Are your customer service representatives ready to assist limited English proficient (LEP) callers properly? Each year, the Centers for Medicare & Medicaid Services (CMS) conducts test calls that directly influence your Star Rating and your bottom line. Preparation isn’t optional. It’s essential to maintain compliance, build member trust, and maximize incentive payments and your CMS Star Rating.
What Is CMS and Why Does It Matter
The Centers for Medicare & Medicaid Services (CMS) oversees Medicare and works with states to manage Medicaid, the Children’s Health Insurance Program (CHIP), and health insurance portability standards. For health plans, CMS is both a regulator and a gatekeeper, shaping how benefits are delivered and evaluated.
Understanding CMS Star Ratings
CMS rates Medicare plans on a 1–5 star scale to assess quality and help beneficiaries make informed choices. This star rating system was established by CMS to evaluate the quality of the plans and help seniors select the most suitable option. Even so, ratings influence more than reputation. They also play a crucial role in CMS’s decisions on whether plans can continue to bill Medicare for their services. In addition:
- Plans with 4+ stars receive a 5% quality bonus from CMS.
- In 2023, these bonuses totaled $12.8 billion for Medicare Advantage plans.
- Yet, average ratings have declined in recent years, reflecting the lingering effects of COVID-19 and a new methodology for calculating ratings..
A higher rating means stronger member acquisition, retention, and financial performance.
How the CMS Accuracy and Accessibility Study Impacts You
Every fall, the CMS publishes its annual Accuracy and Accessibility Study, which measures performance in assisting limited English proficient (LEP) callers. The result of this annual study plays a big role in determining the star rating a plan receives. If your team struggles to connect callers with interpreters quickly or provides inaccurate information, then the consequences are immediate: lower ratings, reduced bonuses, and potential reputational risk. This is why it is crucial to partner with a Strategic Globalization Organization like Piedmont Global. We ensure your customer service representatives are equipped with the resources they need to assist your LEP patient population.
What Happens During a CMS Test Call
CMS measures performance by conducting test calls. Test calls are made by “secret shoppers” who are limited English proficient (LEP) individuals posing as patients or family members of patients seeking information about their insurance plan benefits and coverage. A typical test call follows strict benchmarks:
- Step 1: The caller must reach a live representative within 10 minutes (including hold time).
- Step 2: Once connected with an interpreter, the first of three survey questions must begin within 8 minutes.
- Step 3: Each survey question must be answered within 7 minutes, using information pulled from CMS publications (like Medicare & You 2024) and plan-specific details.
These calls are conducted annually, from February through June. During the testing period (conducted annually from February through June), any inbound call could be a test call. As an insurance provider, it is crucial to prepare your customer service team for these calls and to make sure they have quick and easy access to the appropriate resources.
CMS Test Call Assessment Criteria
The test calls conducted by CMS evaluate a number of criteria, including:
- Ease of navigating automated phone systems
- Speed of reaching a live representative
- Accuracy and completeness of answers provided
- Availability and accuracy of interpreters in key languages: Spanish, Mandarin, Cantonese, French, Vietnamese, and Tagalog
For LEP callers, interpreter connection and communication quality are often the deciding factors.
Preparing Your Customer Service Team
Your customer service team needs to be prepared when the next test call season comes around. They need to know what metrics CMS evaluates, and more importantly, they need to know how to quickly access the appropriate resources to support LEP members effectively. Key steps include:
- Staff Awareness: Ensure representatives are aware of the CMS test call season to plan and staff accordingly.
- Assessment Familiarity: Educate your team on the CMS assessment criteria and the weight they carry in Star Ratings.
- Interpreter Access: Train representatives on how to quickly connect with professional phone or video interpreters.
- Simulation Practice: Run mock test calls so your team can practice how to interact with a professional interpreter under realistic conditions and conduct test calls of your own.
With preparation, your staff won’t just pass CMS evaluations; they’ll provide a consistently higher level of service for every member, year-round.
Final Thought: Preparation Shapes Performance
CMS test calls are not simply a compliance hurdle; they are a reflection of how well you serve your diverse member population. Plans that prioritize language access earn stronger ratings, higher incentive payments, and greater member satisfaction.