Network Adequacy and What Health Plans Need to Know for 2025

In today’s episode of Regulatory Joe, we’re diving into the important topic of network adequacy and significant changes that health plans need to be aware of for 2025 and beyond. 

Network adequacy involves establishing time and distance standards to ensure that members of a health plan can access primary care physicians and specialists quickly and compliantly within a specific geography. Typically, this is measured at the county or ZIP code level. 

While network adequacy is by no means new, there are some changes coming down the pipeline. 

Key Changes in 2025 

  • New CMS Guidance 
    The Centers for Medicare & Medicaid Services (CMS) has introduced new guidance for the 2025 network adequacy templates. One notable change is the separation of the Essential Community Providers (ECP) portion from the adequacy template, now available as a separate document online.
  • Quantitative Time and Distance Standards 
    Health plans are now required to aggregate provider data more accurately, enabling clearer measurements and analytics for time and distance standards. This is especially crucial for identifying and closing gaps in network adequacy. 
  • Provider Telehealth Status 
    In response to the increasing use of vritual care, CMS now requires health plans to track and report the telehealth status of providers. This ensures members know if virtual care options are available, though collecting this data can be challenging.

Regulatory Joe’s Recommendations 

  • Stay Informed and Prepared 
    Stay up-to-date with CMS instructions and be in close contact with your CMS account manager. 
  • Early Data Aggregation 
    Begin the data aggregation process early to ensure all ECP providers are included and validation checks are completed timely. 
  • Proactive Telehealth Tracking 
    Develop a process to track telehealth availability proactively, even if not currently required by your state. 
  • Establish a Workgroup 
    Form a workgroup to handle network adequacy submissions, ensuring all stakeholders are informed and involved in the filing process. 

Navigating the changes in network adequacy for 2025 will require diligence and proactive planning. By staying informed and prepared, health plans can ensure they meet new standards and continue to provide adequate care to their members. 

Be sure to watch the full episode for a more detailed run-down of changes and recommendations. 

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