In the 2025 Final Rule, CMS released its expectations and reporting requirements to ensure timely access to care.
By the second Friday in June each year, issuers that offer Qualified Health Plans (QHPs)—including stand-alone dental plans—in the federally-facilitated exchanges or the federally-facilitated Small Business Health Options Programs must report secret shopper survey results assessing compliance with appointment wait time standards.
QHP Issuers Requirements
- Contract with a third party to administer surveys
- Survey a statistically valid sample of behavioral health and primary care providers
- Complete annual surveys by May 31 each plan year
- Meet or exceed a 90% compliance rate for appointment wait times, either in-person or via telehealth
Challenges to Complete and Meet Access Requirements
- Meeting the 90% CMS compliance rate requirement
- Significant volume of nonresponsive and ineligible surveys
- Minimal survey outcomes that can apply to CMS’s compliance numerator and denominator
- Time needed to complete necessary reserve surveys to meet goals
Not Sure You’re Meeting CMS and State Expectations? Start Here:
- Does your plan meet the CMS 90% compliance rate requirement?
- Is your provider network meeting access requirements?
- Does your team have the capacity to educate contracted providers?
- Do your access surveys and/or complaints identify network access issues?
- Is your provider directory data accurate, valid, and continually monitored?
If you answered ‘no’ to any of the questions, or you don’t know, ATTAC’s Provider Network Management team is here to help meet your network access, availability, provider education and provider data validation needs. We support clients to ensure successful continued monitoring and access to care improvement. We offer a flexible approach to support your survey and audit goals.
Contact ATTAC today to discuss how we can help your organization complete, review and improve your provider network access and availability outcomes.
