Redline: Network Adequacy Guidance

Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance
(Last updated: April 2024)

Medicare Advantage and Section 1876
Cost Plan Network Adequacy Guidance
(Last updated: April 2024)

Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance
(Last updated: April 2024)

Table of Contents
1. Introduction ............................................................................................................................. 1
2. Network Adequacy Requirements ......................................................................................... 1
2.1. Specialty Types............................................................................................................... 2
2.2. Provider and Facility Health Service Delivery (HSD) Tables.................................... 2
2.3. Provider and Facility Supply File................................................................................. 2
3. Triennial Network Adequacy Reviews .................................................................................. 3
3.1. Triggering Events ...........................................................................................................3
3.2. Timing of Network Adequacy Reviews ........................................................................ 4
3.3 Organization- Initiated Testing of Contracted Networks .......................................... 4
4. Exceptions to Network Adequacy Criteria. .......................................................................... 4
4.1. Criteria for Submitting Exception Requests ............................................................... 5
4.2. Standards for Evaluating Exception Requests ............................................................ 6
4.3. Exception Request Upload Instructions ....................................................................... 7
5. Specific Circumstances ............................................................................................................. 7
5.1. Partial Counties. .............................................................................................................. 7
5.1.1. Partial County Justification Submission Instructions ....................................... 9
5.1.2. Partial County Request in the Application Module .......................................... 9
5.2. Regional Preferred Provider Organizations ................................................................ 9
5.2.1. RPPO-Specific Exception to Written Agreements ........................................ 9
5.3. Sub-Networks ................................................................................................................ 10
5.4. Certificate of Need Credit ............................................................................................ 10
5.5. Telehealth Credit .......................................................................................................... 11
5.6. New or Expanding Service Area Applicant Credit………………………………...11
5.7. Letter of Intent during the Application Process

Appendix A: Crosswalk of HSD Specialty Code to Provider and Facility Specialties ......... 12
Appendix B: Partial County Justification Template ............................................................. 14
Appendix C: External Links .................................................................................................. 16

Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance
(Last updated: April 2024)
pg. i

Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance
(Last updated: April 2024)

1.

Introduction

The Centers for Medicare & Medicaid Services (CMS) regulations at 42 C.F.R. 417.414, 42 C.F.R.
417.416, 42 C.F.R. 422.112(a)(1)(i), and 42 C.F.R. 422.114(a)(3)(ii) require that all
Medicare Advantage (MA) organizations offering coordinated care plans (CCP), network-based private
fee-for-service (PFFS) plans, network-based medical savings account (MSA) plans, as well as section
1876 cost organizations, maintain a network of appropriate providers that is sufficient to provide adequate
access to covered services to meet the needs of the population served1. These organization types must
provide enrollees health care services through a contracted network of providers that is consistent with
the prevailing community pattern of health care delivery in the network service area (see 42 C.F.R.
422.112(a)(10)).
In June 2020, CMS published MA and Cost plan network adequacy rules at 42 C.F.R.
422.116 to codify our existing network adequacy methodology and finalize policies that address
maximum time and distance standards in rural areas, telehealth, and Certificate of Need (CON) laws. The
standards identified at § 422.116 define how CMS quantifies prevailing community patterns of health
care delivery for each provider and facility specialty type in each county in a service area.
In May 2022, CMS finalized revisions at 42 C.F.R. § 422.116
(https://www.federalregister.gov/documents/2022/05/09/2022-09375/medicare-program-contract-year-2023policy-and-technical-changes-to-the-medicare-advantage-and) which would establish the requirement beginning
for contract year 2024, that applicants for a new or expanding service area must demonstrate compliance with
network adequacy standards as part of an MA application and that CMS may deny an application on the basis of
an evaluation of the applicant's network. Additionally, the revisions added a 10-percentage point credit for new
and service area expansion applicants, and that CMS will allow Letters of Intent (LOIs) to be used in lieu of a
signed provider contract, at the time of application and for the duration of the application review.
In April 2023, CMS finalized revisions at 42 C.F.R. § 422.116 (b)(1) to include Clinical Psychology and
Clinical Social Work under the specialty types applicable to network adequacy evaluation. CMS also
amended 422.116(d)(5) to include Clinical Psychology and Clinical Social Work to the list of specialties
eligible for the 10-percentage point credit towards the percentage of beneficiaries residing in published time
and distance standards when a plan includes one or more telehealth providers that provide additional
telehealth benefits in its contracted networks.
In April 2024, CMS finalized revisions to 42 C.F.R. § 422.116 to include Outpatient Behavioral Health under
the specialty types applicable to network adequacy evaluation. CMS also amended 422.116(d)(5) to include
Outpatient Behavioral Health to the list of specialties eligible for the 10-percentage point credit towards the
percentage of beneficiaries residing in published time and distance standards when a plan includes one or
more telehealth providers that provide additional telehealth benefits in its contracted networks.
Specialists under this category will include MFTs (Marriage and Family Therapists) and MHCs (Mental
Health Counselors), Opioid Treatment Program providers, Community Mental Health Centers, addiction
medicine physicians, and other providers who furnish addiction medicine and behavioral health counseling or

1

MA regional preferred provider organizations (RPPOs) are an exception and, under specified conditions and upon CMS preapproval, can arrange for care in portions of a regional service area on a non-network basis (42 C.F.R.
422.112(a)(1)(ii)).

1

Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance
(Last updated: April 2024)

therapy services in Medicare today.
To be considered as regularly furnishing behavioral health services for the purposes of this regulation, a
physician assistant, nurse practitioner, or clinical nurse specialist must have furnished specific psychotherapy
or medication prescription services to determine that a physician assistant, nurse practitioner, or clinical nurse
specialist meets the standard in paragraph (b)(2)(xiv)(A).
Finally, CMS finalized regulations to broaden the acceptable rationales for an exception from the
requirements in § 422.116(b) through (e) for facility-based I-SNPs. We proposedfinalized regulations that
allow facility-based I-SNPs mayto request an exception from the network adequacy requirements.
The purpose of this document is to provide additional information related to network adequacy reviews
and how they are conducted in accordance with the standards set at § 422.116. Please note that the
guidance contained in this document does not apply to the following product types: Medicare/Medicaid
Plans (MMPs), section 1833 cost plans, non-network PFFS plans, and MSA plans.

2.

Network Adequacy Requirements

Organizations must meet current network adequacy requirements as defined under 42 C.F.R.
422.1162 3 CMS requires that organizations continuously monitor their contracted networks throughout
the respective contract year to ensure compliance with the current network adequacy criteria.
CMS network adequacy criteria includes provider and facility specialty types that must be available
consistent with CMS number, time, and distance standards. Access to each specialty type is assessed using
quantitative standards based on the local availability of providers and facilities to ensure that organizations
contract with a sufficient number of providers and facilitiesto furnish health care services without placing
undue burden on enrollees seeking covered services.
CMS programs network adequacy criteria into the Network Management Module (NMM) in the Health
Plan Management System (HPMS) to conduct an automated review of an organization’s network
adequacy. CMS also provides organizations an opportunity to request exception(s) to the network
adequacy criteria.
2.1.
Specialty Types
CMS measures 29 provider specialty types and 14 facility specialty types to assess the adequacy of the
network for each service area. CMS has created specific codes for each of the provider andfacility
specialty types which may be found in Appendix A. Organizations must use the codes when completing
Provider and Facility HSD Tables. Additional information on specialty types and codes is available in the
current HSD Reference File posted on CMS’s website and in the Network Management Module HPMS
User Guide.

The term “organization” used throughout this document refers to both MA organizations and section 1876 cost organizations.
Provider-Specific Plans (PSPs) are also subject to CMS network adequacy requirements. As part of the bid submission
process that begins in June, an organization offering a PSP must confirm and attest that the PSP’snetwork meets current
CMS network adequacy standards.

2

3

2

Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance
(Last updated: April 2024)

2.2.
Provider and Facility Health Service Delivery (HSD) Tables
Contracts are required to demonstrate network adequacy through the submission of provider and facility
Health Service Delivery (HSD) Tables in the Network Management Module (NMM) in HPMS. An
organization must list every provider and facility with a fully executed contract in its network in the HSD
Tables45. Organizations can refer to the NMM Plan User Guide, sections “Specialty Types” and
“Preparing Your Submission,” for detailed instructions on populating HSD tables.
In order for the NMM to process the information, organizations must submit provider and facility names
and addresses exactly the same way each time, including spelling, abbreviations, etc. Providers should be
listed at the address(es) where they see patients in an office-based setting for consultations and not at a
location where they solely perform procedures, (e.g., an orthopedic surgeon should be listed at his/her
office location, not the hospital where he/she performs surgical procedures). Any differences will result
in problems processing data and may result in network deficiencies. CMS expects all organizations to use
the NMM to check their networks and to review the results to ensure that their provider and facility HSD
Tables are accurate and complete.
The following providers and facilities do not count toward meeting network adequacy criteria:
• Specialized, long-term care, and pediatric/children’s hospitals
• Providers that are only available in a residential facility.
• Providers and facilities contracted with the organization only for its commercial,
Medicaid, or other products.
2.3. Provider and Facility Supply File
The supply file is a cross-sectional database that includes information on provider and facility name,
address, national provider identifier, and specialty type and is posted by state and specialty type. The
supply file is segmented by state to facilitate development of networks by service area.Contracts with
service areas near a state border may need to review the supply file for multiple states, as the network
adequacy criteria are not restricted by state or county boundaries. The current supply file is published in
HPMS>Monitoring>Network Management>Documentation>Reference Files.
Given the dynamic nature of the market, the file is a resource and may not be a complete depiction of
the provider and facility supply available in real-time. MA organizations remain responsible for
conducting validation of data used to populate HSD tables, including data initially drawn from the
supply file. MA organizations should not rely solely on the supply file when establishing networks, as
additional providers and facilities may be available.
CMS uses the supply file when validating information submitted on exception requests. Therefore, CMS
may update the supply file periodically to reflect updated provider and facility information and to capture
information associated with exception requests.

3.

Triennial Network Adequacy Reviews

4

RPPOs may list on their HSD tables those non-contracted providers and facilities for which they have a CMS pre-approved
exception to the written agreement (42 C.F.R. 422.112(a)(1)(ii)).

5

Initial applicants and Service Area Expansion applicants may list providers without fully executed contracts if they submit a valid
Letter of Intent during the application process.

3

Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance
(Last updated: April 2024)

CMS monitors network compliance by reviewing contract-level networks on a triennial basis.This
requires each contract to upload its full network into the NMM in HPMS. For more information, please
see the Office of Management and Budget (OMB)-approved information collection “Triennial Network
Adequacy Review for Medicare Advantage Organizations and 1876 Cost Plans” (OMB 0938-1346,
CMS-10636).
3.1.
Triggering Events
CMS may perform a network review after specific triggering events. Triggering events include:
1. Application: Any organization seeking to offer a new contract or to expand their servicearea must
demonstrate compliance with network adequacy requirements in the proposed service area at the
time of such MA applications; applicants that utilized LOIs to meet network adequacy standards
during the application process are required to participate in the triennial review in the first year that
the contract(s) are operational in the new service area.
2. Significant provider/facility contract termination: When a contract between an organization
and a provider or facility is terminated, and CMS determines it to be significant, then CMS may
request to review the network to ensure ongoing compliancewith network adequacy
requirements. For more information on significant network changes, please refer to chapter 4 of
the MMCM.
3. Network access complaint: If CMS receives complaints from an enrollee, caregiver, or other
source that indicates an organization is not providing sufficient access to covered health care
services, CMS may elect to review the organization’s contracted network.
4. Organization-disclosed network gap: CMS requires organizations to monitor their networks for
compliance with the current network adequacy requirements. CMS requires organizations to notify
their CMS Account Managers upon discovery that their network isout of compliance. Once
notified, CMS may request that the organization upload its contracted network for CMS review.
CMS will provide organizations with specific instructions for submitting their contracted networks
and identify a specific submission timeframe. If an organization experiences a triggering event
requiring a full network review, then the timing of that organization’s subsequent triennial
review may be reset.
3.2.
Timing of Network Adequacy Reviews
Prior to the formal triennial network review, CMS provides organizations the opportunity to upload their
networks in the NMM for an informal review and technical assistance, also referred to as Consultation.
Applicants and contracts due for their triennial review will be prompted to upload their health service
delivery (HSD) tables into the NMM as part of the application process, and in mid-June, respectively, for
CMS review.
Applicants that utilized LOIs to meet network adequacy standards during the application process are
required to participate in the triennial review in the first year that the contract(s) are operational in the
new service area.
Initial and service area expansion (SAE) applicants must upload their tables for the upcoming contract
year, while organizations due for their triennial review must upload their tables for the current contract
year.
CMS may deny an organization’s application if they fail to meet network adequacy requirements.
4

Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance
(Last updated: April 2024)

Contracts that fail to meet network adequacy requirements during the contract year may be subject to
compliance or enforcement actions.
3.3
Organization-Initiated Testing of Contracted Networks
Organizations with a contract ID number have the opportunity to test their contracted networks’
compliance with network adequacy criteria at any time via the NMM in HPMS. Once an organization
initiates its HSD table upload, the NMM will automatically review the contracted network against CMS
network adequacy criteria for each required provider and facility type in each county.
Organizations can refer to the Evaluate My Network section in the NMM User Guide for detailed
instructions on how to submit an Organization Initiated Upload, and ACC Extracts section for instructions
on how to view the Automated Criteria Check (ACC) report in HPMS. The ACC report displays the
results of the automated network review for each provider and facility. The results are displayed as either
“PASS” or “FAIL.” The NMM also contains the ZIP Code Report for Failed Counties that lists the areas
where enrollees do not have adequate access.
Organizations may find the ZIP Code Report for Failed Counties using the following navigationpath:
HPMS Home Page>Monitoring>Network Management>ACC Extracts.

4.

Exceptions to the Network Adequacy Criteria

Although the time and distance standards vary by county and specialty type, and are generally attainable
across the country, there are unique instances where a given county’s supply of providers/facilities is such
that an organization would not be able to meet the network adequacy criteria. The exceptions process
allows organizations to provide evidence to CMS when the health care market landscape has changed or
does not reflect the current CMS network adequacy criteria. The exceptions standards are outlined at 42
C.F.R. § 422.116(f).
The organization must include conclusive evidence in its exception request that the CMS network
adequacy criteria cannot be met because of changes to the availability of providers/facilities, resulting in
insufficient supply. The organization must then demonstrate thatits contracted network (i.e.,
providers/facilities included on its HSD tables) furnishes enrollees with adequate access to covered
services and is consistent with or better than the Original Medicare pattern of care for a given county and
specialty type.

4.1. Criteria for Submitting Exception Requests
Generally, organizations use the exception process to identify when the supply of providers/facilities
is such that it is not possible for the organization to obtain contracts thatsatisfy CMS’s network
adequacy criteria.
Per 42 C.F.R. § 422.116(f)(1), an MA plan may request an exception to network adequacy
criteriaadequacy criteriawhen both of the following occur:
• Certain providers or facilities listed in the Provider Supply file are not available for the
organization to meet the network adequacy criteria for a given county and specialty type.
• The organization has contracted with other providers and facilities located beyond the limits in the
time and distance criteria, but are available and accessible to most enrollees,consistent with the
5

Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance
(Last updated: April 2024)

•
•

local pattern of care; or.
A facility-based Institutional-Special Needs Plan (I-SNP) is unable to contract with certain
specialty types required under §422.116(b) because of the way enrollees in facility-based I-SNPs
receive care; or
A facility-based I-SNP provides sufficient and adequate access to basic benefits through additional
telehealth benefits (in compliance with § 422.135 of this chapter) when using telehealth providers
of the specialties listed in paragraph (d)(5) in place of in-person provider to fulfill network
adequacy standards in paragraphs (b) through (e).

Valid rationales to submit exception request may include, but are not limited to:
• Provider is no longer practicing (e.g., deceased, retired).
• Does not contract with any organizations or contracts exclusively with another
organization.
• Provider does not provide services at the office/facility address listed in the supply file.
• Provider does not provide services in the specialty type listed in the supply file.
• Provider has opted out of Medicare.
• Sanctioned provider on List of Excluded Individuals and Entities.
• Use of Original Medicare telehealth providers or mobile providers
• Specific patterns of care in a community
There are instances when CMS will consider an organization’s reason for not contracting with anavailable
provider/facility. For example, based on substantial and credible evidence, CMS will consider an
organization’s claim that an available provider may cause beneficiary harm. On the exception request,
from the “Reason for Not Contracting” drop-down list, the organization must select “Other,” and provide
evidence in the “Additional Notes on Reason for Not Contracting” field.
On the exception request, from the “Reason for Not Contracting” drop-down list, an organizationcould
select either “Provider does not contract with any organization” or “Other” if the provider/facility contracts
exclusively with another organization. The organization must provide evidence in the “Additional Notes
on Reason for Not Contracting” field.
An organization could provide substantial and credible evidence that an available provider is
inappropriately credentialed under MA regulations (42 C.F.R. 422.204, Chapter 6 of the MMCM). On
the exception request, from the “Reason for Not Contracting” drop-down list, theorganization must
select “Other” or “Provider does not provide services in the specialty type listed in the database and for
which this exception is being requested,” as appropriate. The organization must then provide evidence in
the “Additional Notes on Reason for Not Contracting” field.6
An organization could provide substantial and credible evidence that they use Original Medicare
telehealth providers or mobile health providers to fulfill network adequacy requirements.
For organizations using Original Medicare telehealth providers, services must meet the requirements for
“Medicare telehealth services” under section 1834(m) of the Social Security Act (the Act) (e.g. provider
types, eligible originating sites, geography, and currently approved list of Medicare telehealth services), as
CMS will generally not accept an organization’s unwillingness to contract with an otherwise qualified
provider/facility due to the organization’s own internal standards.
6

6

Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance
(Last updated: April 2024)

well as the requirements for “communication technology-based services” not subject to the section
1834(m) limitations (brief communication technology- based service/virtual check-in, remote evaluation of
pre-recorded patient information, and inter- professional internet consultation). The organization must
demonstrate that it meets all applicable requirements.
If an organization uses Mobile Providers (e.g., mobile x-ray suppliers, orthoticsorthotics, and prosthetics
mobile units), they must be qualified and furnish services in a scheduled manner.
Organizations requesting an exception using the “Pattern of Care” rationale should provide substantial and
credible evidence that shows there is an insufficient supply of providers/facilities, as well as why they do
not contract with available providers/facilities. The organization must show that the pattern of care in the
area is uniqueunique, and the organization believes their contracted network is consistent with or better
than the Original Medicare pattern of care.
On the exception request PDF, an organization must compare the non-contracted providers/facilities
closer to enrollees in terms of time and distance to other providers/facilities that may be located farther
away. From the “Reason for Not Contracting” drop-down list, an organization could select “Other” and
then provide evidence in the “Additional Notes on Reasonfor Not Contracting” field that demonstrates
that the organization did not contract with the available provider/facility because the organization’s
current network is consistent with or betterthan the Original Medicare pattern of care. For this pattern of
care rationale, CMS will consider the following in the “Additional Notes on Reason for Not Contracting”
field:
• Internal claims data with an explanation that demonstrates the current pattern of care forenrollees
in the given county for the given specialty type, or
• Detailed explanation that supports the rationale that the contracted network provides access
that is consistent with or better than the Original Medicare pattern of care.
4.2. Standards for Evaluating Exception Requests
Per § 422.116(f)(2), in evaluating exception requests, CMS considers whether:
• The current access to providers and facilities is different from the HSD reference andProvider
Supply files for the year;
• There are other factors present that demonstrate that network access is consistent with orbetter
than the Original Medicare pattern of care (§ 422.112(a)(10)(v)); and
• Approval of the exception is in the best interests of beneficiaries.
Finally, CMS will generally not accept an organization’s assertion that it cannot meet current CMS
network adequacy criteria because of an “inability to contract,” meaning they could not successfully
negotiate and establish a contract with a provider/facility. The non-interference provision at section
1854(a)(6) of the Act prohibits us from requiring any MA organization tocontract with a particular
hospital, physician, or other entity or individual to furnish items and services or require a particular price
structure for payment under such a contract. As such, we cannot assume the role of arbitrating or judging
the bona fides of contract negotiations between an MA organization and available providers or facilities.
Because of the way enrollees in facility-based I-SNPs receive care, if a facility-based I-SNP is unable to
contract with certain specialty types, we will accept this as a valid rationale.
4.3. Exception Request Upload Instructions
Please refer to the NMM User Guide sections How to Request Exceptions, How to Upload Documentation for
7

Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance
(Last updated: April 2024)

Exceptions and How to Check the Status of an Exception Request for detailedinstructions on how to upload an
exception.
Organizations must resubmit all previously approved exception requests whenever CMS requests an
organization to upload its HSD tables. Organizations must use the current exception request template and
submit the template in accordance with CMS communications. The current exception request template is
located in HPMS>Monitoring>Network Management>Documentation>TemplatesTemplates.
Organizations should upload their exception forms and any applicable supporting documentation (e.g.,
maps, screenshots, letters, etc.) in a single (zipped) exception upload. Forms and supporting documentation
for a given exception request should not be merged together within a single PDF file. Instead, please
provide individual PDF files for forms and supporting documentation Organizations should submit
supplemental documentation (e.g., maps, screenshots, letters) at end of the exception request template, in
order for CMS to validate the applicable rationale.

Organizations that need additional rows in the Non-Contracted Providers section of the MA Exception form
must add all overflow entries into the MA Exception Template Non-Contracted Providers Overflow template
and submit the file as a continuation of the main exception form.
For exception requests with more than 25 providers in Part V:Table of Non-Contracted Providers on the
exception request template, organizations should submit two separate exception request PDFs to ensure
that all provider rows are captured. In these cases, organizations should submit a second exception request
PDF with the following naming convention: HXXXX_12345_001_Part 2.

5.

Specific Circumstances

This section provides guidance on specific circumstances or flexibilities that may apply
depending on the organization’s contracted network and service area.
5.1
Partial Counties
Organizations submitting networks for CMS review against the current network adequacy criteria
may have full county service areas or partial county service areas.
If an organization offering a local MA plan has an approved partial county service area, it means that they
have an approved exception to the CMS county integrity rule as outlined at 42 C.F.R.
422.2. Specifically, the inclusion of a partial county service area must be determined by CMS to be:
1) Necessary,
2) Nondiscriminatory, and
3) In the best interests of the beneficiaries.
CMS may also consider the extent to which the proposed service area mirrors the service area ofexisting
commercial health care plans or MA plans offered by the organization.
Necessary
For CMS to determine that a partial county is necessary, an organization must be able to demonstrate that
it cannot establish a provider network to make health care services availableandavailable and accessible to
beneficiaries residing in the portion of the county to be excluded from the service area.
The following examples illustrate how a local MA plan may have a health care network that is islimited
8

Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance
(Last updated: April 2024)

tolimited to one part of a county and cannot be extended to encompass an entire county.
•

•

A section of a county has an insufficient number of providers or insufficient capacity among
existing providers to ensure access and availability to covered services. For example, the
organization can submit evidence demonstrating insufficient provider supply (e.g., list of noncontracted provider names/locations and valid reasons for notcontracting).
Geographic features (e.g., mountains, water barriers, large national park) or exceptionally large
counties create situations where the local pattern of care in the county justifies less than a complete
county because covered services are not available and accessible throughout the entire county. For
example, the organization can demonstrate the geographic features or characteristics of the county
using a clear, current map showing the barriers creating access issues.

The inability to establish economically viable contracts is not an acceptable justification for approving a
partial county service area, as it is not consistent with CMS regulations. CMS may validate statements
made on the Partial County Justification. However, CMS will consideran organization’s justification
for a partial county if a provider/facility either:
•
•

Does not contract with any organizations, or
Contracts exclusively with another organization.

CMS will consider these two justifications if the organization provides substantial and credible evidence.
For example, an organization could submit letters or e-mails to and from the providers’offices
demonstrating that the providers were declining to contract with any MA organization; thus no MA
organizations could be offered in the area in question. Where this evidence is present, CMS would
consider this information when reviewing the partial county request.
Nondiscriminatory
In order for CMS to determine if a partial county is nondiscriminatory, an organization must be able to
demonstrate the following:
•

•

The anticipated enrollee health care cost in the portion of the county it proposes to serve is
comparable to the excluded portion of the county. For example, the organization can demonstrate
its anticipated cost of care (in the partial county area) by using data from the previous year of
contracting, comparing the health care costs of its enrollees in the excluded area to those in the
area of the county it proposes to serve; and
The racial and economic composition of the population in the portion of the county it proposes to
serve is comparable to the excluded portion of the county. For example, theorganization can use
current U.S. Census data to show the demographic make-up of theincluded portion of the county
as compared to the excluded portion.

Note: The existence of other MA plans operating in the entire county may provide evidence toCMS that
approving a partial county service area would be discriminatory.
In the Best Interests of the Beneficiaries
In order for CMS to determine whether a partial county is in the best interests of the beneficiaries, an
organization must provide reasonable documentation to support its request. Examples of reasonable
documentation include reliable and current enrollee satisfaction surveys,grievance and appeal files,
9

Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance
(Last updated: April 2024)

utilization information, or other credible evidence.
5.1.1. Partial County Justification Submission Instructions
Organizations may request an exception to the county integrity rule at 42 C.F.R. 422.2 by completing and
submitting a Partial County Justification. Organizations must submit separate justifications for each county
in which the partial county is being requested. Organizations with current partial county service areas
must resubmit their previously approved Partial County Justification(s) whenever CMS requests a network
upload for those service areas in the NMM. Organizations must complete the Partial County Justification
template in Appendix B and submitthe completed template to CMS’s website portal. If an organization
with partial counties fails thenetwork adequacy criteria in a certain area, then the organization may submit
an exception request. Please see section 5 for information on exception requests.
5.1.2 Partial County Request in the Application Module
Organizations requesting partial county service areas for the first time (initial and SAE applicants) and
organizations expanding a current partial county by one or more zip codes (whenthe resulting service area
will continue to be a partial county) must submit their Partial County Justifications with their applications.
For the Application Module, organizations must use the Partial County Justification template in HPMS
and submit the template in accordance with CMS’s application instructions defined in HPMS and
available on our website. Please note that organizations expanding from a partial county to a full county
do NOT need to submit a Partial County Justification template.
5.2
Regional Preferred Provider Organizations
Regional Preferred Provider Organizations (RPPOs) offer MA regional plans, which are a type of MA
coordinated care plan. Unlike other MA coordinated care plans, 42 C.F.R. 422.2 defines the service area
of an MA regional plan as one or more entire regions. Regions consist of one ormore states as opposed to
counties. The list of current RPPO regions is available on CMS’s website.
Following successful HSD table uploads RPPOs will receive the automated results of their review as
discussed in section 4. In the event that an RPPO’s contracted network receives one or more failures on the
ACC reports, the RPPO may submit an ER. However, unlike other organizations, the MA regulation
allows RPPOs to request an exception to written agreements (i.e., operate by non-network means) in those
portions of the regional service area where it is not possible to build a network that meets CMS network
adequacy criteria.
5.2.1. RPPO-Specific Exception to Written Agreements
RPPOs have the flexibility under 42 C.F.R. 422.112(a)(1)(ii), subject to CMS pre-approval, to operate by
methods other than written agreements in those areas of a region where they are unable to establish
contracts with sufficient providers/facilities to meet CMS network adequacy criteria. RPPOs that use this
RPPO-specific exception must agree to establish and maintain a process through which they disclose to
their enrollees in non-network areas how the enrollees can access plan-covered medically necessary health
care services at in-network cost sharing rates(see 42 C.F.R. 422.111(b)(3)(ii) and 42 C.F.R.
422.112(a)(1)(ii)). As discussed in Chapter 1 of the MMCM, CMS expects that the RPPO-specific
exception to written agreements will be limited to rural areas.
Please note that, while this flexibility exists, CMS expects that RPPOs will establish networks in
those areas of the region when there are a sufficient number of providers/facilities within time and
distance criteria available to contract with the RPPO.
10

Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance
(Last updated: April 2024)

1. When the RPPO contract is due for its CMS network review in the NMM, for the providers
and/or facilities for which the RPPO is requesting exceptions to written agreements, the RPPO
must (1) list these providers/facilities on its HSD tables, and (2) enter ‘Y’ under the column
labeled ‘RPPO-Specific Exception to Written Agreements.’This serves as the RPPO’s official
request to CMS for the RPPO-specific exception per42 C.F.R. 422.112(a)(1)(ii).
2. The RPPO will receive information regarding the approval or denial of the RPPO request in CMS’s
formal network review notification.
3. If the RPPO receives CMS’s approval to use methods other than written agreements toestablish
that access requirements are met, then the RPPO must follow all guidance pertaining to this
RPPO-specific exception, including the attestations above.
Please note, any RPPO with a CMS-approved, RPPO-specific exception per 42 C.F.R. 422.112(a)(1)(ii)
must resubmit its request whenever the RPPO contract undergoes a CMS network review in the NMM.
In addition, if there is an indication of enrollee access issues, the RPPO’s disclosure to enrollees residing
in non-network areas is subject to CMS review as necessary (e.g., EOC and/or provider directory).

5.3
Sub-Networks
A sub-network occurs when the network provider group they join guides enrollee access to
providers/facilities. Each provider group furnishes primary care and may furnish specialty and
institutional care. For example, a plan with sub-networks has more than one provider group, andreferrals
by an enrollee’s primary care provider (PCP) are typically made to providers/facilities in the same group.
A plan with sub-networks must allow enrollees to access all providers/facilities in the CMS- approved
network for the plan’s service area; that is, the enrollees may not be “locked-in” tothe sub-network.
If an enrollee wants to see a specialist within their plan's overall network, but that is outside of the referral
pattern of their current PCP in a sub-network, then the plan can require the enrolleeto select a PCP that
can refer the enrollee to their preferred specialist. However, each plan must ensure that it has a network
that meets current CMS network adequacy criteria.
5.4
Certificate of Need Credit
CMS’s network adequacy requirements also account Certificate of Need (CON) laws, or other
anticompetitive restrictions, as described at 42 C.F.R. 422.116(d)(6). In a state with CON laws, or other
state imposed anti-competitive restrictions that limit the number of providers or facilities in the state or a
county in the state, CMS will either award the organization a 10-percentage point credit towards the
percentage of beneficiaries residing within published time and distance standards for affected providers
and facilities or, when necessary due to utilization or supply patterns, customize the base time and distance
standards. CMS conducted extensive analyses to identify all counties and specialties where the CON credit
is applicable publishes the list with the annual Reference File update. Networks submitted to the NMM
will automatically be reviewed for the CON criteria and receive the credit as applicable. Please note, in
accordance with § 422.116(d)(6), the 10% - percentage point credit will not be applied if the county
maximum time and distance standards are customized. For more information about customization, see §
422.116(d)(3).
If an organization determines there are additional county/specialty combinations that are not reflected in
11

Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance
(Last updated: April 2024)

the CON reference file, they may request an exception related to the CON criteria
and must provide
substantial and credible evidence that a provider or facility type is adversely affected by a CON law.
Organizations must use the current exception request template.
Organizations should select “other” as the reason for not contracting on the exception request template
and include supplemental documentation at the end of the PDF. Organizations can find the MA
Exception template at the following navigation path: HPMS>Home>Page>Monitoring>Network
Management>Templates
Organizations should select “other” as the reason for not contracting on the exception request template
and include supplemental documentation at the end of the PDF. Organizations can find the MA
Exception template at the following navigation path: HPMS>Home>Page>Monitoring>Network
Management>Templates.

5.5
Telehealth Credit
Organizations will receive a 10- percentage point% credit towards the percentage of beneficiaries that must
reside within required time and distance standards when they contract with telehealth providers in the
following specialties: Dermatology, Psychiatry, Cardiology, Otolaryngology, Neurology, Ophthalmology,
Allergy and Immunology, Nephrology, Primary Care, Gynecology/ OB/GYN, Endocrinology, Infectious
Diseases Clinical Psychology, and Clinical Social Work and, Outpatient Behavioral Health.
Detailed technical instructions on reporting telehealth providers during a MA organization’s network
submission are outlined in the HPMS NMM Plan User Guide. Organizations can findthe find the Plan User
Guide at the following navigation path: HPMS Home Page>Monitoring>Network
Management>Guidance.
5.6
New or Expanding Service Area Applicant Credit
In May, 2022, CMS finalized changes (CMS-4192-F) to § 422.116. We understand that organizations may
have difficulties with building a full provider network almost one year prior to being approved for an MA
contract. Therefore, beginning for contract year 2024, an applicant for a new or expanding service area
will receive a 10-percentage point credit towards the percentage of beneficiaries residing within published
time and distance standards for the contracted network in the pending service area, at the time of
application and for the duration of the application review. If the application is approved, at the beginning
of the contract year, the MA organization must be in full compliance with network adequacy standards
and the credit would no longer apply.
Networks submitted in the NMM, by initial and SAE applicants, will automatically receive the credit as
applicable.
5.7
Letter of Intent During the Application Process
As part of the network adequacy review process, applicants must notify CMS of their use of each LOI to
meet network standards using the instructions below.
When first submitting their application, applicants may include providers and facilities for whom they
have secured valid LOIs. Applicants must notify CMS that they are using LOIs as follows: 

• Applicants must mark “Y” in the indicated column on the HSD table to denote LOI use.
• Applicants are not required to upload the actual LOI PDFs during application submission. However,
CMS reserves the right to request LOIs at any time during or after the application review process to

Formatted: Font: Not Bold

12

Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance
(Last updated: April 2024)

ensure all applicants and eventual contracts are in compliance with regulatory requirements under §
422.116(d)(7).
Formatted: Indent: Left: 0.38", Tab stops: 0.25", Left

When responding to CMS issued Deficiency Notices and Notices of Intent to Deny, applicants must
resubmit their complete HSD tables. Applicants may include new, additional providers, including
providers and facilities with whom the applicant has secured valid LOIs. Applicants must notify CMS
about their use of an LOI(s), each time the applicant responds to any noted deficiency that they are seeking
to address with an LOI(s).
•
•

If an applicant needs to exclude a provider or facility for whom they no longer have a valid LOI, they
must resubmit the HSD tables without that provider or facility.
If the applicant has successfully secured a contract with the provider or facility, the applicant must
remove the “Y” indicator from the LOI column.
Formatted: Font: Not Bold
Formatted: No bullets or numbering

•

Applicants must mark “Y” in the indicated column on the Health Service Delivery (HSD) table to
notify CMS of the use of LOIs during the network submission. An LOI must be uploaded into the NMM in
HPMS for each county/specialty where the organization has indicated the use of an LOI on their HSD
table, when indicated by CMS. Please review the Network Management Plan User Guide for specific
upload instructions, including for specific instructions for uploading group level LOIs..
• Organizations must provide a one-page LOI in PDF format for each NPI identified in each county/specialty

Formatted: Font: 12 pt
Formatted: Normal, Indent: Left: 0.75", No bullets or
numbering

Formatted: Normal, Indent: Left: 0.38", No bullets or
numbering

listed on the provider or facility table as having a Letter of Intent. This one-page document must include: the
Medicare Advantage Organization’s (MAO) letterhead, and signatures from both the MAO and the provider or
facility.
Files that are too large may not be able to be uploaded with your submission in HPMS (the upload file should be
one zip file not to exceed 500MB).
CMS suggests the use of the following sample language in your one-page LOI:
[MA organization name] [contract number] has signed a letter of intent (LOI) to contract for Contract Year 20xx
with [Provider name and NPI number].
Provider/Facility Signatory Printed Name:
Provider/Facility Signatory Signature:
Provider/Facility Signatory Signature Date:
Organization Signatory Printed Name:
Organization Signatory Signature:
Organization Signatory Signature Date:

Formatted: Indent: Left: 0.38"

13

Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance
(Last updated: April 2024)

Once the MAO is operational, the 10-percentage point credit will no longer apply and the use of LOIs will not be
permitted. If the application is approved, the MAO must be in full compliance with network standards. If a MAO
uses an LOI during the application, the organization will be required to participate in the triennial network
review during the first contract year they are operational.
Additional guidance for LOI submission in the NMM can be found in the NMM Plan User Guide which is
available online: HPMS > Monitoring > Network Management > Documentation > Guidance > User Guide

14

Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance
(Last updated: April 2024)

Appendix A: Crosswalk of HSD Specialty Code to Provide and Facility Specialties
Provider Type Specialties
HSD Specialty
Code

HSD Specialty Name

Medicare Specialty Codes Included

S03

Primary Care

General Practice (01) Family Practice (08), Internal Medicine
(11), Geriatric Medicine (38)

007

Allergy and Immunology

Allergy/Immunology (03)

008

Cardiology

Cardiology (06)

010

Chiropractor

Chiropractic (35)

011

Dermatology

Dermatology (07)

012

Endocrinology

Endocrinology (46)

013

ENT/Otolaryngology

Otolaryngology (04)

014

Gastroenterology

Gastroenterology (10)

015

General Surgery

General Surgery (02)

016

Gynecology, OB/GYN

Obstetrics & Gynecology (16)

017

Infectious Diseases

Infectious Disease (44)

018

Nephrology

Nephrology (39)

019

Neurology

Neurology (13)

020

Neurosurgery

021

Oncology - Medical, Surgical

Neurosurgery (14)
Hematology (82), Hematology-Oncology (83), Medical
Oncology (90), Surgical Oncology (91), Gynecological
Oncology (98)

022

Oncology - Radiation/Radiation
Oncology

Radiation Oncology (92)

023

Ophthalmology

Ophthalmology (18)

025

Orthopedic Surgery

Orthopedic Surgery (20), Hand Surgery (40)

026

Physiatry, Rehabilitative Medicine

Physical Medicine and Rehabilitation (25)

027

Plastic Surgery

Plastic and Reconstructive Surgery (24)

028

Podiatry

Podiatry (48)

029

Psychiatry

Psychiatry (26), Geriatric Psychiatry (27)

030

Pulmonology

Pulmonary Disease (29)

Formatted Table

15

Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance
(Last updated: April 2024)
031

Rheumatology

Rheumatology (66)

033

Urology

Urology (34)

034

Vascular Surgery

Vascular Surgery (77)

035

Cardiothoracic Surgery

Thoracic Surgery (33), Cardiac Surgery (78)

036

Clinical Psychology

Psychologist (62), Clinical Psychologist (68)

037

Clinical Social Work

Licensed Clinical Social Worker (80)

16

Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance
(Last updated: April 2024)

Facility Type Specialties
HSD
Specialty
Code

HSD Specialty Name

040

Acute Inpatient Hospitals

041

Cardiac Surgery Program

042

Cardiac Catheterization Services

043

Critical Care Services – Intensive Care Units (ICU)

045

Surgical Services (Outpatient or ASC)

046

Skilled Nursing Facilities

047

Diagnostic Radiology

048

Mammography

049

Physical Therapy

050

Occupational Therapy

051

Speech Therapy

052

Inpatient Psychiatric Facility Services

057

Outpatient Infusion/Chemotherapy

058

Outpatient Behavioral Health

17

Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance
(Last updated: April 2024)

Appendix B: Partial County Justification Template
Instructions: Organizations requesting service areas that include one or more partial counties
must upload a completed Partial County Justification template into HPMS for each partial county
in the organization’s current and proposed service area.
This template is appropriate for organizations (1) offering a current partial county, (2) entering
into a new partial county, or (3) expanding a current partial county by one or more zip codes
when the resulting service area will continue to be a partial county. This template applies for any
organization that has a partial county as part of its service area. Organizations must complete
and upload a Partial County Justification for any active/existing partial county or
pending/expanding partial county.
Organizations expanding from a partial county to a full county do NOT need to submit a Partial
County Justification.
HPMS will automatically assess the contracted provider and facility networks against the current
CMS network adequacy criteria. If the ACC report shows that an organization fails the criteria
for a given county/specialty, then the organization must submit an exception request using the
same process available for full-county service areas.
NOTE: CMS requests that you limit this document to 20 pages.
SECTION I: Partial County Explanation
The organization must provide CMS short description (two to three sentences) regarding why
they are proposing a partial county service area.
SECTION II: Partial County Requirements
The Medicare Advantage Network Adequacy Criteria Guidance provides guidance on partial
county requirements. The following questions pertain to those requirements.
The organization must explain how and submit documentation to show that the partial county
meets all three of the following criteria:
1. Necessary – It is not possible to establish a network of providers to serve the entire
county.
Describe the evidence provided to substantiate the above statement and (if applicable)
attach it to the template.
2. Non-discriminatory – The organization also must be able to demonstrate the following:
•

The anticipated enrollee health care cost in the portion of the county you are
proposing to serve is comparable to the excluded portion of the county.
Describe the evidence provided to substantiate the above statement and (if
applicable) attach it to the template.

18

Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance
(Last updated: April 2024)

•

The racial and economic composition of the population in the portion of the
county the organization is proposing to cover is comparable to the excluded
portion of the county.
Describe the evidence provided to substantiate the above statement and (if
applicable) attach it to the template.

3. In the Best Interests of the Beneficiaries – The partial county must be in the best
interests of the beneficiaries who are in the pending service area. Organizations must
describe the evidence substantiating the above statement and (if applicable) attach it to
the template.
SECTION III: Geography
The organization must describe the geographic areas for the county, both inside and outside the
proposed service area, including the major population centers, transportation arteries, significant
topographic features (e.g., mountains, water barriers, large national park), and any other
geographic factors that affected the service area designation.

19

Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance
(Last updated: April 2024)

Appendix C: External Links
•

CMS-10636 Triennial Network Adequacy Review for Medicare Advantage Organizations
and 1876 Cost Plans (OMB 0938-1346)
https://www.reginfo.gov/public/do/PRAViewICR?ref_nbr=202010-0938-003

•

CMS-4190-F Contract Year 2021 Policy and Technical Changes to the Medicare Advantage
Program, Medicare Prescription Drug Benefit Program, and Medicare Cost Plan Program
https://www.govinfo.gov/content/pkg/FR-2020-06-02/pdf/2020-11342.pdf

•

CMS-4192-F Contract Year 2023 Policy and Technical Changes to the Medicare Advantage
Program, Medicare Prescription Drug Benefit Programs
https://www.federalregister.gov/documents/2022/05/09/2022-09375/medicare-program-contractyear-2023-policy-and-technical-changes-to-the-medicare-advantage-and

•

CMS-4201-P Contract Year 2024 Policy and Technical Changes to the Medicare Advantage
Program, Medicare Prescription Drug Benefit Programs
https://www.federalregister.gov/documents/2022/12/27/2022-26956/medicare-program-contractyear-2024-policy-and-technical-changes-to-the-medicare-advantage-program

•

CMS- 4201-F1 Contract Year 2024 Policy and Technical Changes to the Medicare Advantage
Program, Medicare Prescription Drug Benefit Programs
https://www.federalregister.gov/documents/2023/04/12/2023-07115/medicare-program-contractyear-2024-policy-and-technical-changes-to-the-medicare-advantage-program

•

CMS-4205-P Medicare Program; Contract Year 2025 Policy and Technical Changes to the
Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost
Plan Program, and Program of All- Inclusive Care for the Elderly; Health Information
Technology Standards and Implementation Specifications
https://www.federalregister.gov/documents/2023/11/15/2023-24118/medicare-program-contractyear-2025-policy-and-technical-changes-to-the-medicare-advantage-program

•

CMS-4205-F Medicare Program; Contract Year 2025 Policy and Technical Changes to the
Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost
Plan Program, and Program of All- Inclusive Care for the Elderly; Health Information
Technology Standards and Implementation Specifications [Link TBD]

•

CMS Medicare Advantage Applications
https://www.cms.gov/Medicare/Medicare-Advantage/MedicareAdvantageApps/index

•

CMS Medicare Plan Finder
https://www.medicare.gov/find-a-plan/questions/home.aspx
20

Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance
(Last updated: April 2024)

•

DMAO Portal
https://dmao.lmi.org/

•

Medicare Managed Care Manual:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-ManualsIOMs-Items/CMS019326
Chapter 4 Benefits and Beneficiary Protections
Chapter 6 Relationships with Providers
Chapter 11 Medicare Advantage Application Procedures and Contract Requirements

•

HPMS NMM User Guide: instructions on how to populate and submit HSD tables and
exception requests
https://hpms.cms.gov ~ Monitoring ~ Network Management ~ Guidance

•

HPMS NMM Reference Files: MA Reference File and MA Supply File
https://hpms.cms.gov ~ Monitoring ~ Network Management~
Documentation~ Reference Files

•

HPMS NMM Templates: Provider, Facility and Exception Templates
https://hpms.cms.gov ~ Monitoring ~ Network Management ~
Documentation~ Templates

21