// . //  Insights //  3 Ways To Prepare For New Network Adequacy Requirements

In the 2025 Notice of Benefit and Payment Parameters Proposed Rule, the Centers for Medicare and Medicaid Services (CMS) continues to emphasize network adequacy in the Marketplace to ensure timely and reasonable access to healthcare for enrollees. One of the key proposals, and the focus of this article, is that State-based Marketplaces (SBM) and SBMs on the Federal Platform “establish and impose quantitative time and distance network adequacy standards for qualified health plans (QHPs) that are at least as stringent as Federally Facilitated Exchange’s (FFE) network adequacy standards established for QHPs under section 156.230.”

While some state regulators and carriers are familiar with these requirements and review processes, others will need to consider them in terms of timelines, staffing, and budgets. Here are three key considerations for state regulators and carriers who may be new to these requirements.

1. State regulators and carriers should review the current FFE Network Adequacy standards

If implemented as proposed, the FFE Network Adequacy standards would serve as a national floor and while it may sound obvious, as the saying goes the devil is in the details. For example, do state regulators and carriers utilize the same definitions and classifications for each of the counties in the state? Do they align with those used by CMS? Are there any federal requirements that overlap and differ from state mandates, and if so, how will they be reconciled? Knowing where there may be areas of ambiguity or uncertainty and addressing them early on will help both state regulators and carriers ensure a smooth implementation of the new requirements.

2. State regulators should define what success looks like for carriers

The key question all carriers will want to know is, What will they need to do to satisfy the state’s requirements? This becomes especially difficult if the state’s testing must be “at least as stringent” — which can mean many things. Will the state leverage the FFE requirements and not deviate from them? Will there be tighter time/distance requirements than the federal minimum? Will the standard for the percentage of enrollees covered (90% for FFE’s) be different? How will any network adequacy exemptions be structured? Whatever the final decisions from state regulators are, the key will be to establish the requirements with sufficient time available for carriers to make the necessary adjustments while still meeting required timelines.

3. Carriers should review networks ahead of state testing

Waiting for the state to either test or review network adequacy can be a recipe for stress, especially if this is a new or relatively new process for both the carrier and the state. By performing an initial network adequacy review early in the filing timeline, carriers can identify and address gaps ahead of time. For example: Are there specialties or facilities with material gaps in coverage? Is the provider directory up to date? Does the provider directory allow for identification of the specialties and facilities that the FFE Network Adequacy standards require? Knowing where the headwinds will come from and developing a plan to address them should help lay the groundwork for an efficient review process.

While the considerations above may seem intuitive, the theme to walk away with is that if these requirements are finalized, both state regulators and carriers should get started with these recommendations sooner rather than later. There will inevitably be unexpected issues that arise — the sooner the major issues are known, the easier for all parties to develop a successful path forward.