By The 2025 Final Rule from CMS outlined expectations and reporting requirements related to timely access to care.
Effective PY 2025, CMS requires that all states with Medicaid and the Children’s Health Insurance Program (CHIP) develop, conduct, and enforce independent secret shopper surveys to evaluate compliance with appointment wait time standards. States are required to:
- Set written standards for providers that meet or exceed those created by CMS
- Survey a statistically valid sample of primary care, obstetric/gynecological, and behavioral health providers
- Contract with a third-party vendor to administer surveys
- Complete annual surveys between January 1 and May 31 of each plan year
- Report results to CMS by the second Friday of June each year
Does Your State Require Each Organization to Complete Access-to-Care Surveys?
Currently, most states require provider surveys to verify compliance with access to care standards. In some states, the state will complete provider outreach; in other states, plans will administer surveys and report results to the state. Many states, in addition to the provider survey process, require health plans to complete provider surveys for CMS and state requirements based on standards set for all primary care, specialty care, and behavioral health access and availability. The frequency, script, and reporting requirements vary by state and may present significant challenges if not properly managed.
Top Four Challenges in Completing Access Requirements
Health plans and providers may face the following hurdles to ensure compliance with CMS and state access to care mandates:
- Development of a process and tracking system
- Script design
- Continued monitoring to ensure ongoing compliance
- Improving access to care by addressing network gaps
It’s Time To Start Considering the Following Questions
- Is your provider network meeting access requirements?
- Do your provider contracts or manuals include the most recent CMS-required standard language?
- Does your team have the capacity to survey and educate contracted providers?
- Do your access surveys and/or complaints identify network access issues?
- Is your provider directory data accurate and valid?
If you answered “no” to any of these questions, or you simply don’t know, ATTAC Consulting Group’s Provider Network Management team is here to help you meet your network access and availability requirements. We provide expert guidance and hands-on support to help your organization monitor and improve access to care.
Contact ATTAC today to get started on meeting your access requirements and ensuring your provider network is fully prepared for 2025 and beyond.
