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Appointment Wait Time FAQs

General

Q1: What changes can QHP issuers expect related to the appointment wait time policy in plan year 2025?

  • In the 2025 Final Letter to Issuers in the Federally-facilitated Exchanges (FFEs), published April 10, 2024, the Centers for Medicare & Medicaid Services (CMS) stated that, beginning January 1, 2025, Qualified Health Plan (QHP) issuers, including stand-alone dental plan (SADP) issuers, in the FFEs are required to meet appointment wait time standards established by the FFEs, which we established in Chapter 2, section 3.ii.b of the 2023 Final Letter to Issuers in the FFEs. These standards are also reflected in the table below. For the 2025 plan year, QHP issuers, including SADP issuers, will be required to ensure that enrollees seeking an appointment are able to schedule an appointment within the time frames below at least 90% of the time. CMS is particularly concerned with the ability of new patients to schedule appointments with in-network providers; more than half of enrollees on the FFEs newly enroll in QHPs or change their enrollment to a new QHP each year, and these enrollees may need to seek care as a patient who is new to a provider.

Provider specialty type

Appointments must be available within

Behavioral Health

10 business days

Primary Care (Routine)

15 business days

Specialty Care (Non-urgent)

30 business days

CMS will also require medical QHP issuers offering QHPs in the FFEs to contract with a third-party entity to administer secret shopper surveys to assess how often provider networks are able to meet appointment wait time standards. The third-party entity that conducts the surveys must be a separate and distinct entity from the medical QHP issuer. For example, the third-party entity and the issuer cannot be affiliated companies, and they cannot be subsidiaries of the same parent company. To limit the burden on medical QHP issuers, CMS intends to require only that secret shopper surveys be conducted for a medical QHP issuer’s primary care (routine) and behavioral health providers. CMS expects to require secret shopper surveys to be administered with respect to specialty care (non-urgent) providers in future plan years. As SADP issuers would generally contract with specialty care (non-urgent) providers, SADP issuers would not be required to contract with a third-party entity to conduct secret shopper surveys for the 2025 plan year.

CMS may require medical QHP issuers to provide CMS with documentation underlying the results of those surveys for CMS’s review. Medical QHP issuers must retain relevant documentation related to the surveys in accordance with the broad record retention policies set forth in 45 CFR 156.705.

Q2: Where can QHP issuers find more information about how to administer secret shopper surveys to assess compliance with appointment wait time standards?

Q3: Will QHP issuers be required to pick a third-party entity from a defined list that CMS provides?

  • No, CMS will not be providing a defined list of third-party entities from which issuers may select a third-party entity. It is up to QHP issuers to select and contract with a third-party entity to conduct secret shopper surveys.
Q4: Will there be a separate attestation for the appointment wait time standards?
  • No, there will be no separate attestation for the appointment wait time standards. Issuers will attest generally to meeting the standards and operational requirements in 45 CFR 153, 155, and 156 (i.e., the attestation required of both QHPs and stand-alone dental plans).

Identifying the Population to Be Surveyed

Q5: How will a QHP issuer know which providers are eligible to be surveyed via secret shopper for purposes of assessing compliance with appointment wait time standards?
  • Each fall, CMS will provide issuers with a provider population file (PPF) that contains the population or “universe” of providers from which QHP issuers’ third-party entities shall draw a statistically valid, randomized oversample for use in survey administration. Only providers included in the provider population file may be surveyed. 
The provider population file will be derived by CMS from provider data submitted by issuers on the “Network Adequacy Provider” tab in the Network Adequacy template submitted during the annual QHP certification process. The provider population file will include providers that have been validated and approved by CMS to count toward the issuer’s satisfaction of the time and distance standards for the corresponding specialty types (i.e., primary care [routine] and behavioral health). The provider population file will not include facility provider types (e.g., Outpatient Behavioral Health Clinics). CMS will create the provider population file after the final round of QHP certification data submission is complete. 

Q6: What data will be included in the provider population file?
  • The provider population file that CMS will generate for each issuer will include the following data fields for each individual provider:
    1. National Provider Identifier (NPI)
    2. Provider Name 
    3. Specialty Type 
    4. Street Address
    5. Street Address 2
    6. City
    7. State
    8. County
    9. ZIP Code
    10. Network ID
Q7: Why aren’t psychiatrists included in the behavioral health provider specialty type? 

Sample Selection

Q8: How many providers must a QHP issuer’s third-party entity survey via secret shopper?
  • A QHP issuer’s third-party entity shall survey a minimum number of providers of each provider specialty type included in the provider population file (i.e., primary care [routine] and behavioral health). The minimum number of providers that must be surveyed, based on the total number of providers of a specific specialty type in an issuer’s QHP provider network, has been identified by CMS to produce maximum confidence limits of +/- 5% for an expected compliance rate of 90% with a 95% confidence level for the issuer’s QHP provider network per service area. Please refer to Table 4 in the Appointment Wait Time (AWT) Secret Shopper Survey Technical Guidance for Qualified Health Plan (QHP) Issuers in the Federally-facilitated Exchanges (FFEs) to determine the minimum sample size to be surveyed for each provider type from each of an issuer’s QHP provider networks. 
Q9: How will QHP issuers’ third-party entities select providers for surveying?
  • A QHP issuer’s third-party entity will follow the required sampling approach summarized in the steps below: 
    1. Select the Oversample: CMS acknowledges that network adequacy provider data submitted by an issuer in the Network Adequacy template during the certification process are a point-in-time representation of an issuer’s QHP provider networks. Thus, to account for providers that are nonresponsive or ineligible when surveys are conducted, a QHP issuer’s third-party entity will select a statistically valid random oversample of providers from the provider population file that is 50% larger than the minimum sample sizes identified in Table 4 in the Appointment Wait Time (AWT) Secret Shopper Survey Technical Guidance for Qualified Health Plan (QHP) Issuers in the Federally-facilitated Exchanges (FFEs). QHP issuers’ third-party entities should round-up to the nearest whole number when calculating the size of the oversample population. If there are not enough providers in an issuer’s provider population file to draw a full oversample that is 50% larger than the required minimum sample, then the third-party entity will create a reserve sample from the remaining providers that were not included in the minimum sample.
    2. Draw the Minimum Sample: For each issuer’s QHP provider network, the QHP issuer’s third-party entity shall draw, from the oversample population, a random, statistically valid, minimum sample size for surveying of each provider type (i.e., primary care [routine] and behavioral health). 
    3. As Applicable, Utilize the Reserve Sample: If the minimum sample includes ineligible or nonresponsive providers, replacements will be drawn from the reserve sample. If the reserve sample is exhausted, and if additional providers remain in the provider population file, QHP issuers’ third-party entities must add additional providers of that same provider type to the oversample via random selection. The QHP issuer’s third-party entity shall continue to add providers to the oversample using a random selection process until either the required minimum number of providers per QHP provider network/service area are surveyed or all providers within the QHP provider network/service area for the applicable provider type have been surveyed.
For example, if an issuer’s QHP provider network contains 108 individual primary care providers, then the minimum sample size that must be surveyed for the primary care provider type for that issuer’s QHP provider network is 62. The QHP issuer’s third-party entity must select one randomized oversample of 93 primary care (routine) providers (consisting of the minimum sample of 62 plus a reserve sample of 31).

Q10: Can QHP issuers’ third-party entities use the same sample of providers if the issuer has multiple provider networks that are identical?
  • If a QHP issuer has multiple, identical provider networks, then only one statistically valid, randomized oversample of each provider type must be drawn and used for surveying the minimum required number of providers of each provider type. The same oversample can be used for all identical provider networks. Moreover, the same third-party entity can be used to survey different provider networks.
Please keep in mind that CMS will provide issuers with a file, referred to as the “provider population file,” that contains the population or “universe” of providers from which QHP issuers’ third-party entities shall draw a statistically valid, randomized oversample. The provider population file will be derived by CMS from provider data submitted by issuers on the “Network Adequacy Provider” tab in the Network Adequacy template submitted during the annual QHP certification process. The provider population file will include providers, from the list submitted by the issuer, that have been validated and approved by CMS to count toward the issuer’s satisfaction of the time and distance standards for the corresponding specialty types (i.e., primary care [routine] and behavioral health). Only providers included in the provider population file may be surveyed.

Q11: Can the same appointment wait time survey results be used for a provider that is included in samples from different provider networks?
  • If a QHP has multiple, nonidentical provider networks, then a statistically valid, randomized oversample population of each provider type must be drawn from the provider population file for each issuer’s QHP provider network. If the same provider is included in the oversample population drawn for more than one issuer’s QHP provider networks and a survey result is obtained from that provider, then that result can be reported and applied for that same provider for each sample in which the provider appears.

Survey Protocol Development

Q12: What requirements must QHP issuers’ third-party entities adhere to when developing a secret shopper survey protocol? 
  • QHP issuers shall work with their third-party entities to develop and finalize a secret shopper survey protocol that reasonably approximates an enrollee’s experience as a new patient attempting to obtain appointment availability from a provider. The protocol must be appropriately designed to obtain an offer for a first available appointment and adhere to the following minimum requirements:
    • The third-party entity must conduct secret shopper surveys while presenting as a new patient (i.e., a patient attending their first-ever clinical encounter with a practitioner at the location being surveyed). The survey script must be designed such that the third-party entity confirms whether the provider specifically offers primary care (routine) and/or behavioral health services at the location being surveyed. 
    • The survey script must be designed such that the third-party entity, posing as a new patient, ascertains whether the provider offers both in-person appointments and telehealth appointments, offers only telehealth appointments, or offers only in-person appointments. If a provider offers both in-person and telehealth appointments for new patients, and the first (i.e., soonest) available appointment offered is a telehealth appointment, then the third-party entity must also obtain appointment availability information for the next available in-person appointment. 
Alternatively, if a provider offers both in-person and telehealth appointments for new patients, and the first (i.e., soonest) available appointment offered is an in-person appointment, then the third-party entity must also obtain appointment availability information for the next available telehealth appointment. 
    • The survey protocol must be designed such that the third-party entity does not actually accept an offered appointment (therefore precluding actual patients from being able to access that appointment). For example, once an appointment is offered to the secret shopper, the third-party entity can say that they need to consult their calendar before confirming and then end the call.
Q13: Can QHP issuers’ third-party entities create simulated enrollee profiles when conducting secret shopper surveys?
  • QHP issuers and their third-party entities may consider a protocol that uses simulated enrollee profiles (consisting of, for example, name, address, and date of birth  and/or other identifying information) if the QHP issuer and the QHP issuer’s third-party entity determine this approach is feasible and/or believe this approach would increase the likelihood that providers would provide appointment availability information to secret shoppers. Neither simulated enrollee profiles nor survey scripts used by third-party entities should convey the existence of an urgent medical need.
Q14: Do QHP issuers' third-party entities need to present as existing patients, new patients, or both when conducting secret shopper surveys?
  • For plan year 2025, the third-party entity must conduct secret shopper surveys while presenting as a new patient (i.e., a patient attending their first-ever clinical encounter with a practitioner at the location being surveyed).

Survey Administration

Q15: What requirements related to timing must QHP issuers’ third-party entities follow when conducting secret shopper surveys calls?
  • Secret shopper survey calls must begin on or shortly after January 1 and must be completed by May 31 of the plan year. All outgoing secret shopper survey calls shall be conducted between 8:00 a.m. and 5:00 p.m. in the providers’ respective time zone. The third-party entity may not contact a provider’s office more than three times to obtain appointment availability information. For example, if the first contact attempt for a provider fails due to the provider being nonresponsive as defined in the disposition codes enumerated in Appendix B of the Appointment Wait Time (AWT) Secret Shopper Survey Technical Guidance for Qualified Health Plan (QHP) Issuers in the Federally-facilitated Exchanges (FFEs), the third-party entity may attempt to call that same provider’s office two additional times for a maximum of three contact attempts.
Q16: Do QHP issuers’ third-party entities need to separate contact attempts for a single provider by a minimum length of time? 
  • If the third-party entity’s secret shopper encounters communication difficulties when calling a provider, such as poor call quality or not being able to hear the call recipient, the third-party entity must initiate the next contact attempt with the provider after a minimum of 24 hours have elapsed since the prior contact attempt. 
Q17: How and from where will QHP issuers’ third-party entities identify provider contact information (i.e., phone numbers) necessary to administer secret shopper surveys?
  • QHP issuers are responsible for identifying and sharing the necessary provider contact information with their third-party entities. 

Collecting and Documenting Survey Results Data

Q18: How must QHP issuers’ third-party entities collect and document secret shopper survey results?
  • QHP issuers’ third-party entities must document secret shopper survey results for each provider contacted and/or surveyed and providers are to be surveyed according to the fields, definitions, and disposition codes as described in Appendices A (Appendix A: Required Secret Shopper Survey Results) and B (Appendix B. Valid Survey Disposition Codes) of the Appointment Wait Time (AWT) Secret Shopper Survey Technical Guidance for Qualified Health Plan (QHP) Issuers in the Federally-facilitated Exchanges (FFEs). Third-party entities will assign a disposition that best describes the survey outcome (e.g., the provider is not accepting new patients, an appointment is available with an equivalent provider, the provider is on family leave at the time of the survey, etc.). Third-party entities must also note whether the appointment offered was an in-person or telehealth appointment.

Calculating Compliance Rate and Other Figures Based on Results

Q19: How will QHP issuers’ third-party entities calculate the compliance rate for the wait time standard for each provider type?
  • The compliance rate for the wait time standard for each provider type, for each issuer’s QHP provider network, must be calculated according to the following formula:
Numerator: Number of providers that offered appointments within the time elapsed standard as reflected by provider survey results with any of the following disposition codes: A, B, J, K, S, T and accompanying Compliance_Indicator of “Y.” For disposition code definitions, see Appendix B.

Denominator: Total number of eligible providers surveyed. 
Q20: Are there additional calculations and results QHP issuers will need to submit to CMS? 
  • Yes. QHP issuers’ third-party entities will also need to calculate and submit the percentage of nonresponsive and ineligible providers for each QHP provider network according to the following formula:
Numerator: Number of providers that were deemed nonresponsive or ineligible as classified by any of the following disposition codes: C, D, E, F, G, L, M as call outcomes documented for each of the three contact attempts (if three contact attempts were required to be made) and Compliance_Indicator of “N/A.” 

Denominator: Total number of providers contacted.

Q21: How does CMS define an ineligible provider?
  • For the purposes of the appointment wait time standards, a provider is defined as ineligible to be surveyed (and therefore must be replaced by a randomly selected provider from the reserve sample) if: (a) at the time of the call, the provider is no longer contracted with the issuer as an in-network provider; or (b) at the time of the call, the provider is not practicing and classified as a primary care provider specialty type or behavioral health provider specialty type according to the specialty types/descriptions listed in Tables 2 and 3. If a provider is determined to be ineligible upon the first contact attempt, no additional contact attempts should be made, and the provider must be replaced by a randomly selected provider of the same specialty type from the reserve sample.
Q22: How does CMS define a nonresponsive provider?
  • For the purposes of the appointment wait time standards, a provider is defined as nonresponsive if any of the following dispositions are documented for each of three contact attempts associated with the same provider: (a) The provider’s phone rang for 5 minutes without an answer; (b) The provider’s phone number is not valid (for example, the number is disconnected or the phone number is not associated with the provider). If a provider’s phone number is not valid, the secret shopper shall not make two additional contact attempts before replacing the provider with another provider from the reserve sample; (c) A voicemail greeting was received during regular business hours, not during a designated lunch hour, and the voicemail greeting was not part of an appointment scheduling procedure; (d) The secret shopper was placed on hold for more than 15 minutes; or (e) the call could not be completed due to communication issue(s) such as poor call connectivity.

Submitting Survey Results Data to CMS

Q23: How will QHP issuers submit their survey results to CMS?
  • QHP issuers must submit the data and documentation from the completed secret shopper surveys through a secure file submission portal. Issuers will need to submit all the data elements outlined in “Appendix A: Required Secret Shopper Survey Results” of the Appointment Wait Time (AWT) Secret Shopper Survey Technical Guidance for Qualified Health Plan (QHP) Issuers in the Federally facilitated Exchanges (FFEs) including, the compliance rates, percentage of non-responsive providers, and contracts with third party entities. Valid survey results and accompanying calculations will be due to CMS by the second Friday of June each year. The link to the Portal, along with a unique access code, will be provided by a CMS contractor within the data submission request distributed to the QHP issuer. The QHP issuer must provide an accurate email address for a specific point of contact who will be given access to CMS requests through the Portal. CMS will provide additional instructions for the file formats and file-naming conventions within the data submission request submitted to the QHP issuer by email or through the Portal.
Q24: Who should QHP issuers contact should they have any challenges with the secured portal site?