Time and Distance Standards, and How Plans Meet Them on Paper

When a plan says its network is adequate, it usually means it has passed a time and distance test: enough of its members live within a set drive of at least one contracted provider of each type. The test is real and regulators enforce it. It is also built in ways that let a network pass while members still cannot get an appointment. Knowing the exact rules shows where a closed panel is vulnerable and where it is not.

How does the Medicare Advantage test work?

Medicare Advantage network adequacy is set out in 42 CFR 422.116. CMS sorts every county into one of five types by population and density (422.116(c)): large metro, metro, micro, rural, and counties with extreme access considerations (CEAC), which are counties of any size with fewer than 10 people per square mile. For each county type and each of 29 provider specialty types and a list of facility types, the regulation sets a maximum drive time in minutes and a maximum distance in miles (422.116(d)(2)).

Some of the base standards, as the regulation reads in October 2026 (time in minutes / distance in miles):

Plans must also contract with a minimum number of each provider type, calculated from a ratio per 1,000 beneficiaries (for primary care, 1.67 in large metro and metro counties and 1.42 elsewhere) multiplied by the number of beneficiaries the plan must be able to cover (422.116(e)).

Where is the test more forgiving than it looks?

Six features of the rule explain how a network can pass while patients wait.

It is a percentage, not every member

In large metro and metro counties, at least 90 percent of beneficiaries must have access to at least one provider of each type within the standard; in micro, rural and CEAC counties, at least 85 percent (422.116(d)(4)). Up to 15 percent of rural members can be outside the limit and the plan still passes.

One provider in range is enough for the distance test

The time and distance metric measures "the relationship between the approximate locations of beneficiaries and the locations of the network providers" (422.116(d)(1)(i)). A single contracted office in range satisfies it for that member, whether or not that office is taking new patients.

Credits lower the bar

A plan earns a 10 percentage point credit toward the percentage test for listed specialties, including primary care, psychiatry, clinical social work and outpatient behavioral health, when it contracts with telehealth providers that furnish additional telehealth benefits (422.116(d)(5)). Another 10-point credit applies in states with certificate of need laws or similar restrictions for affected types (422.116(d)(6)). New and expanding service area applicants get a 10-point credit during the application and may use signed letters of intent in place of signed contracts (422.116(d)(7)).

Customization can only stretch the standard

CMS may customize the standard for a county based on supply and utilization, but "customization may only be used to increase the base time and distance standards" (422.116(d)(3)(iv)).

Exceptions

A plan may ask CMS for an exception when providers "are not available" in a county and the plan has contracted with others who are farther away but "currently available and accessible to most enrollees" (422.116(f)(1)(i)). CMS considers whether "current access to providers and facilities is different from" its reference and provider supply files (422.116(f)(2)(i)). See Medicare Advantage network adequacy exceptions.

Not every contract counts, which can cut both ways

Providers contracted only for a plan's commercial or Medicaid products do not count toward its Medicare Advantage adequacy (422.116(a)(4)(i)(C)), and telehealth-only providers do not count toward the minimum number (422.116(e)(1)(ii)). A plan that relies on either in your county may be thinner than its directory suggests.

How do state standards for commercial plans compare?

State rules vary widely. Two examples we have verified:

• Texas PPO and EPO plans. Texas adopted its own county-type table using CMS's county classifications as of March 1, 2023 (Tex. Ins. Code 1301.00553(b)). In a large metro county the limits include 10 minutes and 5 miles for adult primary care and for licensed, accredited or certified outpatient clinical behavioral health settings, 20 minutes and 10 miles for psychiatry and physical therapy, and 30 minutes and 15 miles for chiropractic. For any physician specialty not listed, the maximum distance in any county type is 75 miles (1301.00554(b)). Texas adds appointment wait limits (1301.00555) and requires a waiver, decided after a public hearing, when a network misses a standard (1301.0055 and 1301.00565). See Texas waiver hearings.
• Pennsylvania managed care plans. At least 90 percent of enrollees in each county must have access within 20 miles or 30 minutes from home or work in metropolitan statistical area counties, and 45 miles or 60 minutes elsewhere (28 Pa. Code 9.679(d)). A plan that cannot meet it must tell the Department of Health in writing and describe its alternative arrangements (9.679(f)).

For Medicaid, each state sets its own quantitative standards and must consider distance, travel time and "the means of transportation ordinarily used by Medicaid enrollees," as well as "the numbers of network providers who are not accepting new Medicaid patients" (42 CFR 438.68(c)(1)). See Medicaid MCO network adequacy.

Where can a closed panel still fail the test?

Look for these patterns in your county:

1. Coverage that depends on one or two offices. If the only in-range providers for a specialty are a couple of practices that are not accepting new patients, the plan may pass the distance test on paper while failing the appointment standards that apply to the same product. Medicare Advantage plans must meet wait standards for primary care and behavioral health (42 CFR 422.112(a)(6)(i)); Texas sets wait limits in its code; Medicaid wait limits begin for rating periods on or after July 9, 2027.
2. An exception or waiver in force. A plan relying on an exception or a Texas waiver has said that providers are not available. A qualified provider who applied and was refused is evidence against that claim.
3. Counts inflated by the wrong contracts. Commercial-only or telehealth-only contracts propping up a Medicare Advantage count.
4. The rural edge. In micro, rural and CEAC counties, the 15 percent of members allowed outside the standard often live in the same few towns. If you practice there, you are the gap.

Where is the test not on your side?

If the plan has several contracted providers of your type within the base standard, most of whom take new patients within the wait limits, the time and distance argument is weak, and a dispute built on it is unlikely to move the plan. That is worth knowing before spending money. A specific niche (a language, a population, a service the network lacks) or a group exception may still help. See joining a participating group.

How do you measure it for your own practice?

Identify your county type, look up the standard for your specialty, measure driving time and distance from the ZIP codes where members live to each in-network provider of your type, and call each one. Then compare. The method is in documenting an access gap, and the letter that presents it is in how to write a network adequacy letter.

Can we check your county?

A Network Rejection Review ($249, credited toward a dispute) tells you which standard applies to each plan that turned you down and whether there is a plausible gap. A Payer Network Dispute ($799 per payer) runs the full measurement and prepares the letter for you to sign and send. We are not a law firm and do not give legal advice; a healthcare attorney is the right person for questions about your legal rights.