Understanding Medicare Advantage Network Adequacy Requirements

CY2025 Medicare Advantage Network Adequacy Updates

If you’re in the world of Medicare Advantage, you likely know how crucial it is to stay on top of CMS updates. The Contract Year 2025 Medicare Advantage and Part D Final Rule introduced policy modifications, most notably in the areas of network adequacy and provider directory accuracy. These amendments have the potential to significantly influence the operational dynamics of Medicare Advantage Organizations.

1. Outpatient Behavioral Health as a Facility-Specialty Type

Expansion of Behavioral Health Specialties

One of the major updates is the addition of “Outpatient Behavioral Health” as a facility-specialty type. This category includes various specialties such as Marriage and Family Therapists, Mental Health Counselors, Opioid Treatment Programs, Community Mental Health Centers, Addiction Medicine Physicians, Outpatient Mental Health and Substance Use Treatment Facilities, and Psychotherapy or Prescription of Medication for Substance Use Disorders (including Physician Assistants, Nurse Practitioners, and Clinical Nurse Specialists). The new specialty is in addition to the existing behavioral health requirements for MA organizations.

Network Adequacy Criteria and Evaluation

MA organizations are evaluated for network adequacy during the initial application process, applying for a service area expansion, and during triennial network adequacy reviews. Outpatient Behavioral Health will be included in the Health Services Delivery (HSD) table as part of the network review process. CMS will assess the inclusion of Outpatient Behavioral Health based on MA Network Adequacy criteria, focusing on:

  • Maximum Time and Distance
  • Minimum Number of Facility-Specialty Type in Each County
  • Eligible for 10% Telehealth Credit 

HSD Tables and Limits on Provider Submissions

When submitting HSD tables, MA organizations are restricted from using a single provider to fulfill multiple provider network requirements. For example, a provider cannot be listed simultaneously in categories such as psychiatry, clinical social work, or clinical psychology, and also as an Outpatient Behavioral Health facility.

Provider Verification Requirements: Addressing Ghost Providers

The rule introduces measures to minimize “ghost networks“—scenarios where providers are listed in directories without active patient engagement. The new regulations require substantial proof of service—specifically, MA organizations must verify that listed Physician Assistants (PAs), Nurse Practitioners (NPs), and Clinical Nurse Specialists (CNSs) have provided behavioral health counseling or therapy to at least 20 patients in the past year. This evidence is required for inclusion in the HSD table, ensuring active and current provider participation.

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2. Network Adequacy Exception Rationales for Facility-Based I-SNP

Addressing Institutional Challenges

In a move to address specific challenges faced by facility-based Institutional Special Needs Plans (I-SNPs), CMS has introduced two new network adequacy exceptions. This includes exceptions for situations where I-SNPs are unable to contract with required specialty providers and when they can provide basic benefits predominantly through telehealth services. 

CMS Oversight and Compliance

As CMS seeks to enhance transparency across the healthcare spectrum and elevate consumer confidence, increasing oversight is upon us—the ramifications of which will be acutely felt in the domain of provider directory accuracy. MA organizations must strategically incorporate these new standards into their operational protocols and demonstrate their adherence in tangible terms during CMS evaluations.

The shifting tides of network adequacy and provider directory accuracy necessitate a proactive and meticulous approach. MAOs are summoned to navigate these waters with steadfast adherence to the rules set forth and an innovative mindset that embraces the possibilities inherent in regulation. By meeting and exceeding the updated requirements posited by CMS, these organizations stand to significantly enhance the reliability and credibility of their Medicare Advantage plans.

The Path Forward with Quest Analytics

Quest Analytics is at the forefront of navigating the intricacies of regulatory compliance in the dynamic healthcare sector. Quest Enterprise Services™, provides MA organizations with actionable analytics and advanced tools to excel. Our expertise ensures your organization is equipped to meet current standards and poised to anticipate & adapt to future regulatory evolutions, aligning with CMS’s vision of a transparent, accurate, and trusted healthcare ecosystem.

Connect with one of our experts today to learn how we convert regulatory challenges into opportunities for success in your Medicare Advantage strategy. Start a Conversation

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