ Chemotherapy Skilled Nursing Facilities County Name 045 Distance (Miles) 045 Time (Minutes) 080 Distance (Miles) 080 Time (Minutes) Androscoggin 30 45 30 45 Aroostook 70 110 170 225 Cumberland 35 50 30 45 Franklin 70 100 70 95 Hancock 60 80 60 80 Kennebec 30 45 30 45 Knox 75 190 60 125 Lincoln 65 85 60 80 Oxford 60 80 60 80 Penobscot 70 80 60 80 Piscataquis 100 120 100 110 Sagadahoc 60 80 60 80 Somerset 60 80 60 80 Waldo 60 80 60 80 Washington 100 150 95 145 York 30 45 30 45 The salmon-shaded cells represent the alternative times and distances for the respective facility provider specialty type / county combinations. Surgical Services (Ambulatory Surgical Centers and Outpatient Hospital) Urgent Care Facility Provider Specialty Types 1 Carriers that cannot comply with the provider ratios and time and distance standards established in the Maine Bureau of Insurance’s annual network adequacy bulletin, issued pursuant to Rule 850 § 7(B)(2), may request an exception to these requirements. Carrier Information Company Name Address City State Zip Contact Name Contact Phone Number Email If no providers or facilities meet the specific time and distance standards for a specialty in a specific county: Please provide the distance and travel time that beneficiaries would have to travel beyond the required criteria to reach a contracted provider within a given specialty. Please provide the name of the next closest provider and explain what good faith efforts have been made to contract with them. Appendix 2 Network Adequacy Exception Request Form 2 If patterns of care in the service area do not support the need for the required 90% ratio for the provider or facility type: Please provide a narrative and data on claims and referral patterns, indicating where beneficiaries currently seek this type of care or where providers currently refer beneficiaries. Other information and documentation supporting exception requests for specific counties and provider types: