CMS Releases Rules On Wait Times And Payment Standards In Medicaid

The Centers for Medicare and Medicaid Services on Monday released two final rules regarding Medicaid that establish maximum wait times for medical care and ensure payment to workers.

The Medicaid and Children’s Health Insurance Program Managed Care Access, Finance and Quality Final Rule applies to managed care plans. Over 70% of Medicaid and CHIP beneficiaries receive some or all of their care through a managed care plan, CMS said.

It sets maximum appointment time wait standards of 15 business days for routine primary care for adult and pediatric care, obstetrics and gynecological services. The maximum is 10 business days for outpatient mental health and for substance use disorder services.

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

Medicaid managed care plans are required to submit actual expenditures and revenues for state-directed payments as part of their medical loss ratio reports to states.


This is the first time states are being required to have national appointment wait-time standards.

States will enforce these wait-time standards by conducting “secret shopper” surveys, which can help verify compliance.

States will also now be required for the first time to disclose provider payment rates publicly.

States are being required to publish all fee-for-service Medicaid fee schedule payment rates on a publicly available and accessible website. They are also required to compare their fee-for-service payment rates for primary, obstetrical and gynecological care, and also outpatient mental health and substance use disorder services to Medicare rates, and publish the analysis every two years.

Additionally, the rules create a new beneficiary advisory committee in every state, which will allow for direct feedback to state Medicaid and CHIP programs on benefits and service delivery from the people who access it daily.


  • States are required to report how they establish and maintain Home and Community Based Services (HCBS) wait lists, assess wait times and report on quality measures. This policy allows states to take into account small providers and providers in rural areas, to promote training and quality and ensure smooth implementation with additional data collection prior to full phase-in, CMS said.
  • States must have a grievance process for all HCBS participants.
  • States need to publish the average hourly rate paid for personal-care, home-health aide, homemaker and habilitation services, and publish the disclosure every two years.
  • States’ Medical Care Advisory Committees and the renamed Medicaid Advisory Committees (MAC) will advise states on an expanded range of issues.
  • Twenty-five percent of the MAC members will be drawn from a Beneficiary Advisory Council (BAC) comprised of Medicaid beneficiaries, their families and/or caregivers.
  • In three years, states must report on their readiness to collect data regarding the percentage of Medicaid payments for homemaker, home-health aide, personal-care and habilitation services spent on compensation to the direct care workers furnishing these services.
  • In four years, states must report on the percentage of Medicaid payments for homemaker, home-health aide, personal-care and habilitation services spent on compensation to the direct care workers furnishing these services, subject to certain exceptions.
  • In six years, states need to ensure a minimum of 80% of Medicaid payments for homemaker, home-health aide, and personal-care services be spent on compensation for direct care workers furnishing these services, as opposed to administrative overhead or profit, subject to certain flexibilities and exceptions (referred to as the Home and Community Based Services payment adequacy provision).
  • The rules specify the scope of ILOSs – in lieu of services and settings – to better address health-related social needs such as housing- and nutrition-related services.
  • They establish a quality rating system for Medicaid and CHIP managed care plans – a “one-stop-shop” where beneficiaries can learn about eligibility for plans and compare them based on quality and other factors.


The Access and Managed Care rules create the strongest requirements yet for improving accountability, transparency and access to health coverage in the nation’s largest healthcare program, CMS said.

These two rules together create historic national standards that will allow people with Medicaid and CHIP to better access care when they need it, finalize payment standards for direct-care workers providing HCBS, and make provider rates more transparent.

The three final rules announced Monday, with the nursing home staffing standard rule, support President Biden’s April 2023 Executive Order on Increasing Access to High-Quality Care and Supporting Caregivers.


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