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Take it freeCMS has tightened time-and-distance standards for Medicare Advantage plans over the past three benefit years. Here's what changed, what's coming, and how network ops teams should prepare their builds.
Medicare Advantage plans have operated under CMS network adequacy standards since the early 2000s, but the past three benefit years have seen a meaningful tightening of those requirements. The 2025 benefit year brought the most substantive revisions in nearly a decade, and network operations teams that haven't updated their modeling frameworks risk filing submissions that no longer meet threshold.
This guide covers the key changes, the specialty categories most affected, and what high-performing network ops teams are doing now to prepare for 2026 benefit year submissions.
CMS sets maximum time-and-distance thresholds for each provider type across urban, suburban, and rural geographies. For 2025, CMS tightened thresholds in several urban and suburban county classifications while also adjusting the definitions of those classifications using updated census tract data.
During the COVID-19 public health emergency, CMS permitted plans to count telehealth providers toward certain network adequacy standards. Those flexibilities are now substantially unwound. For 2025 and going forward, telehealth providers may only count toward adequacy in limited circumstances — specifically for behavioral health and certain primary care categories where CMS has codified telehealth as an acceptable modality in the final rule.
This is arguably the biggest operational change for plans that leaned on telehealth to fill adequacy gaps in thin counties. If your adequacy model was counting virtual-only providers in counties where you had physical provider gaps, those counties now need real contracted providers or exception filings.
CMS now evaluates adequacy across 22 provider specialty categories for MA plans. The categories receiving the most scrutiny in recent audit cycles include:
Plans with gaps in these specialties that previously used exception filings should anticipate tighter scrutiny. CMS has signaled in its Final Rule commentary that repeat exception filings in the same county and specialty category will receive additional review.
The teams that consistently pass adequacy review without corrective action plans share a few common practices:
Network adequacy is increasingly a competitive differentiator. Plans that pass clean on first submission spend less on corrective action overhead and reach market faster. The investment in rigorous pre-submission modeling pays for itself many times over.
Blueprint automates the network build workflows described in this article — from adequacy modeling to provider outreach tracking. See it with your state and line of business.