Specialized Health Plan Solutions

Network Adequacy Solutions for Health Plans

Expert data modeling, interactive mapping, and compliance reporting to meet CMS network adequacy standards. Build robust provider network analysis with ArcGIS and QGIS expertise.

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Meeting CMS Network Adequacy Standards

Starting in 2023, CMS requires health plans to meet specific time/distance standards for network adequacy. We help you build compliant, data-driven solutions.

Time/Distance Standards

Ensure at least 90% of enrollees live within maximum distance requirements for:

  • Primary Care (10-70 min/5-60 miles)
  • Specialty Care (20-145 min/10-130 miles)
  • Emergency Services (20-110 min/10-100 miles)
  • County-specific requirements

Appointment Wait Times

Monitor and report on appointment availability standards:

  • Routine primary care (within 10 business days)
  • Routine specialty care (within 15 business days)
  • Urgent care (within 48 hours)
  • Real-time monitoring dashboards

Compliance Reporting

Automated reporting and documentation for regulatory compliance:

  • CMS network adequacy reports
  • State-specific requirements
  • Provider directory accuracy tracking
  • Audit-ready documentation

Our Network Adequacy Solutions

Comprehensive data modeling and mapping solutions tailored to health plan requirements

Network Adequacy Data Models

Build robust data models that integrate provider locations, enrollee demographics, and geographic boundaries to calculate network adequacy metrics.

  • Provider location geocoding
  • Enrollee address mapping
  • Distance and travel time calculations
  • Network adequacy scoring

Interactive Network Adequacy Maps

Create dynamic, interactive maps using ArcGIS and QGIS that visualize provider networks, coverage areas, and network adequacy gaps.

  • ArcGIS Online/Enterprise solutions
  • QGIS desktop and web applications
  • Heat maps and coverage analysis
  • Provider network visualization

Network Analysis & Reporting

Comprehensive analysis of network breadth, provider mix, and geographic distribution with automated reporting dashboards.

  • Network breadth analysis
  • Provider mix evaluation
  • Geographic distribution reports
  • Gap analysis and recommendations

Provider Directory Management

Maintain accurate, up-to-date provider directories with automated validation and accuracy monitoring.

  • Directory accuracy validation
  • Automated update workflows
  • Provider status monitoring
  • CMS directory compliance

CMS Network Adequacy Standards (2023+)

Federal marketplace plans must meet these time/distance requirements. At least 90% of enrollees must have access within these limits.

Specialty Large Metro Metro Micro Rural
Primary Care 10 min / 5 mi 15 min / 10 mi 30 min / 20 mi 40 min / 30 mi
Cardiology 20 min / 10 mi 30 min / 20 mi 50 min / 35 mi 75 min / 60 mi
Emergency Medicine 20 min / 10 mi 45 min / 30 mi 80 min / 60 mi 75 min / 60 mi
Oncology 20 min / 10 mi 45 min / 30 mi 60 min / 45 mi 75 min / 60 mi
Endocrinology 30 min / 15 mi 60 min / 40 mi 100 min / 75 mi 110 min / 90 mi

Standards vary by county type. Counties with extreme access considerations have extended limits. Source: KFF Network Adequacy Standards

Our Technology Stack

Specialized tools for network adequacy analysis and mapping

Geospatial & Mapping Tools

ArcGIS QGIS

Specialized in network adequacy mapping and analysis

Data Platforms

Snowflake SQL Server

10+ years building health plan data solutions

Why Health Plans Choose Us

Specialized expertise in network adequacy compliance and data modeling

Regulatory Expertise

Deep understanding of CMS network adequacy standards and state-specific requirements:

  • CMS 2023+ time/distance standards
  • State-specific network adequacy rules
  • Provider directory accuracy requirements
  • Appointment wait time standards

Proven Methodology

Battle-tested approach to network adequacy analysis:

  • Provider location geocoding and validation
  • Enrollee address mapping and analysis
  • Automated distance and travel time calculations
  • Interactive mapping and visualization

Ready to Ensure Network Adequacy Compliance?

Let's discuss how we can help your health plan meet CMS standards with robust data models and interactive mapping solutions.

Get Your Free Network Adequacy Assessment

Schedule a consultation to discuss your network adequacy requirements and see how our solutions can help ensure compliance.

Free Consultation Includes:

  • Network adequacy gap analysis
  • Compliance requirements review
  • Solution recommendations
  • Implementation timeline

Request Your Free Consultation