Accessibility Standards

HMSA has established standards approved by HMSA's Quality Improvement Operations (QI Ops) Committee to ensure that members have timely access to the medical care they need. HMSA conducts annual assessments of its network to verify member access to medical care.

Access to Medical Care

For any emergency need, members should be directed to go to their nearest emergency room or to call 911.

For non-emergency primary medical care needs:

• A member should be seen within 21 days for regular or routine care (e.g., non-urgent, non-symptomatic conditions such as well-baby checks, preventive care, physical exams, medication monitoring or the ongoing management of a chronic condition).
• A member should be seen within 24 hours for an urgent, symptomatic condition (e.g., high fever, ear pain/infection).
• A member should receive a response to an after-hours call within three hours.

For the 2025 plan year, QHP issuers, including Stand Alone Dental Plan (SADP) issuers, will be required to ensure that new patients seeking an appointment are able to schedule an appointment within the time frames below at least 90% of the time.

• 15 business days for Primary Care Providers
• 10 business days for Behavioral Health Providers
• 30 business days for Specialty Care Providers 

Assessment of access to medical care

Medical care appointment accessibility for Regular and Routine Care and Urgent Care is monitored through questions on the annual CAHPS®1 (Consumer Assessment of Healthcare Providers and Systems) member survey with the following goals:  

Regular and Routine Care – Summary rate of 90 percent of members reporting “always “ or “usually” to the CAHPS® Survey question,  “How often did you get an appointment for a check-up or routine care at a doctor’s office or clinic as soon as you needed?”

Urgent Care - Summary rate of 90 percent of members reporting “always” or “usually” to the CAHPS® survey question, "When you needed care right away, how often did you get care as soon as you needed?"

After-Hours Care – Summary rate of 85 percent of members responding to the CAHPS® survey question that a response to an after-hours call was received within 3 hours

Access to medical care is also monitored by complaints received from HMSA members.

1 CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

Recommended average office wait time

The average office wait time should be no more than 15 minutes for patients who arrive on time for a scheduled appointment.

After-hours care

In addition to normal office hours, primary care providers participating in any HMSA line of business are responsible for assuring accessibility of services to patients 24 hours a day, seven days a week. This includes arrangements for coverage after hours by another HMSA participating provider, access through Physician's Exchange or an answering service. A member should receive a response to an after-hours call within three hours.

Revision History