The 5 Biggest Myths About CMS Network Adequacy

Why Myths Persist in a Regulatory Environment

Network adequacy compliance is dense enough that misconceptions take root easily. A plan's compliance team learns a rule in year one, codifies it into internal policy, and repeats it for five years without revisiting whether CMS guidance has shifted. A consultant passes along an interpretation that was accurate in 2019 but is no longer operative. A network VP remembers how the standards worked at their prior employer and applies the same assumptions to a different market, a different product type, and a different regulatory year.

The result is a set of persistent myths that cost plans real money — failed filings, deficiency remediation, delayed market entry. Below are the five most consequential ones, with the accurate picture for each.

Myth 1: Telehealth Always Counts Toward Adequacy

This is the most dangerous myth in current circulation, because it contains a grain of truth that makes it sound authoritative. Telehealth can count toward network adequacy determinations — CMS has expanded its recognition of telehealth, particularly for behavioral health, in recent years. But "can count" is doing a lot of work in that sentence, and many plans have treated it as "always counts."

The accurate picture: telehealth provider credit is specialty-specific, product-specific, and requires precise documentation. A telehealth-credentialed behavioral health provider may satisfy time-distance standards in certain county types under certain conditions. A telehealth cardiologist does not automatically satisfy the in-person cardiology access standard for a county with no contracting cardiologists within the required distance. CMS's recognition of telehealth is not a blanket offset for physical access gaps.

The documentation requirement alone disqualifies many plans from the credit they assume they're receiving. The telehealth provider must be properly credentialed, the service agreement must explicitly cover the county in question, and the HSD table must correctly identify the arrangement. Plans that add a telehealth vendor to their network and assume it resolves specialty shortages across the board are going to learn the limits of that assumption from a deficiency notice.

Myth 2: HSD Categories Are Fixed

Health Service Delivery (HSD) table categories — the specialty types that CMS requires plans to demonstrate access to — are not immovable. CMS updates its required specialty categories periodically, adds specialties, adjusts the definitions of existing categories, and in some years makes changes that take effect for the upcoming filing cycle with limited advance notice.

Plans that build their network strategy around a static HSD category list from a prior year are building toward the wrong target. This is especially consequential when a specialty is added or when the counting rules for an existing specialty change. A plan that has not reviewed the current HSD requirements against its prior-year strategy may discover gaps in specialties it didn't know it needed to cover — after the submission window has opened.

The correct posture is to treat HSD categories as annually verified, not assumed. Pull the current HPMS filing instructions and HSD table requirements at the start of each build cycle and diff them against last year. Changes are not always telegraphed prominently.

Myth 3: A Single Provider Satisfies Any County

Many network build leaders operate under the impression that if they have one in-network provider for a required specialty within a county's time-distance threshold, that county is covered. This is incorrect in two distinct ways.

First, CMS applies a minimum provider count standard for certain specialties in certain county types. Urban counties in particular may require more than one in-network provider for primary care and several key specialties. A single provider in a dense urban county will not satisfy adequacy requirements regardless of geographic proximity.

Second, and more practically: a single provider in any county is an adequacy risk even when CMS does not require multiples. If that provider retires, terminates their contract, stops accepting new patients, or changes their practice scope between submission and the CMS review period, the county falls out of compliance. Plans that have single-provider coverage in any specialty-county combination are sitting on contingent deficiencies that one practice-level event can activate.

The operational standard should be redundancy, not minimalism. A county covered by two providers in a required specialty is not gold-plating — it is the minimum defensible position.

Myth 4: Deficiency Notices Are Negotiable

There is a persistent belief in plan operations circles that a deficiency notice is the beginning of a conversation, not a finding — that a well-written response can negotiate the underlying adequacy standard down to a level the plan can meet, rather than simply demonstrating compliance with the standard that exists.

This is wrong, and acting on it is expensive. CMS's deficiency response process provides a response window — typically 30 to 60 days depending on the filing type — during which a plan can submit corrective documentation, evidence of good faith outreach, or evidence that new providers have been contracted and credentialed to close the gap. What the process does not provide is flexibility on the standard itself. A county that fails the time-distance test requires either a compliant provider or an approved exception based on documented good faith and alternative access arrangements. A well-written letter explaining why the standard is unreasonable for that county is not a path to approval.

Deficiency notices are correctable, not negotiable. The correction is provider access, exception documentation, or both — not persuasive writing about market conditions.

Plans that approach deficiency response as a negotiation tend to spend their response window drafting arguments instead of building the provider access or documentation record they actually need to close the deficiency. That misallocation of effort ends in inadequate remediation and an escalated compliance situation.

Myth 5: Passing Once Means Passing Again

A plan that filed a compliant network in the prior cycle has no guarantee of compliance in the current cycle. Provider rosters are not static. Providers retire, relocate, and terminate contracts. Specialties shift between scarcity and availability. CMS updates county-type classifications, which changes the applicable time-distance standards for individual counties. A county that was a comfortable pass last year may be a borderline failure this year if a provider left and the applicable threshold tightened.

The plans that treat a prior approval as a baseline they can coast from are the plans that discover mid-build that their "stable" network has drifted out of compliance in three specialties across a dozen counties. The prior year's submission is a starting point for the current year's analysis, not a proxy for it. Every build cycle requires a full county-by-specialty assessment against current standards and current provider status — not a diff of what changed since last year. The diff approach misses the cumulative drift that occurs when multiple small changes compound.

Persistent compliance is an active posture, not a status that persists once achieved.