Qualified Health Plan
Issuer Application Instructions
Plan Year 2025
Extracted section:
Section 2J: Network Adequacy
2J-1 2025 QHP Application Instructions
Section 2J: Network Adequacy
1. Introduction
In the Network Adequacy (NA) section of the Marketplace Plan
Management System (MPMS), qualified health plan (QHP) issuers must
demonstrate that they have a sufficient number and geographic distribution
of providers, including providers that specialize in mental health and
substance use disorder services, to ensure that all services will be
accessible to enrollees without unreasonable delay. QHP issuers must
submit provider data in each network associated with a QHP (Figure 2J-1).
2. Data Requirements
To complete this section, issuers will need the following:
1. Health Insurance Oversight System (HIOS) Issuer ID
2. Issuer state
3. Completed Network ID Template
4. A list of providers in each of the networks. When completing the NA Template, providers outside the
service area may be included to satisfy time and distance requirements, even if they are across state
lines. If a provider is in-network and enrollees can access services from the provider within the requisite
time and distance standards for the respective county type designation, include the provider name,
National Provider Identifier (NPI), individual provider or facility specialty type, telehealth service
availability (only for individual providers), street address of the location providing services, city, state,
county, and ZIP Code.
5. NA Justification Form (as applicable). Issuers will retrieve a partially populated NA Justification Form
from MPMS with information regarding their deficient network, county, and specialty combinations. Once
issuers have completed their portions of the NA Justification Form, they will submit the completed form
to MPMS by the required deadline. CMS will accept only the official NA Justification Form in Excel
format and does not accept individually customized supplemental response forms as a substitute for the
official form.
3. Quick Reference
Key Changes for PY2025
Network Adequacy
♦ Existing issuers should download their previous year’s NA provider data into their upcoming year’s NA Template in
MPMS. New issuers should download and populate a new NA Template.
♦ After making updates to the previous year's data or completing a new NA Template, issuers must upload the completed
file to the Validation Workspace. All errors must be corrected before linking the NA Template to an application.
♦ Issuers will now retrieve and submit the NA Justification Forms in the Network Adequacy section in MPMS rather than in
the Plan Management (PM) Community.
♦ All medical QHPs and stand-alone dental plans (SADPs) operating on the Federally-Facilitated Exchange (FFE),
including issuers in states performing plan management functions and State-based Exchange on the Federal Platform
(SBE-FP) states, will submit their completed NA Template via MPMS.
♦ Provider validations will identify provider data errors that an issuer has made upon upload of their NA Template into the
Plan Validation Workspace of MPMS and require the issuer to correct such errors within the Plan Validation Workspace
and verify that no additional errors exist before submitting their NA Template.
The instructions for this section apply to
the following issuer types:
• Medical QHP
• SADP
See Appendix D for additional
information.
Tips for the NA Section
General
♦ Complete the Issuer Information section on the User Control tab before creating and entering data into the other tabs.
♦ Do not change the file names on NA files after finalizing the template. This file-naming convention helps CMS identify
each issuer’s NA Template. If the file name is changed, CMS may issue a required correction.
2J-2 2025 QHP Application Instructions
Tips for the NA Section
♦
Complete the Network ID Template before completing the NA Template.
♦ Issuers must only include providers on the NA Template that are not at known risk for potential contract termination for
the upcoming plan year.
♦ All medical QHPs and SADPs operating on the FFE, including issuers in states performing plan management functions
and SBE-FP states, will submit their completed NA Template via MPMS.
♦ NA Justifications are only required when at least one element of the NA standard is not met. Issuers that do not meet all
elements of the NA standards are issued a correction notice and a partially populated NA Justification Form for the issuer
to retrieve, complete, and submit via MPMS.
Network Adequacy
♦ All medical QHPs and SADPs must use a provider network and submit an NA Template, with the limited exception of
SADPs that sell plans in areas where it is prohibitively difficult for the issuer to establish a network of dental providers as
determined by CMS; this exception is not available to medical QHP issuers.
Under this limited exception, an area is considered “prohibitively difficult” for the SADP issuer to establish a
network of dental providers based on attestations from state departments of insurance (DOIs) with at least
80 percent of their counties classified as counties with extreme access considerations (CEAC), meaning that
at least one of the following factors exists in the area of concern: a significant shortage of dental providers, a
significant number of dental providers unwilling to contract with Marketplace issuers, or significant geographic
limitations impacting consumer access to dental providers.
CMS will not be accepting requests for this limited exception directly from SADP issuers. Once an eligible
state DOI submits to CMS an attestation that they consider the area to be prohibitively difficult to establish a
network of dental providers, CMS will review the attestation to determine if an exception will be granted. CMS
will notify the SADP issuer directly if they qualify for this limited exception. SADP issuers that qualify for this
limited exception will not be required to use a provider network or submit an NA Template.
♦ Issuers complete the NA Template by including all providers in their network in the Network Adequacy Provider tab,
using the Taxonomy Codes tab of the NA Template to crosswalk provider taxonomy codes to provider specialty types
and categories for time and distance standards.
♦ Providers in another state that are part of the network may be included if they are located within the time and distance
allowed for reasonable access
1
These parameters are foundationally based on approaches used by the Census Bureau
and the Office of Management and Budget. Use this file only to reference the Provider Time & Distance tab columns A
through E for QHP county type designations. Other information in this Health Service Delivery (HSD) Reference file is not
applicable to QHP certification.
♦ Issuers must submit valid and active NPI values. If an NPI value is not found in the National Plan and Provider
Enumeration System (NPPES), the issuer must remove the NPI from their NA Template data to clear the validation error
in the Plan Validation Workspace within MPMS.
♦ Issuers must not select more than three individual provider specialty types for a single NPI within the NA Template. If
greater than three individual provider specialty types are selected for a single NPI, the issuer must remove any excess
selections to clear the validation error in the Plan Validation Workspace within MPMS.
♦ Issuers must not report an individual provider as practicing at more than 10 unique locations or a provider facility as
operating at more than 10 unique locations within their NA Template. To clear the validation error, issuers must remove
locations that exceed the limit of 10 unique locations for the respective provider.
♦ Issuers must enter no greater number of Acute Inpatient Hospitals (with emergency services available 24/7) within their
NA Template than the total number of such hospitals operating in the respective states in which the providers are located
(excluding specialty hospitals, such as those on the [Department of Health and Human Services [HHS] Essential
Community Provider [ECP] List). If an issuer receives this validation error, the issuer must review their data and make the
necessary corrections to accurately report their in-network Acute Inpatient Hospitals within their NA Template to clear the
validation error in the Plan Validation Workspace within MPMS.
♦ Issuers must not enter a PO Box in the address field for a provider within their NA Template. To clear the validation error
in the Plan Validation Workspace within MPMS, issuers must replace any PO Boxes with a valid street address at which
the provider offers services to enrollees. Entering a valid street address enables CMS to calculate time and distance
measurements for the respective provider.
♦ Issuers should reference the Taxonomy Codes tab of the NA Template to crosswalk provider taxonomy codes to
provider specialty types and categories for time and distance standards.
1
https://www.cms.gov/Medicare/Medicare-Advantage/MedicareAdvantageApps.
2J-3 2025 QHP Application Instructions
Tips for the NA Section
♦
Under the following circumstances, advanced practice registered nurses (APRNs) and physician assistants (PAs) could
be included as primary care providers. Under the circumstances below, APRNs who specialize in behavioral health
services could be included in the outpatient clinical behavioral health provider category. The purpose of including APRNs
and PAs is to inform CMS of the rare instances in which an issuer contracts with non-Medical Doctor (MD)/Doctor of
Osteopathy (DO) primary care and behavioral health services providers in underserved counties to serve as the major
source of these types of care for enrollees. In these instances, organizations may include submissions under the non-
MD/DO primary care and outpatient clinical behavioral health specialty codes if the contracted APRN or PA satisfies the
following conditions:
(1) Currently licensed in the state,
(2) Meets the state’s requirements governing the qualifications of that provider type,
(3) Fully credentialed by the organization as a provider of primary care or behavioral health services,
(4) Functions in accordance with state law as the primary source for the enrollee’s primary care or behavioral
health services (i.e., not to supplement a physician’s care), and
(5) Practices in or renders services to enrollees residing in a health professional shortage area (HPSA).
Additional Resources
♦
There are supporting documents for this section.
♦ There are no instructional videos for this section.
♦
There are templates for this section.
4. Detailed Section Instructions
Existing issuers should navigate to the Application Tools section in MPMS, select Application Materials, and
download the data from the prior year’s template directly into the current year’s NA Template. New issuers
download a blank NA Template from the QHP certification website and populate it according to the following
instructions and guidelines. All issuers must upload the NA Template into the Plan Validation Workspace and
verify that no errors exist.
Use the NA Template to identify each provider and any networks to which the provider belongs. Download the
NA Template and save a local copy, then ensure macros are enabled before completing the NA Template.
Complete all required fields, which are identified with an asterisk (*).
2J-4 2025 QHP Application Instructions
Figure 2J-1. Sample User Control Tab
User Control Tab Steps
Issuer ID Enter the five-digit HIOS Issuer ID.
SADP Only Choose from the following:
♦ Yes—if the issuer only submits SADPs.
♦ No—if the issuer submits QHPs.
Source System Select the name of the system used to submit the QHP Application:
HIOS—if the issuer is in an FFE state.
SERFF—if the issuer is in a state performing plan management functions.
State
Use the drop-down menu to select the state in which the issuer is applying to offer
QHPs.
Import Network IDs: Click Import Network IDs to import data from the Network ID Template (please refer to
Section 2H: Network ID for detailed instructions on this template). Once the Network ID Template is imported, it
will automatically populate networks into the Network IDs field as a drop-down list on the Network Adequacy
Provider tab.
Follow these instructions and guidelines to determine the appropriate providers to include in the NA Template.
• Include a list of all the providers in each of the proposed networks, even those outside of the immediate
geographic area meeting time and distance requirements. Such providers must meet the following
requirements:
Be appropriately licensed, accredited, or certified to practice in their state, as applicable, and
Offer in-person services.
• Include only providers not at known risk for potential contract termination for the upcoming plan year.
• Do not report an individual provider as practicing at more than 10 unique locations or a provider facility
as operating at more than 10 unique locations.
2J-5 2025 QHP Application Instructions
• Reference the Taxonomy Codes tab of the NA Template to crosswalk provider taxonomy codes to
provider specialty types and categories for time and distance standards.
• Acute Inpatient Hospitals (facility specialty type code 040) are defined as facilities that provide inpatient
medical care and other related services for surgery, acute medical conditions or injuries (usually for a
short-term illness or condition), and 24/7/365 emergency services. Due to known data integrity issues
(e.g., a high number of hospital outpatient facilities being incorrectly reported by providers as acute
inpatient hospitals in NPPES), issuers should not use the National Uniform Claim Committee (NUCC)
hospital taxonomy code to identify such hospitals for NA submissions. Additionally, inpatient specialty
hospitals that fall within the ECP inpatient hospital category (e.g., Children’s Hospitals, Free-standing
Cancer Centers, Critical Access Hospitals) that are participating in an issuer’s network should be listed
only within the ECP section of MPMS, rather than within both the NA and ECP sections.
• For Cardiac Surgery Programs (facility specialty type code 041), Cardiac Catheterization Services
(facility specialty type code 042), and Critical Care Services – Intensive Care Units (ICUs) (facility
specialty type code 043), issuers must report within their network adequacy submissions the respective
provider types that filter into these facility specialty types. Since these are services rather than facility
types, there are no specific taxonomy codes that align completely with these specialty codes.
• For rural counties and CEACs for which issuers report within the issuer’s NA Justification a provider
supply shortage of primary care pediatricians, issuers are permitted to enter the family medicine
physician provider type to count toward satisfaction of the “Primary Care–Pediatric” specialty type. This
is in addition to the family medicine physician provider type currently counting toward issuer satisfaction
of the “Primary Care–Adult” specialty type.
• Under the following circumstances, APRNs and PAs can be included as primary care providers. APRNs
who specialize in behavioral health services could be included in the outpatient clinical behavioral health
provider category. Including APRNs and PAs informs CMS of the rare instances in which an issuer
contracts with non-MD/DO primary care and behavioral health services providers in underserved
counties to serve as the major source of these types of care for enrollees. In these instances,
organizations can include submissions under the non-MD/DO primary care and outpatient clinical
behavioral health specialty codes if the contracted APRN or PA satisfies the following conditions:
(1) Licensed in the state,
(2) Meets the state’s requirements governing the qualifications of that provider type,
(3) Fully credentialed by the organization as a provider of primary care or behavioral health services,
(4) Functions in accordance with state law as the primary source for the enrollee’s primary care or behavioral
health services (i.e., not to supplement a physician’s care), and
(5) Practices in or renders services to enrollees residing in a HPSA.
To complete the Network Adequacy Provider tab, follow the steps in the tables.
Network
Adequacy
Provider Tab
Steps
NPI (required)
Enter the provider’s 10-digit NPI. Issuers should contact providers directly to acquire their
NPIs. For NA purposes, issuers must report each individual provider under their unique
practitioner NPI and each provider facility under their site-specific facility NPI. The parent
organization-level NPI should not be reported. Issuers should only include providers in the NA
Template after obtaining their NPI. CMS no longer accepts dummy entries for the NPI field.
Ensure that the NPI is valid and active in the NPPES database.
Provider Name
(First Name, Last
Name or Facility
Name
Enter the individual provider’s first and last name or the name of the provider facility. An
individual practitioner’s name should not be entered for a provider facility type, unless it is part
of the name of the facility. Similarly, a provider facility’s name should not be entered for an
individual provider specialty type.
2J-6 2025 QHP Application Instructions
Network
Adequacy
Provider Tab
Steps
Specialty Type
(area of
medicine) of
Individual
Provider or
Facility
From the drop-down menu, select all specialties offered at the identified provider location. If a
provider has multiple specialties at the same address, select all specialties in the same record
that do not exceed three specialty types for individual providers.
♦ The template does not allow direct entry into this field. However, data may be copied and pasted
into the template if the specialty type names match how they appear in the Specialty Types tab
data, such as 001 General Practice. Errors will appear if pasted data do not exactly match the
specialty type format used in the Network Adequacy Provider tab.
♦ To enter more than one specialty type for a provider, each specialty type must be separated by a
comma and a space. Issuers must not select more than three individual provider specialty types for
a single NPI within the NA Template. A validation error will result if an issuer exceeds this limit.
♦ Do not include provider specialties except those the provider is actively practicing and providing
services.
♦ If the specialty type is not listed in the Specialty Types tab, do not list the provider. CMS does not
accept specialties that do not fall within the defined Specialty Types lists.
Does this
provider offer
Telehealth?
For the purpose of this data collection and reporting, the term “telehealth” is defined as
“professional consultations, office visits, and office psychiatry services through brief
communication technology–based service/virtual check-in, remote evaluation of pre-recorded
patient information, and inter-professional internet consultation.”
From the drop-down menu, select Yes or No to indicate whether the provider offers telehealth
services. If the issuer has reached out to the provider and is awaiting a response, select
Requested information from provider and awaiting their response.
Street Address
Enter the provider’s street address. If the provider has multiple locations, enter each street
address in a separate row. Do not use a PO Box in the address field, because it cannot be
geocoded for analysis. All providers with a PO Box in the address will be excluded from time
and distance analysis. Issuers must not report an individual provider as practicing at more than
10 unique locations or a provider facility as operating at more than 10 unique locations within
their NA Template. A validation error will result if an issuer exceeds this limit.
Street Address 2 Enter additional street address information, if applicable.
City Enter the city where the provider is located.
State Enter the state where the provider is located or select the state using the drop-down menu.
County
Enter the county where the provider is located or select the county using the drop-down menu.
A list of accepted county names is available on the County Names tab of the NA Template. Do
not include the Federal Information Processing Standards (FIPS) code when entering the
county name.
ZIP Code
Enter the ZIP Code where the provider is located. ZIP Codes must include either five (12345)
or nine (12345-6789) digits.
Network ID
When entering network IDs, use the same network IDs as those assigned in the Network ID
Template and the Plans & Benefits Template. Issuers that offer both medical QHPs and
SADPs must create separate network IDs for their medical and dental plans. Using the drop-
down menu, select all network IDs that correspond to the networks in which the provider is
included. If a provider is in multiple networks, select all networks in the same record.
2J-7 2025 QHP Application Instructions
Figure 2J-2. Sample Network Adequacy Provider Tab
Reference information is provided in the four tabs listed below:
• The Specialty Types tab contains the specialty/facility types that can be added into the NA Template.
• The Taxonomy Codes tab contains the taxonomy codes that correspond to provider specialty types
listed within the Specialty Types tab. The Taxonomy Codes tab may be used as a guide for the provider
taxonomy types required for inclusion in submissions. The Taxonomy Codes tab also has columns to
show which taxonomy codes crosswalk into each time and distance specialty type.
• The County Names tab contains the county names that are used and accepted in the NA Template.
• The Errors tab displays any validation errors identified when a completed NA Template is validated.
1. Column A—Tab: indicates the tab that produced the error.
2. Column B—Cell: indicates the cell location for the specific error and creates a hyperlink that allows
the issuer to navigate to the exact cell in the correct tab.
3. Column C—Validation Error Message: describes the error.
After entering all data, click Save to ensure no data are lost. Once the NA Template is completed, it must be
validated, finalized, and uploaded into MPMS.
Template Validation
and Submission Step
Step Description
Validate Template
Click Validate on the User Control tab. The validation process identifies any data issues
that need to be resolved. If no errors are identified, the message “No validation errors
were identified. Validation is complete.” will display, indicating that the template may be
finalized.
Errors
Errors will appear on the Errors tab, which shows the data element, cell location, and
validation error message for each error. Correct any identified errors and click Validate
again. Repeat until all errors are resolved.
Create Documents
Once all validations are complete, click Create Documents on the User Control tab to
create a separate .XML file for each tab in the workbook and compress all files into one
.ZIP file.
Save Template
Save the .ZIP file and template. CMS recommends saving the validated template as a
standard Excel .XLSM file in the same folder as the finalized .ZIP file for easier reference.
2J-8 2025 QHP Application Instructions
Template Validation
and Submission Step
Step Description
Upload and Validate
Template In MPMS
Upload the saved .ZIP file in the Plan Validation Workspace in MPMS. Refer to the
MPMS User Guide for additional guidance on how to complete these steps.
Link Template In
MPMS
Link the validated template to the issuer’s application. Refer to the MPMS User Guide for
additional guidance on how to complete these steps.
After uploading the necessary NA files and linking them to the application, NA Justifications Forms may also
need to be uploaded. Completed NA Justification Forms must be submitted in the Network Adequacy section in
MPMS.
Supporting
Documents
Steps
NA Justification
Form
♦ If a required correction for not meeting one or more of the NA standards is received, all
required fields in the prepopulated NA Justification Form generated by CMS must be
completed. This form can be retrieved from MPMS. Refer to the MPMS User Guide.
♦ The completed NA Justification Form should be saved in the required macro-enabled
Excel format (.xlsm) and uploaded into the Network Adequacy section of MPMS by the
required deadline for each submission round. Do not rename the Justification Form. If
the file is renamed, the following naming convention should be used: (Issuer ID)-NA-
(Round Abbreviation). For example, Issuer ID 12345 in the Initial Round would be 12345-
NA-IR. Replace IR with SR for the Second Round of submission and with FR for the
Final Round of submission.
♦ If CMS learns of local challenges impacting all issuers in a given service area, such as
topographical features or insufficient provider supply, which have resulted in assignment
of required corrections, CMS will assess any such challenges to verify the extent to
which they impede issuers’ ability to satisfy the respective NA standard for the purpose
of potentially clearing the assigned correction, as CMS deems appropriate.
♦ On the Monitoring & T&D Justification tab of the NA Justification Form, an answer must
be provided to the four service area monitoring questions at the top of the worksheet for
CMS to consider any barriers reported within the “Primary Reasons on Record for Unmet
Standard” column.
♦ On the Monitoring & T&D Justification tab of the NA Justification Form, a Primary
Reason(s) must be provided for not meeting the standard related to each correction.
♦ On the Recruitment Activity tab of the NA Justification Form, CMS strongly encourages
issuers to include provider recruitment activities for the network, county, and specialty
combinations for which required corrections were received, including any ongoing,
concluded, and unsuccessful activities. This additional provider recruitment data will
inform next steps that may be required of the issuer as part of a compliance plan.
♦ All required fields in the NA Justification Form must be completed before submission.
Incomplete justifications will not be accepted.
♦ After issuers submit the completed NA Justification Form, CMS will send additional
corrections via MPMS if further corrections are required.
This concludes the NA section of the QHP Application Instructions.
