CMS Releases Final Rules for Medicaid: Wait Time Standards and Payment to Workers

CMS Releases Final Rules on Medicaid Wait Times and Worker Payment

The Centers for Medicare and Medicaid Services (CMS) has announced two final rules that will have a significant impact on Medicaid beneficiaries and workers. The rules, which focus on Medicaid managed care plans, set maximum wait times for medical appointments and ensure proper payment to workers.

The first rule, the Medicaid and Children’s Health Insurance Program Managed Care Access, Finance and Quality Final Rule, establishes maximum wait time standards for various types of medical care. For routine primary care for adults and pediatric care, obstetrics and gynecological services, the maximum wait time is set at 15 business days. For outpatient mental health and substance use disorder services, the maximum wait time is 10 business days.

The second rule, the Ensuring Access to Medicaid Services Final Rule, sets minimum threshold standards for payments to the direct care workforce. It requires that at least 80% of Medicaid Home and Community Based Services payments directly compensate workers rather than going towards administrative overhead.

One of the key aspects of these rules is the requirement for states to have national appointment wait-time standards for the first time. States will enforce these standards through “secret shopper” surveys and will also be required to disclose provider payment rates publicly.

Additionally, the rules create a new beneficiary advisory committee in every state, allowing for direct feedback to state Medicaid and CHIP programs. States are also required to report on various aspects of their Home and Community Based Services (HCBS) programs, including wait lists, quality measures, and average hourly rates paid to workers.

Overall, these rules represent a significant step towards improving accountability, transparency, and access to health coverage for Medicaid beneficiaries. They align with President Biden’s Executive Order on Increasing Access to High-Quality Care and Supporting Caregivers, and aim to ensure that people with Medicaid and CHIP can access care when they need it.