CMS Managed Care Rule Implementation: How Secret Shoppers Can Enhance the Beneficiary Experience

The Centers for Medicare & Medicaid Services (CMS) released the Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality final rule earlier this year, effective July 9, 2024. This rule aims to improve Medicaid member experience, enhance care quality, and increase transparency and accountability within managed care plans. One way in which the rule promotes accountability is through a requirement that states use secret shopper surveys by July of 2027. These surveys will help states accurately monitor access to care and ensure high-quality services for beneficiaries. 

Secret Shopper Survey Requirement 

Secret shopper surveys are a research method used to evaluate the quality of customer service provided and access to care by health care providers. The researcher, posing as an enrollee (or their representative), contacts the provider to schedule an appointment, simulating a real patient experience.  

The purpose of secret shopper surveys is to help payers and managed care plans gather reliable feedback on provider availability, wait times, and overall beneficiary experiences. These surveys offer insights that other metrics, such as provider-to-enrollee ratios, might overlook. The rule stresses that secret shopper surveys must be conducted independently and objectively to obtain reliable and useful results. 

These secret shopper surveys are intended to play a key role in validating access standards. The final rule establishes new appointment wait time standards for routine services, including mental health, substance use disorder, OB/GYN, primary care, and one additional service category chosen by each state. States must maintain these standards alongside existing network adequacy requirements and ensure 90% compliance, as verified by secret shopper surveys. Survey results will be included in the annual network certification report to CMS, enhancing oversight and accountability. 

How States Can Use Information from Secret Shopper Surveys 

Twenty-one states already engage in this practice. CMS aims to provide beneficiaries with consistent and reliable access to care by mandating secret shoppers across the nation. The results of these surveys will be reported to CMS and made publicly available. 

Kentucky and Michigan are examples of states already using secret shoppers’ data to uncover significant gaps in provider accessibility and drive program improvement: 

• Kentucky: Secret shopper surveys revealed that the overall compliance rates for routine, urgent, and after-hours calls were substantially below the compliance rate to satisfy applicable appointment standards. Nearly two-thirds of providers were either unreachable for routine and urgent calls or, when reached, were unable to schedule appointments due to issues such as the provider not accepting new patients.  As a result, Kentucky pushed for better network management by managed care organizations and implemented corrective actions to ensure appointment availability meets state standards. 

• Michigan: Secret shopper surveys focused on dental services revealed that only 60.4% of dental providers who reported accepting the MI Health Link program and new patients offered an appointment, and appointment wait times often exceeded state standards. In response, Michigan required plans to implement corrective action plans to improve network adequacy and reduce wait times. The state may impose penalties if improvements are not achieved. 

Aurrera Health Blog Series on Access and Managed Care Final Rules  

Implementing the Access and Managed Care Rules will require a significant investment in state time and resources. Aurrera Health looks forward to helping states and other stakeholders understand and implement requirements to support Medicaid beneficiary access and managed care transparency. If you would like to discuss how we can help your state, please reach out to Aurrera Health Managing Principals Megan Thomas or Kristal Vardaman. 

Reatha Conn [Policy Consultant]