Network Adequacy FAQs

• Issuers in all FFE states, including states performing plan management functions, must submit their network adequacy provider data to CMS via the NA Template. CMS evaluates network adequacy for all plans to be offered as QHPs on Healthcare.gov, except in certain states that perform plan management functions that elect and are approved by CMS to perform their own NA reviews in lieu of CMS NA reviews, so long as the state applies and enforces quantitative network adequacy standards that are at least as stringent as the federal network adequacy standards under 45 C.F.R. 156.230, and the state’s reviews are conducted prior to plan confirmation in support of QHP certification.

• CMS assesses QHP compliance with time and distance standards at the county level. In alignment with Medicare Advantage’s approach, CMS classifies counties into five county- type designations: Large Metro, Metro, Micro, Rural, or Counties with Extreme Access Considerations (CEAC). Designations for each county are available from the latest Medicare Advantage Health Services Delivery (HSD) Reference file on CMS’s website at Medicare Advantage Applications. These parameters are foundationally based on approaches used by the Census Bureau and the Office of Management and Budget.

Please note that the HSD Reference file should only be used to reference the "Provider Time & Distance" tab columns A through E for QHP county- type designations. Other information in the Medicare Advantage HSD Reference file is not applicable to QHP NA certification.

Q5: How are the network adequacy time and distance standards calculated and measured?

• CMS uses industry standard technology to calculate estimated driving time and distance between Marketplace-eligible consumers (see FAQ describing the target QHP Population Sample File) and servicing provider locations. Street addresses for consumers (based on census data sampling) and providers are assigned latitude and longitude geocodes. Once those coordinates are created, estimated driving time and distance are calculated between consumers and providers. Time is calculated using the estimated distance and applying a driving speed based on the geographic area, and distance is measured by determining the estimated driving distance between the geocodes and the average number of Marketplace-eligible consumers in the designated geographic areas. Finally, the results are compared against the time and distance metric standards for the respective provider specialty type and county designation type to determine if the standard is met.

• For the purposes of network adequacy, CMS defines telehealth as “professional consultations, office visits, and office psychiatry services delivered through technology-based methods, including virtual check-ins, remote evaluation of pre-recorded patient data, and inter-professional internet consultations.”

• Issuers should not list a single individual practitioner or facility provider with the same address multiple times within the 'Network Adequacy Provider' tab of the NA Template. Instead, issuers may assign multiple NA Individual/Facility Specialty Types to a single individual practitioner or facility provider in two ways:
• The first way is to use the selection box feature that is built into the 'Network Adequacy Provider' tab of the NA Template. The selection box allows users to select the applicable Individual/Facility Specialty Types for the selected provider. Beginning in PY2025, issuers are permitted to select no more than three specialty types for an individual practitioner NPI. 
• The second way is to manually create a list of each Individual/Facility Specialty Type separated by commas. The process for doing this is described on the 'Specialty Types' tab of the ECP/NA Template. Users should be careful when using this method that they match the Individual/Facility Specialty Type listed in the 'Specialty Types' tab exactly or they will receive a template validation error. For instance, if a user would like to assign the Facility Specialty Types of Cardiac Surgery Program and Cardiac Catheterization Services to a facility, they should enter "041 Cardiac Surgery Program, 042 Cardiac Catheterization Program."

• The NA Justification Form contains partially prepopulated information for each unmet NA standard. Issuers are required to provide the following information:
• Responses to the four monitoring questions at the top of the 'Monitoring & T&D Justification' tab:
• What sources are used to monitor new providers entering the service area?
• How often do you monitor your sources for new providers entering the service area?
• Do you hold QHP enrollees of this plan responsible for only in-network cost sharing for out-of-network care received when you do not meet the network adequacy standards for network/county/specialty combinations?
• What is the number of QHP enrollee complaints received regarding network adequacy during the prior Plan Year?
• Primary Reason(s) for not meeting each network adequacy standard for the respective correction finding, starting on row 10 of the 'Monitoring & T&D Justification' tab. There should not be any blank records in this column.
• A populated 'Recruitment Activity' tab listing providers with the 'Status of Recruitment Efforts' column completed.

• Yes, for PY2025 CMS will continue the Network Breadth Pilot for all QHP issuers in states participating in the Network Breadth Pilot, which include Tennessee and Texas for PY2025. As in previous years, each QHP network’s breadth will be compared to the network breadth of other QHPs available in the same geographic area. An issuer's network breadth classification is then publicly reported on HealthCare.gov, based on CMS's final review results for all issuers in the participating state have been calculated.

• CMS determines network breadth classifications by comparing an issuer’s contracted providers to the number of specific individual practitioner and facility providers included across all Qualified Health Plan (QHP) networks available in a county. The classification focuses on acute inpatient hospitals, adult primary care, and pediatric primary care with a separate classification for each of these three provider specialty types. CMS calculates the classifications of network breadth for each plan at the county level.

• All issuers must meet all network adequacy standards for QHPs, regardless of whether they use an integrated delivery model or have exclusivity contracts with providers. If you are in an exclusivity contract with a provider or group of providers that is hindering your ability to satisfy the network adequacy standards by limiting your ability to contract with a sufficient number of providers within the time and distance parameters for the respective specialty type, such exclusivity contracts do not exempt an issuer from the NA requirements. You will need to either: 1) identify additional providers with whom you could contract without violating the exclusivity contract; or 2) consider modifying the terms and/or conditions of your exclusivity contract such that it allows for contracting with other providers when the exclusivity arrangement fails to satisfy QHP Certification requirements.

• Please see the table below that details whether CMS or the state will conduct the network adequacy reviews for QHP certification purposes for your state for Plan Year (PY) 2025, as outlined in the 2025 Notice of Benefit and Payment Parameters final rule.

• The QHP Population Sample File (available on the Network Adequacy page of the QHP Certification website), is based on US Census data. For each county, an eligible population sample is identified based on age and income requirements for consumers to qualify for health coverage through the Exchange. The population file is used to measure provider access for Marketplace-eligible consumers residing in that county and to certify that provider networks offered by QHPs meet network adequacy requirements. This file is updated each year just prior to the start of the annual certification cycle.

• Please see the instructional guidance on Completing the Network Adequacy Justification Forms on within the NA Application Resources section of the QHP certification website.

• Completed NA Justification Forms are due to CMS on the same timeline as the NA Template and other QHP Issuer Application documentation, so by each review round deadline (i.e., Second Round if the issuer submitted their application during Round; Final Round if the issuer submitted their application during Second Round)

• CMS encourages issuers to prioritize provider updates to their NA Template that reflect fully executed contracts. Issuers should then use the NA Justification Form to provide details regarding their recruitment activities to fill network gaps, as well as details regarding any gaps that issuers believe cannot be fully remedied due to local conditions (such as provider supply shortages, etc.).

• Issuers in this situation should select among the following response options within the NA Justification Form, as applicable: 

• CMS is making the following changes regarding Network Adequacy data submissions and CMS review results for PY2025:

• No. All columns and data restrictions are the same as in PY2024.

• NA reviews will continue to be conducted in rounds for PY2025 due to constraints in executing real-time time and distance reviews. CMS continues to investigate options for generating real-time results.

• For PY2025, CMS will not conduct Network Adequacy reviews during the Early Bird Round. The first Network Adequacy reviews will be conducted for the Initial Round. However, issuers can  upload their populated NA Template to the Plan Validation Workspace in MPMS to run the validation checks and receive provider validation results any time after the certification window opens on 04/17/2024.

• For PY2025, CMS has implemented several provider data accuracy checks in the NA Template validation step in MPMS. These validation checks are designed to address and resolve data quality issues that impact CMS’s ability to perform time and distance reviews. These validation errors include:
• An NPI value submitted that is inactive or not found in the National Plan and Provider Enumeration System (NPPES) will be rejected. This validation replaces the NPI Validation Report (NVR) used in previous years.
• An address that contains a PO Box will not be accepted. A PO Box cannot be accurately geocoded for time and distance analysis, as a PO Box address does not identify the physical address where the health care service is provided. Entering any form of PO Box (e.g., P.O Box, PO Box) in the “Street Address” or “Street Address 2” columns will result in an error.
• Issuers must not report more than 10 unique address locations for any one individual practitioner NPI or facility provider NPI. CMS considers these data to be incorrect as it is not practical for an individual to actively see patients at more than 10 locations. For facilities with multiple locations, issuers should use the location specific NPI (i.e., the servicing NPI), rather than an organizational level NPI. CMS has relaxed this validation error to generate a validation warning instead for the following specialties that can sometimes reasonably exceed 10 unique addresses for a single NPI: 037 Emergency Medicine, 049 Physical Therapy, 050 Occupational Therapy, 051 Speech Therapy, and 080 Urgent Care.
• Issuers must not report more than 4 specialty types for individual practitioners. CMS will consider the data to be inaccurate as it is not plausible for an individual practitioner to actively practice more than four specialty areas.
• The number of unique 040 Acute Care hospitals cannot exceed the total number of hospitals available in that state. Issuers must not submit multiple provider records for the same hospital coded as 040 Acute Care hospitals. If a hospital has separate NPIs for different departments, the issuer must code that NPI appropriately. For example, a hospital Mammography Center should be coded as 048 Mammography, not as an 040 Acute Care hospital.

• For PY2025, CMS has implemented National Provider Identifier (NPI) validation checks in MPMS including verifying that an NPI is marked as valid and active in the National Plan and Provider Enumeration System (NPPES). Issuers will receive real-time feedback at time of submission on NPIs that do not pass these NPPES validations. This eliminates the need for a separate report to be generated after NA reviews.

• MPMS will display the results after an issuer validates their data. There is a 500-row limit to the number of errors/warnings displayed in the MPMS UI and downloadable report. The results can be downloaded as an Excel file from the results page in MPMS.

• The NA Template checks network IDs and can only support basic validations such as identifying dummy NPIs and duplicate rows. The validations in MPMS are more sophisticated and will be expanded over time. The goal is to eventually move all NA validations to MPMS in future plan years. In the meantime, issuers should consider the MPMS validations when populating their NA Template for PY2025 (see FAQ titled, “What new data validation checks are being implemented in MPMS for PY2025?”).

• Issuers in FFE states, SBE-FP states, and states performing plan management functions must submit their NA template in MPMS. Issuers in SBE states should consult with their respective state for guidance on submitting their NA data.

• For PY2025, CMS will continue to identify issuers that have significant gaps in meeting time and distance standards. Starting in PY2025, these issuers will be referred to the Division of Compliance Oversight and Monitoring (DCOM) team who will work with issuers and their account managers to ensure issuers continue to make progress in resolving those gaps.

• CMS evaluates QHP issuer compliance with network adequacy time and distance standards by reviewing provider data for in-network providers that QHP issuers submit via the NA Template. For each provider specialty, CMS reviews the QHP issuer-submitted data to ensure that the plan provides access to at least one provider for each of the provider specialty types for at least 90 percent of the Marketplace-eligible population in the county (see FAQ describing the target QHP Population Sample File). In order to satisfy this standard, the issuer may be required to contract with more than one provider of a given provider specialty type if more than one provider is needed to ensure that at least 90 percent of the target Marketplace-eligible population in the county can access such a provider. 

• Yes. Returning issuers may download their previous plan year data from MPMS under the Application Tools section. The downloaded template will be in the PY2025 format. Issuers will then make any applicable changes and upload their new NA template back into MPMS for validation and review.

• The table below displays the MPMS Network Adequacy Validations introduced in the 2025 plan year as well as best practices to avoid errors and warnings.

• CMS has developed state-specific hospital caps in the form of an MPMS validation to ensure that issuers do not exceed the maximum number of General Acute Inpatient Hospitals operating in a state when reporting their in-network General Acute Inpatient Hospitals via their NA Template. 

• There is no place within the actual Network Adequacy Template to add notes. If you have specific notes to provide concerning a provider, please submit a helpdesk ticket to alert CMS.

• While it is possible to submit to CMS a Network Adequacy (NA) Justification Form that has missing data, it is not advisable because missing data for required fields will count against you for certification and compliance purposes. It is expected that issuers continue to make progress toward compliance with NA standards during the QHP certification process by submitting updated NA Templates and NA Justification Forms until all corrections are addressed and standards are met. If an issuer believes they have addressed all corrections within their updated NA Template that they have submitted via the Marketplace Plan Management System (MPMS), the issuer is not required to submit completed NA Justification Forms for that round.

• In this situation, issuers should first confirm with their state what data the state requires to be submitted on the Network Adequacy (NA) Template. If the state confirms that submission of network adequacy data on the NA Template is not required, issuers should enter the dummy data as described below on the ‘Network Adequacy Provider’ tab to enable validation of the NA Template without network adequacy data.

• Issuers must list all in-network individual and facility providers on the ‘Network Adequacy Provider’ tab of the Network Adequacy (NA) Template. When completing the Specialty Type column on those tabs, the issuer should select all specialties offered at the identified provider location. If a provider has multiple specialties at the same address, select all the specialties in the same record. If entering more than one facility type, each facility type must be separated by a comma and a space. For example, if an issuer has an in-network hospital where cardiac surgery is also available in-network, that facility can be listed on one row of the ‘Network Adequacy Provider’ tab of the NA Template with both acute inpatient hospital and cardiac surgery program selected for the Specialty Type column. If an issuer only lists acute inpatient hospital as the Specialty Type and does not list cardiac surgery program, that facility will only count towards meeting the time and distance standards for acute inpatient hospitals.

• Issuers should only list the provider specialties that a provider currently practices and is licensed, accredited, or certified to practice in their state, as applicable. For example, if a provider previously completed a fellowship in cardiology, but currently works only as an emergency medicine physician, the provider should only be listed under emergency medicine.

• As explained in the Network Adequacy (NA) section of the Plan Year (PY) 2025 QHP Issuer Application Instructions, issuers should include a list of all the providers in each of the proposed networks for which CMS is conducting network adequacy reviews, even those outside of the immediate geographic area that are meeting time and distance requirements. Providers must meet the following requirements be appropriately licensed, accredited, or certified to practice in their state, as applicable; and offer in-person services. 

• CMS will assess network breadth based on analysis of a QHP issuer's Network Adequacy (NA) Provider Data. Issuers will submit NA Provider Data via the NA Template as part of the Plan Year 2025 certification process.

• For issuers that receive required corrections assigned by CMS that pertain to unmet Network Adequacy (NA) standards, CMS will provide a partially pre-populated NA Justification Form, as applicable, via the HIOS Marketplace Plan Management System (MPMS) Module after each QHP review round. Issuers must download the respective form from the HIOS MPMS Module, complete all required fields within the form, and then upload the completed Excel form to the HIOS MPMS Module by the required deadline.

• If CMS determines that a QHP applicant does not meet one or more Network Adequacy (NA) standards, the issuer can:

• Yes, issuers in states performing plan management functions should use the same Network Adequacy (NA) Template as issuers in Federally-facilitated Exchange (FFE) states that are not performing plan management functions.

• If an issuer does not see a specific specialty type listed in the 'Specialty Types' tab, it should refer to the 'Taxonomy Codes' tab in the Network Adequacy (NA) Template to select the correct specialty type. If the issuer cannot locate a taxonomy code, the provider type has not been approved as an appropriate type for QHP certification review.

• Taxonomy codes that map to each individual provider and facility provider specialty type are listed in the Network Adequacy (NA) Template and the Network Adequacy Justification Form so that issuers know which providers to include in which individual provider and facility provider specialty categories.

• For PY2025, CMS will collect from QHPs via the Network Adequacy (NA) Template information on whether providers participating in their network offer telehealth services. For each provider, issuers will indicate whether that provider offers telehealth by selecting one of the following responses: ‘Yes,’ ‘No,’ or ‘Requested information from provider and awaiting their response.’

• CMS evaluates QHP issuer compliance with network adequacy time and distance standards by reviewing provider data for in-network providers that QHP issuers submit via the Network Adequacy (NA) Template. For each provider specialty, CMS reviews the QHP issuer-submitted data to ensure that the plan provides access to at least one provider for each of the provider specialty types for at least 90 percent of the Marketplace-eligible population in the county (see FAQ describing the target QHP Population Sample File). In order to satisfy this standard, the issuer may be required to contract with more than one provider of a given provider specialty type if more than one provider is needed to ensure that at least 90 percent of the target Marketplace-eligible population in the county can access such a provider. 

For example, in a large metro county type, the issuer must ensure that at least 90 percent of the Marketplace-eligible population in the county has reasonable access to at least one endocrinologist within 15 miles and 30 minutes. Note that for network adequacy standards, the provider may be located outside of the county in which the Marketplace-eligible population resides, so long as the provider's location is within the time and distance requirements of the Marketplace-eligible population for the given provider specialty type.