CMS Network Adequacy Standards
The complete time and distance standards for Medicare Advantage, Medicaid, Exchange/QHP, and D-SNP networks — with county type breakdowns, access exception rules, and practical guidance.
Standards based on CMS 2025 MA network adequacy final rule and state Medicaid managed care guidance. Verify current year standards before filing.
Time OR Distance
CMS uses the lesser of the two. If you meet the time standard but not the distance standard (or vice versa), you must meet BOTH. Blueprint evaluates each independently and flags a county adequate only when both are satisfied.
County Classification
Counties are classified as urban, suburban, rural, or frontier based on RUCA (Rural-Urban Commuting Area) codes. Classification determines which threshold applies. Blueprint auto-assigns RUCA codes at the county level.
Straight-line vs. Drive Time
CMS uses drive time for time standards and straight-line distance for distance standards. Both are calculated from the enrollee's residence to the nearest in-network provider of that specialty.
MA Time & Distance Standards
CMS-regulated standards apply uniformly across all MA and MA-PD plans. Standards are enforced by county and measured against the plan's contracted in-network provider locations. Frontier thresholds apply to counties with fewer than 7 persons per square mile.
| Provider Type | Urban | Suburban | Rural | Frontier | Notes |
|---|---|---|---|---|---|
| Primary Care | 15 min / 10 mi | 30 min / 20 mi | 60 min / 60 mi | 90 min / 90 mi | — |
| OB/GYN | 30 min / 15 mi | 45 min / 30 mi | 75 min / 75 mi | 90 min / 90 mi | — |
| Behavioral Health (MH/SUD) | 30 min / 15 mi | 45 min / 30 mi | 75 min / 75 mi | 90 min / 90 mi | — |
| Cardiology | 30 min / 15 mi | 45 min / 30 mi | 75 min / 75 mi | 90 min / 90 mi | — |
| Dermatology | 30 min / 15 mi | 45 min / 30 mi | 75 min / 75 mi | 90 min / 90 mi | — |
| ENT / Otolaryngology | 30 min / 15 mi | 45 min / 30 mi | 75 min / 75 mi | 90 min / 90 mi | — |
| Endocrinology | 30 min / 15 mi | 45 min / 30 mi | 75 min / 75 mi | 90 min / 90 mi | — |
| Gastroenterology | 30 min / 15 mi | 45 min / 30 mi | 75 min / 75 mi | 90 min / 90 mi | — |
| General Surgery | 30 min / 15 mi | 45 min / 30 mi | 75 min / 75 mi | 90 min / 90 mi | — |
| Infectious Disease | 30 min / 15 mi | 45 min / 30 mi | 75 min / 75 mi | 90 min / 90 mi | — |
| Mental Health (Psychiatry) | 30 min / 15 mi | 45 min / 30 mi | 75 min / 75 mi | 90 min / 90 mi | — |
| Nephrology | 30 min / 15 mi | 45 min / 30 mi | 75 min / 75 mi | 90 min / 90 mi | — |
| Neurology | 30 min / 15 mi | 45 min / 30 mi | 75 min / 75 mi | 90 min / 90 mi | — |
| Oncology (Medical / Surgical / Radiation) | 30 min / 15 mi | 45 min / 30 mi | 75 min / 75 mi | 90 min / 90 mi | Medical, surgical, and radiation tracked separately |
| Ophthalmology | 30 min / 15 mi | 45 min / 30 mi | 75 min / 75 mi | 90 min / 90 mi | — |
| Orthopedics | 30 min / 15 mi | 45 min / 30 mi | 75 min / 75 mi | 90 min / 90 mi | — |
| Physical / OT / Speech Therapy | 30 min / 15 mi | 45 min / 30 mi | 75 min / 75 mi | 90 min / 90 mi | — |
| Podiatry | 30 min / 15 mi | 45 min / 30 mi | 75 min / 75 mi | 90 min / 90 mi | — |
| Pulmonology | 30 min / 15 mi | 45 min / 30 mi | 75 min / 75 mi | 90 min / 90 mi | — |
| Rheumatology | 30 min / 15 mi | 45 min / 30 mi | 75 min / 75 mi | 90 min / 90 mi | — |
| Urology | 30 min / 15 mi | 45 min / 30 mi | 75 min / 75 mi | 90 min / 90 mi | — |
| Skilled Nursing Facility (SNF) | 30 min / 15 mi | 45 min / 30 mi | 75 min / 75 mi | 90 min / 90 mi | — |
| Home Health Agency (HHA) | 30 min / 15 mi | 45 min / 30 mi | 75 min / 75 mi | 90 min / 90 mi | — |
| Diagnostic Radiology (Imaging) | 30 min / 15 mi | 45 min / 30 mi | 75 min / 75 mi | 90 min / 90 mi | — |
Row shading: blue = primary care; gray = facility / ancillary; white = specialist. Standards shown as drive time / straight-line distance.
Medicaid Adequacy Standards
Governing rule: 42 CFR Part 438 — state-specific access standards
County Type Classification
Urban / Rural (state-defined)
Access Exception Path
State Medicaid agencies grant exceptions; documentation requirements vary by state. Contact your state MCO liaison for the current exception template.
Key Standards & Differences
- Standards vary significantly by state
- Most states require 30 min / 30 mi for PCPs in rural counties
- Behavioral health standards are often stricter than MA
- ENR (Enrollee-to-Network Ratio) may apply in addition to time/distance
State-specific standards may exceed federal minimums. Always verify current state guidance before filing. Blueprint surfaces state-specific overrides where data is available.
Exchange / QHP Adequacy Standards
Governing rule: 45 CFR Part 156 — QHP certification standards
County Type Classification
Urban / Rural (varies by state/exchange)
Access Exception Path
QHP access exceptions are reviewed by the state insurance commissioner or CMS for FFE states. Mental health parity exceptions require additional documentation.
Key Standards & Differences
- Standards set at state level for state-based exchanges
- Federal fallback: generally 30 min / 30 mi for PCPs
- Mental health parity requirements are strictly enforced
- Pediatric specialty standards apply even for adult-only plans
State-specific standards may exceed federal minimums. Always verify current state guidance before filing. Blueprint surfaces state-specific overrides where data is available.
D-SNP Adequacy Standards
Governing rule: MA standards apply + state MOU requirements
County Type Classification
Urban / Suburban / Rural / Frontier
Access Exception Path
D-SNP plans must document exceptions under both the MA framework (CMS) and the state MOU terms. Dual documentation is required — a single CMS exception filing does not satisfy state requirements.
Key Standards & Differences
- All MA time/distance standards apply
- Additional state-specific requirements via D-SNP MOU
- Behavioral health and SUD standards often exceed MA minimums
- Provider directory must cross-reference both Medicare and Medicaid enrollment
D-SNP plans reference both the CMS MA final rule and state MOU exhibit standards. Blueprint tracks both sets of requirements simultaneously.
When CMS Grants Access Exceptions
Access exceptions let plans demonstrate reasonable efforts to meet standards when no in-network provider exists within the required distance — but they come with strict documentation requirements and limits.
When CMS Grants an Exception
- No in-network provider exists within the standard time/distance in that specialty and county type
- The gap is due to a documented provider shortage (HPSA, MUA, or state-verified shortage area)
- The plan has made documented good-faith recruitment outreach to all available providers in the area
- Alternative access arrangements are in place (telehealth, transportation assistance, or LOAs with OON providers)
What You Must Document
- HPSA or MUA designation documentation from HRSA (or state equivalent for Medicaid)
- Outreach log: dates, provider names, NPI numbers, and responses for every provider contacted
- Alternative access arrangement: telehealth agreement, transportation vendor contract, or signed LOA with OON provider
- Beneficiary communication plan: how enrollees will be notified and directed to the alternative access
Exception Limits
- CMS does not publish a fixed percentage cap, but reviewers scrutinize plans with exceptions in multiple counties for the same specialty
- Exceptions are more readily granted for frontier and rural counties than urban or suburban
- Plans with repeated exceptions in the same county/specialty across benefit years may receive heightened review
- State-level Medicaid exceptions may have explicit percentage caps — check your state MCO contract
Impact on Adequacy Score
- Exceptions are counted separately from adequacy — they do not improve your adequacy score
- Counties covered by exceptions are flagged as 'exception counties' in your HSD submission
- Blueprint Analytics tracks exception counties separately and surfaces them in your gap report dashboard
- Exception counties still require an approved alternative access plan before enrollment can begin
Standards Are Updated Annually
CMS updates network adequacy standards annually in the MA Call Letter and final rule. Standards listed here reflect the 2025 final rule. Always verify against the current year’s CMS guidance before your network adequacy filing. Blueprint automatically applies updated thresholds at the start of each new benefit year.
Related Reference Tools
Run real-time adequacy scoring against 2025 standards in Blueprint Analytics.
Blueprint scores your contracted network against every county, every specialty, and every county type — surfacing gaps, exception candidates, and recruiting priorities in one unified view. No spreadsheets required.