ME| Bulletin 487 from the Maine Bureau of Insurance providing new network adequacy guidance for health insurance plans effective for the 2026 plan year. It adopts the Centers for Medicare and Medicaid Services (CMS) standards for maximum travel time and distance to health care providers and facilities, with certain Maine-specific modifications accounting for local provider shortages and geographic challenges. Insurers must ensure at least 90% of enrollees have access within these standards and maintain a ratio of at least one primary care provider per 2,000 enrollees. An exception process is detailed for plans unable to meet these requirements due to circumstances beyond their control.
Key Points:
- The standards require that insurers contract with enough providers so that at least 90% of enrollees in each county can access primary care and various specialty/facility services within specified travel time and distance, as set by CMS and modified for Maine’s unique needs.
- Carriers unable to comply must submit an exception request form explaining the reasons (such as provider shortages or geographic barriers), and the Bureau will review these exceptions based on supporting data and documentation provided by the carrier.