Since January 1, 2025, qualified health plans (QHPs), including standalone dental plans (SADPs), on the Federally-Facilitated Exchanges (FFEs) are subject to appointment wait time standards to enable timely access to care for enrollees. To validate performance according to these standards, CMS has introduced a compulsory third‑party secret shopper survey, conducted between January 1 and May 31 each year.
Together, the appointment wait time standards and secret shopper survey requirements are a significant administrative and compliance lift for QHP issuers. In this article, we explore the details of these requirements, how health plans can maintain compliance, and how Forvis Mazars can assist with the process.
What Are the FFE Appointment Wait Time Standards?
As of January 1, 2025, the appointment wait time standards for QHP and SADP issuers in the FFEs are as follows:
- Behavioral Health Providers: 10 business days
- Primary Care (Routine) Providers: 15 business days
- Specialty Care (Non-Urgent) Providers: 30 business days
QHP issuers are expected to ensure that enrollees can schedule an appointment within these time frames at least 90% of the time. The requirement is aimed, in part, at improving appointment availability for new patients, as more than half of FFE enrollees select a new QHP each year.
What Are the Secret Shopper Survey Requirements?
CMS assesses compliance with the appointment wait time standards through mandated secret shopper surveys. QHP issuers must contract with a third-party entity to administer the surveys. Currently, secret shopper surveys are required only for primary care and behavioral health providers, but CMS plans to expand the requirement to include specialty care providers. Secret shopper surveys should be conducted from the perspective of a new patient attempting to schedule their first appointment with a provider at the location being surveyed.
QHP issuers are required to retain survey documentation in accordance with the Affordable Care Act broad record retention policies, and they should be prepared to provide documentation to CMS for review.
How Can QHPs Navigate These Requirements?
With the appointment wait time standards and secret shopper survey requirements still in their early years of implementation, many QHPs have significant room for improvement in how they navigate the process. The following considerations can help plans succeed in both the short and long term.
- Select a Secret Shopper Survey Administrator: Not all survey administrators are created equal. When contracting with a third-party entity for the upcoming plan year, QHPs should consider the entity’s survey experience, technical capabilities to share real-time results and structured insights, and understanding of CMS’ required methodology, especially the ability to present appropriately as a new patient.
- Identify Barriers to Access: Health plans should approach secret shopper surveys not just as a compliance requirement, but as an opportunity to gather valuable information about their provider network and enrollee experiences. Survey results may reveal directory accuracy issues, wait time anomalies, and other barriers to timely access, helping the plan identify targeted areas for improvement.
- Implement Operational Improvements: Translating survey insights into action is key to maintaining compliance with wait time standards and can also help health plans improve operational performance in the long term. For example, effective analysis may reveal call center training issues or provider office workflow inefficiencies the health plan can address.
How Forvis Mazars Can Help With Appointment Wait Time & Secret Shopper Survey Compliance
Our years of experience in the regulatory survey arena uniquely position Forvis Mazars to support health plans in pursuing regulatory excellence and navigating evolving requirements. We are well-versed in designing and conducting timely access and network adequacy surveys at both state and federal levels, including direct experience as an approved third-party entity for FFE secret shopper surveys. We can assist with data collection, sample selection, script development, survey outreach, and results delivery.
Outside of the survey process, we can also help you leverage survey insights to support a wide range of compliance and performance improvement initiatives. If you need assistance conducting secret shopper surveys or have questions about CMS’ appointment wait time standards, please reach out to our professionals today.