CMS Network Adequacy Standards in 2025: What Every MA Plan Needs to Know

The Regulatory Landscape Has Shifted

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.

Time-and-Distance Standards: What Changed

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.

• Urban counties now require primary care physicians within 10 miles or 20 minutes — down from 15 miles in prior years for certain metropolitan areas
• Specialist time-distance standards for mental health providers were tightened to reflect the growing demand for behavioral health access
• Rural thresholds remain at 60 miles / 60 minutes for most specialties, but CMS added a population-density overlay that reclassified 43 counties previously treated as rural
• Pharmacy access standards were adjusted to require at least two contracted pharmacies within 2 miles for urban members

Telehealth Flexibilities: The Sunset That Matters

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.

Specialty Categories Under the Microscope

CMS now evaluates adequacy across 22 provider specialty categories for MA plans. The categories receiving the most scrutiny in recent audit cycles include:

• Behavioral health (psychiatry, licensed clinical social work, psychology)
• Oncology (medical oncology and radiation oncology evaluated separately)
• Cardiology and interventional cardiology
• Neurology
• OB/GYN

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.

What Network Ops Teams Should Do Now

The teams that consistently pass adequacy review without corrective action plans share a few common practices:

• Run adequacy models at least 90 days before submission using the most current CMS provider enrollment data — not internal claims data, which lags
• Build a gap buffer of 15–20% above threshold for high-scrutiny specialties in urban counties
• Map county reclassifications against your service area before each benefit year — the census tract updates change which standard applies
• Document every exception filing with a detailed rationale and an active outreach log; CMS reviewers want to see that you tried to fill the gap
• Align credentialing close dates with your adequacy model run date — a provider that hasn't cleared credentialing cannot be counted

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.