States are going to have to create new monitoring and enforcement actions for their Medicaid programs thanks to new federal rules that were released at the end of April.

The need for these standards has grown ever more important with the spiraling growth in the use of Medicaid managed care plans. The Inspector General of the US Department of Health and Human Services recently reported that 81% of Medicaid enrollees receive at least part of health benefits through managed care. In fact, managed care plans are now in use in all but eight of the states.

But while there are cases to be made about the efficiency that such plans can bring to Medicaid, problems have abounded including “inappropriately denied service authorizations and the denial of payments,” as we wrote a few weeks ago. 

Up until now, states have had significant flexibility to set adequacy standards and to monitor managed care compliance. But according to a brief from the Kaiser Family Foundation, the new regulations will create maximum wait times that will apply to behavioral health, routine primary care, and obstetrical and gynecological appointments.

Brief details about the new “extensive and complex” Biden Administration final regulations are provided in a May 1, 2024 KFF issue brief, “10 Things to know About Medicaid Managed Care,” which also includes a great deal of information on current Medicaid managed care operations. 

The new regulations provide that, going forward, states will be responsible for establishing a number of new practices. These requirements include the implementation of remedy plans to address areas where managed care plans need access-oriented improvements and efforts to support greater transparency.

Nothing will be happening overnight, and a number of the most important requirements will take a few years to roll out. These include the following, with their effective dates shown in parentheses:

• Submission of an annual payment analysis to compare relevant Medicaid and Medicare provider rates to better understand rate impact on access (2026)

• Establishment of maximum wait time standards for “routine” appointments, including 15 business days for primary and obstetrical/gynecological care and 10 business days for outpatient mental health and substance abuse (2027)

• Requirement to conduct an annual enrollee experience survey for each managed care plan (2027)

• Use of secret shopper surveys to monitor compliance with wait time rules and provider directory accuracy, (2028)

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