What Are The New Wait-Time Standards For Federal Marketplace Plans?

Having sufficient in-network providers to choose from is vital when receiving medical care. Some insurers work with smaller plan networks to keep costs low. But without a wide network of providers, it can be difficult for patients to access care in a timely manner. This is especially true if an individual lives in a rural area and travels long distances to visit a primary care physician.

To remedy this, the Center for Medicare & Medicaid Services (CMS) created the Appointment Wait Time (AWT) rule in April 2024¹. This rule aims to improve access to medical care regardless of where a patient lives.

In this blog post, you’ll learn:

• The new appointment wait-time standards for federal Marketplace plans.
• Which type of health plans must follow the wait-time rules.
• How states will track compliance with the wait-time standards to improve patient care.

What are the new wait times for FFE health plans?

As of January 1, 2025, health insurers with plans on the Federally Facilitated Exchanges (FFEs) must meet specific appointment wait time standards to ensure new patients receive timely medical care. FFEs are exchanges run by the federal government, such as HealthCare.gov.

To ensure compliance with the new rule, insurance companies must guarantee that individuals can book an appointment with an in-network provider within the timeframes listed below at least 90% of the time.

Here are the new wait time requirements for FFE health plans:

CMS's 2025 Final Letter to Issuers in the Federally Facilitated Exchanges provides more details about the AWT rule².

What issuers and plans are subject to the new wait-time standards?

All insurers on the federal Marketplace must adhere to these new network standards. Insurance companies and plans on state-based and private insurance exchanges are exempt.

The following plans and issuers must adhere to the AWT rule:

• Qualified health plan issuers in the FFEs, including stand-alone dental plan insurers
• Federally-facilitated Small Business Health Options Programs (SHOP) plans
• Health plans sold on state-based exchanges that use the HealthCare.gov website³

Starting in 2026, insurers on state-based exchanges will also need to follow new wait time and distance standards.⁴

Beginning in 2027, the Medicaid and Children’s Health Insurance Programs (CHIP) must also follow the AWT rule.

Below are the upcoming appointment wait time standards for Medicaid services and CHIP plans:

States must also create a wait time standard for a state-selected medical service⁵.

How will these changes affect access to patient care?

The goal of the new wait-time standards is to improve access to healthcare by ensuring that patients can schedule appointments within reasonable periods of time. This can lead to better medical care, reduced delays that can prevent chronic health issues, and a stronger customer experience.

CMS also determines health plan network adequacy using provider-to-enrollee ratios and time and distance measurement standards⁶. This means that a qualified health plan must offer a provider network that satisfies a minimum provider-to-enrollee ratio.

It also must include enough providers in locations close enough to the policy’s enrollee population. Most often, insurers use the travel time between patients and providers to measure compliance with time and distance standards.

If a carrier can’t meet the new network standards, it must add more medical professionals to comply, increasing quality access to healthcare.

How are the compliance regulations regarding the new wait times being enforced?

Enforcement of the AWT rule is up to the individual state, even if the consumer purchased their plan on the federal Marketplace. However, CMS will require issuers in the FFEs to contract with third-party companies to conduct “secret shopper” surveys to determine compliance. During this process, the secret shopper will pretend to be a patient to measure how often in-network providers meet the new wait times.

Here are a few more details of how the secret shopper surveys will work:

• The secret survey process will begin on or shortly after January 1 and finish by May 31 of each plan year.
• The secret shopper will collect information from providers regarding the wait times of in-person and telehealth appointments.
• CMS only requires insurers to secret shoppers to survey new patient wait times for primary care services and behavioral healthcare. In the future, non-urgent specialty care will also require surveys.
• The third-party company conducting the survey must be a separate and distinct entity from the insurer. For instance, the third-party group and the insurer can’t be affiliated businesses or subsidiaries of the same parent company⁷.
• Each state’s secret shopper surveys must find that 90% of a health insurance plan’s providers comply with the wait time network standards. If providers don’t meet the required times, the insurer must add more providers to its health plan network.

Qualified health plan issuers must keep relevant survey information on file. Insurers provide the Center for Medicare & Medicaid Services with the results for review each year. They must also conduct annual enrollee satisfaction surveys. Both survey results will be posted on state websites for patient transparency.

Conclusion

Health plans in the FFEs have a new rule to fulfill in 2025. But it comes with good news for patients nationwide. The new standards will make it easier for individuals with Marketplace plans to schedule appointments with various medical providers promptly. Not only will this improve health plan networks for millions of Americans, but it will also prevent delayed medical treatment so individuals can stay happy and healthy long-term.

1. CMS - Appointment Wait Time FAQs

2. The 2025 Final Letter to Issuers in the Federally Facilitated Exchanges

3. Healthcare.gov

4. 45 C.F.R. § 155.1050

5. Final Rules for Medicaid and CHIP Programs

6. Time and Distance Standards for Network Adequacy

7. AWT Secret Shopper Survey Technical Guidance