CMS Cracks Down on Appointment Wait Times for Medicaid MCOs

The Centers for Medicare and Medicaid Services (CMS) want state Medicaid plans to improve patient care access, with the proposed Ensuring Access to Medicaid Services and Managed Care Access, Finance, and Quality notices of proposed rulemaking (Access NPRM) particularly zeroing in on appointment wait times.

The proposed rule will require state Medicaid managed care organizations and Children’s Health Insurance Plan (CHIP) plans to adhere to national maximum standards for appointment wait times. Additionally, plans will be required to conduct independent “secret shopper” surveys to monitor compliance to the maximum allowed appointment wait times.

“Having health care coverage is fundamental to reducing health disparities, but it must go hand-in-hand with timely access to services. Connecting those priorities lies at the heart of these proposed rules,” CMS Administrator Chiquita Brooks-LaSure said in a statement. “With the provisions we’ve outlined, we’re poised to bring Medicaid or CHIP coverage and access together in unprecedented ways—a key priority that’s long overdue for eligible program participants who still face barriers connecting to care.”

Particularly, the proposed rules create maximum allowed appointment wait times for primary care, obstetric/gynecological services, outpatient mental health services, substance use disorder services, and one state-selected service.

In efforts to monitor compliance with appointment wait time standards, CMS proposed state Medicaid and CHIP agencies conduct independent “secret shopper” surveys in which individuals call Medicaid providers, request an appointment, and document the wait time.

CMS said these proposals are in an effort to improve not just healthcare coverage and quality, but access to care. A separate September 2022 study from Merritt Hawkins found that the average appointment wait time in 2022 was 26 days, which can be a detriment to both the patient experience and healthcare outcomes.

“The Biden-Harris Administration has made clear where we stand: we believe all Americans deserve the peace of mind that having health care coverage brings,” HHS Secretary Xavier Becerra said in a CMS press release. “We are proposing important actions to remove barriers to care, engage consumers, and improve access to services for all children and families enrolled in these critical programs.”

In addition to the wait time proposals, CMS proposed that states must collect information about the patient experience through beneficiary surveys. If the proposals stay intact, managed care organizations would need to conduct enrollee experience surveys each year.

Additionally, the proposal outlines a plan for a Medicaid and CHIP quality rating system for each state program. CMS pitched the idea of a “one-stop-shop” for Medicaid members to compare different plans. Comparisons would include details like care quality, access to providers, covered benefits, covered drugs, cost, and other plan performance indicators, the agency said.

Finally, the proposal calls for better beneficiary engagement in Medicaid Advisory Committees. As part of the proposed rules, CMS stated that Medicaid Advisory Committees should have a beneficiaries-only subgroup and include the voice of the beneficiary caregiver.

These proposals come as the nation gets ready for a shift in healthcare coverage as the COVID-19 Public Health Emergency (PHE) ends on May 11. As part of the PHE’s sunset, the healthcare sector expects an influx of individuals losing Medicaid eligibility.

CMS emphasized the role Medicaid has played in enabling patient access to care, noting the number of individuals who have benefitted from the program.

“One in four Americans and over half of all children in the country are enrolled in Medicaid or CHIP – and the Biden-Harris Administration is committed to protecting and strengthening these programs for future generations,” Becerra said.