Are You Meeting CMS and State Access-to-Care Requirements?
In the 2025 Final Rule, CMS released its expectations and reporting requirements to ensure timely access to care.
Effective January 1, 2025, CMS requires issuers that offer Qualified Health Plans (QHPs), including stand-alone dental plans, to take specific actions. These issuers, participating in the federally facilitated Exchanges or Small Business Health Options Programs, must conduct secret shopper surveys to evaluate compliance with appointment wait time standards. QHP issuers are required to:
- Contract with a third-party to administer surveys
- Survey a statistically valid sample of behavioral health and primary care providers, with specialty care providers expected to be included in future plan years
- Begin annual surveys starting on or shortly after January 1, and complete by May 31 of each plan year
- Meet or exceed a 90% compliance rate for appointment wait times, either in-person or via telehealth
Challenges to Complete Access Requirements
- Develop a process and tracking system
- Script design
- Continued monitoring
- Improving access to care
Important Considerations for QHPs
- 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 the questions above—or if you’re unsure—now is the time to act. Contact ATTAC’s Provider Network Management team to ensure your organization meets CMS’s 2025 provider network access and availability requirements.