Network Adequacy Analysis

Required Inputs

Methodology

Step 1: Provider Inventory Validation

• Validate provider network data accuracy:
  • Confirm provider active status (not deceased, retired, or relocated)
  • Verify accepting new patients status (critical for adequacy assessment)
  • Confirm practice location addresses are current
  • Validate specialty taxonomy codes (NUCC taxonomy)
  • Identify ghost network providers (contracted but not actually available)
  • Cross-reference with NPPES database for active NPI status
• Calculate effective network size (only providers actively accepting plan members)
• CMS No Surprises Act and Transparency requirements: directory accuracy within 48 hours of changes

Step 2: Time-Distance Analysis

• Apply CMS and state-specific time-distance standards by provider type and county designation:
  • CMS Medicare Advantage standards (by county type):
    • Primary Care: Large Metro 10 min, Metro 15 min, Micro 30 min, Rural 40 min, CEAC 60 min
    • Cardiology: Large Metro 20 min, Metro 30 min, Micro 60 min, Rural 75 min, CEAC 110 min
    • Behavioral Health: Large Metro 15 min, Metro 25 min, Micro 45 min, Rural 60 min, CEAC 90 min
    • Hospital: Large Metro 20 min, Metro 30 min, Micro 45 min, Rural 60 min, CEAC 75 min
  • Calculate drive time from each member zip code centroid to nearest 2 network providers per specialty
  • Identify members exceeding time-distance standards (compliance gap)
  • Calculate percentage meeting standard per specialty per county (target: 90% of members)
• Apply state-specific standards where more stringent than CMS
• Document distance methodology (driving, public transit, straight line)

Step 3: Provider-to-Member Ratio Analysis

• Calculate ratios by specialty per service area:
  • Primary Care: benchmark 1:1,500 to 1:2,500 (varies by state)
  • Behavioral Health: benchmark 1:1,000 to 1:2,000
  • OB/GYN: 1:2,000 to 1:3,000
  • Pediatrics: 1:1,500 to 1:2,500
• Adjust for provider FTE (part-time providers count proportionally)
• Adjust for provider panel capacity (a provider at 95% panel capacity provides minimal access)
• Compare to regulatory requirements and peer plan benchmarks
• Flag specialties falling below minimum ratio thresholds

Step 4: Appointment Availability Assessment

• Measure actual appointment availability (not just contracted presence):
  • Secret shopper surveys: Call network providers requesting appointments as new patients
  • Appointment wait time standards:
    • Urgent care: 24-48 hours
    • Primary care routine: 7-14 days (varies by state)
    • Specialist routine: 14-30 days
    • Behavioral health non-urgent: 10-14 business days (NCQA)
    • Prenatal care (first trimester): 14 days
  • Measure actual wait times against applicable standards
  • Identify providers who are contracted but have excessive wait times (de facto inadequacy)
• Calculate appointment availability scores by specialty and geography

Step 5: Essential Community Provider (ECP) Analysis

• Evaluate ECP contracting compliance:
  • CMS requires QHP issuers to contract with minimum 35% of available ECPs in service area
  • Identify all ECPs in service area from HHS ECP list:
    • Federally Qualified Health Centers (FQHCs)
    • Ryan White HIV/AIDS providers
    • Family planning providers
    • Indian Health Service providers
    • DSH hospitals
    • Critical access hospitals
    • Children's hospitals
  • Calculate ECP contracting percentage by category
  • Identify uncontracted ECPs with strategic importance (high utilization, underserved areas)

Step 6: Gap Remediation Planning

• For each identified adequacy gap:
  • Quantify the gap (number of members affected, severity)
  • Identify remediation options:
    • Provider recruitment or contracting in gap areas
    • Single-case agreements for members in underserved areas
    • Telehealth extension to expand geographic reach
    • Transportation assistance programs
    • Out-of-network access at in-network cost (when no adequate option exists)
  • Estimate remediation timeline and cost
  • Document alternative access standards submission to regulators (when gaps cannot be closed)
• Prepare regulatory filing with gap analysis and remediation plans

Output Specification

network_adequacy_report:
  analysis_date: date
  service_area: string
  total_members: number
  total_network_providers: number
  effective_network_providers: number
  time_distance_analysis:
    - specialty: string
      standard_minutes: number
      members_meeting_standard: number
      members_meeting_standard_pct: number
      gap_member_count: number
      gap_zip_codes: array
      compliance_status: string
  ratio_analysis:
    - specialty: string
      provider_count: number
      member_count: number
      ratio: string
      benchmark: string
      compliance_status: string
  appointment_availability:
    - specialty: string
      standard_days: number
      actual_median_days: number
      pct_meeting_standard: number
      compliance_status: string
  ecp_analysis:
    total_ecps_in_area: number
    contracted_ecps: number
    contracting_pct: number
    compliance_threshold: number
    compliance_status: string
    uncontracted_priority: array
  gaps_identified:
    - specialty: string
      gap_type: string
      severity: string
      affected_members: number
      remediation_options: array
      remediation_timeline: string
  overall_compliance_status: string
  regulatory_filing_readiness: boolean

Analysis Framework

Apply the CMS Network Adequacy Framework (three pillars):

1. Quantitative standards: Time-distance and provider ratio minimums per specialty and county type
2. Qualitative standards: Appointment availability, cultural competency, language access, ADA accessibility
3. Ongoing compliance: Monitoring, reporting, and remediation processes

Enhanced with NCQA Network Management Standards:

• Standard 5: Provider directory accuracy
• Standard 6: Availability of practitioners
• Standard 7: Accessibility of services (after-hours, cultural, linguistic)

Examples

Example: Medicaid Managed Care Plan (150,000 Members, 12-County Service Area)

• Provider network: 3,200 contracted providers (2,890 effective after ghost network removal)
• Time-distance gaps: Psychiatry fails in 4 rural counties (only 67% of members within standard)
• Ratio gaps: Endocrinology 1:8,200 (standard: 1:5,000), Dermatology 1:9,100 (standard: 1:5,000)
• Appointment availability: Behavioral health median wait 28 days (standard: 10 business days)
• ECP contracting: 72% of FQHCs contracted (above 35% threshold), but 0 of 3 Ryan White providers contracted
• Ghost network finding: 312 providers (9.7%) listed but not accepting plan members
• Priority remediation: Recruit 2 psychiatrists for rural coverage, contract with Ryan White providers, telehealth behavioral health expansion
• Regulatory filing status: 3 alternative access standard requests needed for rural psychiatry

Guidelines

• HIPAA Compliance: Member geographic data used in time-distance analysis must be at zip code level, not individual addresses. Provider data is generally not PHI but may be proprietary. Grievance data must be de-identified for trend analysis.
• CMS Regulatory Compliance: Network adequacy is a regulatory requirement with enforcement consequences. Non-compliance can result in corrective action plans, enrollment sanctions, or contract termination. Treat adequacy analysis as compliance-critical.
• Data Currency: Provider directory data decays rapidly. Validate data within 90 days of analysis. Ghost network identification is a regulatory priority under the No Surprises Act.
• Health Equity: Analyze adequacy specifically for vulnerable populations (dual-eligible, special needs, LEP). Ensure network includes providers with cultural and linguistic competency for major demographic groups.
• Telehealth Consideration: Telehealth can extend geographic reach but does not fully substitute for in-person access. Apply telehealth credit cautiously per state-specific guidance on counting telehealth toward adequacy standards.

Validation Checklist

• Provider network data validated for accuracy and currency
• Ghost network providers identified and flagged
• Time-distance analysis completed for all required specialties
• County type classifications (metro, micro, rural, CEAC) correctly applied
• Provider-to-member ratios calculated with FTE and capacity adjustments
• Appointment availability measured via secret shopper or equivalent method
• Essential community provider contracting percentage calculated
• Gaps quantified with affected member counts
• Remediation plans developed for each identified gap
• Alternative access standard requests prepared where applicable
• Health equity analysis completed for vulnerable populations
• Regulatory filing package complete and reviewed by compliance