Network Adequacy

Time and Distance Standards

QHP issuers are required to maintain a network that is sufficient in number and types of providers, including providers that specialize in mental health and substance use disorder services, to assure that all covered services will be accessible to enrollees without unreasonable delay in accordance with 45 CFR 156.230(a)(2). Issuers must demonstrate that they meet network adequacy standards as part of their QHP Application.

To satisfy network adequacy standards, the applicant has satisfied the following requirements:^ 

  1. Use a provider network that complies with 45 CFR 156.230, subject to a limited exception for certain SADPs as described in the 2024 Letter to Issuers.
  2. Meet the time and distance standards within each plan’s service area with respect to providers^ participating in the plan’s provider network, as set forth in the annual Letter to Issuers for the respective QHP certification plan year. 
  3. Report to CMS whether providers participating in their network offer telehealth services, as detailed in the 2023 Letter to Issuers. 

^To count toward meeting network adequacy standards, providers must be appropriately licensed, accredited, or certified to practice in their state, as applicable, and must have in-person services available. 

For information regarding compliance with appointment wait time standards, please access the Compliance webpage.

Key Changes for PY2025:

  • Existing issuers should download their previous year’s NA provider data into their upcoming year’s NA Template in MPMS. New issuers should download and populate a new NA Template.
  • After making updates to the previous year's data or completing a new NA Template, issuers must upload the completed file to the Validation Workspace. All errors must be corrected before linking the NA Template to an application.
  • Issuers will now retrieve and submit the NA Justification Forms in the Network Adequacy section in MPMS rather than in the Plan Management (PM) Community.
  • All medical QHPs and stand-alone dental plans (SADPs) operating on the Federally-Facilitated Exchange (FFE), including issuers in states performing plan management functions and State-based Exchange on the Federal Platform (SBE-FP) states, will submit their completed NA Template via MPMS.
  • Provider validations will identify provider data errors that an issuer has made upon upload of their NA Template into the Plan Validation Workspace of MPMS and require the issuer to correct such errors within the Plan Validation Workspace and verify that no additional errors exist before submitting their NA Template.

Tips for the Network Adequacy Section

  • General
    • Complete the Issuer Information section on the User Control tab before creating and entering data into the other tabs.
    • Do not change the file names on NA files after finalizing the template. This file-naming convention helps CMS identify each issuer’s NA Template. If the file name is changed, CMS may issue a required correction. 
    • Complete the Network ID Template before completing the NA Template.
    • Issuers must only include providers on the NA Template that are not at known risk for potential contract termination for the upcoming plan year.
    • All medical QHPs and SADPs operating on the FFE, including issuers in states performing plan management functions and SBE-FP states, will submit their completed NA Template via MPMS.
    • NA Justifications are only required when at least one element of the NA standard is not met. Issuers that do not meet all elements of the NA standards are issued a correction notice and a partially populated NA Justification Form for the issuer to retrieve, complete, and submit via MPMS.
  • Network Adequacy
    • All medical QHPs and SADPs must use a provider network and submit an NA Template, with the limited exception of SADPs that sell plans in areas where it is prohibitively difficult for the issuer to establish a network of dental providers as determined by CMS; this exception is not available to medical QHP issuers. 
      • Under this limited exception, an area is considered “prohibitively difficult” for the SADP issuer to establish a network of dental providers based on attestations from state departments of insurance (DOIs) with at least 80 percent of their counties classified as counties with extreme access considerations (CEAC), meaning that at least one of the following factors exists in the area of concern: a significant shortage of dental providers, a significant number of dental providers unwilling to contract with Marketplace issuers, or significant geographic limitations impacting consumer access to dental providers. 
      • CMS will not be accepting requests for this limited exception directly from SADP issuers. Once an eligible state DOI submits to CMS an attestation that they consider the area to be prohibitively difficult to establish a network of dental providers, CMS will review the attestation to determine if an exception will be granted. CMS will notify the SADP issuer directly if they qualify for this limited exception. SADP issuers that qualify for this limited exception will not be required to use a provider network or submit an NA Template. 
    • Issuers complete the NA Template by including all providers in their network in the Network Adequacy Provider tab, using the Taxonomy Codes tab of the NA Template to crosswalk provider taxonomy codes to provider specialty types and categories for time and distance standards.
    • Providers in another state that are part of the network may be included if they are located within the time and distance allowed for reasonable access1These parameters are foundationally based on approaches used by the Census Bureau and the Office of Management and Budget. Use this file only to reference the Provider Time & Distance tab columns A through E for QHP county type designations. Other information in this Health Service Delivery (HSD) Reference file is not applicable to QHP certification.
    • Issuers must submit valid and active NPI values. If an NPI value is not found in the National Plan and Provider Enumeration System (NPPES), the issuer must remove the NPI from their NA Template data to clear the validation error in the Plan Validation Workspace within MPMS.
    • Issuers must not select more than three individual provider specialty types for a single NPI within the NA Template. If greater than three individual provider specialty types are selected for a single NPI, the issuer must remove any excess selections to clear the validation error in the Plan Validation Workspace within MPMS. 
    • Issuers must not report an individual provider as practicing at more than 10 unique locations or a provider facility as operating at more than 10 unique locations within their NA Template. To clear the validation error, issuers must remove locations that exceed the limit of 10 unique locations for the respective provider.
    • Issuers must enter no greater number of Acute Inpatient Hospitals (with emergency services available 24/7) within their NA Template than the total number of such hospitals operating in the respective states in which the providers are located (excluding specialty hospitals, such as those on the [Department of Health and Human Services [HHS] Essential Community Provider [ECP] List). If an issuer receives this validation error, the issuer must review their data and make the necessary corrections to accurately report their in-network Acute Inpatient Hospitals within their NA Template to clear the validation error in the Plan Validation Workspace within MPMS.
    • Issuers must not enter a PO Box in the address field for a provider within their NA Template. To clear the validation error in the Plan Validation Workspace within MPMS, issuers must replace any PO Boxes with a valid street address at which the provider offers services to enrollees. Entering a valid street address enables CMS to calculate time and distance measurements for the respective provider.
    • Issuers should reference the Taxonomy Codes tab of the NA Template to crosswalk provider taxonomy codes to provider specialty types and categories for time and distance standards. 
    • Under the following circumstances, advanced practice registered nurses (APRNs) and physician assistants (PAs) could be included as primary care providers. Under the circumstances below, APRNs who specialize in behavioral health services could be included in the outpatient clinical behavioral health provider category. The purpose of including APRNs and PAs is to inform CMS of the rare instances in which an issuer contracts with non-Medical Doctor (MD)/Doctor of Osteopathy (DO) primary care and behavioral health services providers in underserved counties to serve as the major source of these types of care for enrollees. In these instances, organizations may include submissions under the non-MD/DO primary care and outpatient clinical behavioral health specialty codes if the contracted APRN or PA satisfies the following conditions:
            (1) Currently licensed in the state,
            (2) Meets the state’s requirements governing the qualifications of that provider type,
            (3) Fully credentialed by the organization as a provider of primary care or behavioral health services,
            (4) Functions in accordance with state law as the primary source for the enrollee’s primary care or behavioral health services (i.e., not to supplement a physician’s care), and 
            (5) Practices in or renders services to enrollees residing in a health professional shortage area (HPSA).

                    Application Resources

                    • Templates
                      • Issuers are highly encouraged to use prepopulated templates, which can be generated in the Application Materials tab in the MPMS Module. Any issuers unable to generate these prepopulated templates should use the template below.
                      • PY2025 Network Adequacy Template

                    • Justifications/Supporting Documents
                      • Starting in PY2025, Network Adequacy Justification Forms will be retrieved and submitted via MPMS.