Talk to an Expert
Get a Demo

Medicaid Secret Shopper Readiness for Managed Care Plans

Starting with rating periods on or after July 10, 2028, your state will survey your network every year under 42 CFR 438.68. PRIME® runs independent mock surveys against the same standards and corrects the directory errors they find before the state’s surveyor calls.

Talk to us
90%

Required compliance threshold

4

Directory data points tested per provider

30 Days

For states to publish survey results

<span>Medicaid Secret Shopper Readiness</span> for Managed Care Plans

What the Medicaid Rule Expects From Your Plan

multi

A survey your state runs

Your state contracts the independent surveyor, and that entity cannot be a plan or have ownership ties to one. You won’t control the script, the sample, or when calls happen. 

multi

Directory accuracy on the same call

Surveyors check network status, address, phone, and new-patient acceptance. Errors go to the state within three business days and to you within three more. 

multi

Results your state publishes

Results go to CMS and appear on the state’s website within 30 days. Plans that miss the standards face state-required remedy plans.  

Medicaid Appointment Wait Time Standards

These standards apply from rating periods beginning on or after July 9, 2027. Plans comply when appointments are available within the standard at least 90% of the time. 

Medicaid Appointment Wait Time Standards

[01] Survey Design

Mock surveys built on 42 CFR 438.68

  • New-patient scripts for outpatient MH/SUD, primary care, and OB/GYN
  • Your state’s selected service type added once published
  • In-person and telehealth availability captured separately
  • Random samples across your contracted service areas
medicaid-survey-design

[02] Directory Testing

Four-point checks on every call

  • Active network status confirmed with the practice, not just your roster
  • Street address verified against where the provider actually sees patients
  • Phone number tested for a line that can book for that clinic
  • New-patient acceptance matched to what your directory shows
medicaid-directory-testing

[03] Error Correction

Directory errors routed straight to correction

  • Each error logged at the provider record level
  • Corrections synced to your directory and downstream systems such as claims
  • Audit trail for every change
  • Similar high-risk records flagged across the network
medicaid-error-correction

[04] Readiness Reporting

Compliance rates before the state calls

  • Availability rate by provider type against the 90% threshold
  • Telehealth results reported apart from in-person
  • Directory error rate by field and region
  • Prioritized fix list ahead of your first state survey
medicaid-readiness-reporting

What a Mock Survey Reveals Before 2028

State surveys begin with rating periods on or after July 10, 2028, which means 2029 for states with January contract cycles. A mock survey run now gives you time to act on what it finds.

 

PRIME® fixes the gaps through provider directory validation and keeps them current with ongoing provider data monitoring.

If you also offer Marketplace plans, see our QHP secret shopper surveys. 

Most plans see the same few gaps:

  • Telehealth-only providers who won’t count toward compliance
  • Phone numbers that reach lines unable to book for that clinic
  • Providers no longer seeing patients at the listed location
  • New-patient flags that don’t match the practice

FAQs

Can a Medicaid plan hire its own vendor to run the 42 CFR 438.68 survey?

No. The state must contract an independent entity with no ties to any surveyed plan. Plans can commission independent mock surveys to measure readiness before the official survey. 

When do Medicaid secret shopper surveys begin?

Surveys apply from the first rating period beginning on or after July 10, 2028. For states with January contract cycles, that means 2029.

Which providers will states survey?

Wait time surveys cover outpatient mental health and SUD, primary care, OB/GYN, and one state-selected service type. Directory checks cover the same four provider types. 

Do telehealth appointments count toward compliance?

Only when the same provider also offers in-person appointments. States must report telehealth results separately. 

How is this different from the QHP secret shopper survey?

QHP issuers hire their own third-party surveyor and submit results privately to CMS. In Medicaid, the state runs the survey, tests directory accuracy directly, and publishes the results.