Apr 30, 2024 - Health

Biden plan to reduce Medicaid appointment wait times faces pushback

Illustration of a stopwatch shaped and colored like a red medical cross.

Illustration: Annelise Capossela/Axios

The Biden administration wants to make sure Medicaid enrollees don't have to wait too long to see a doctor, but state officials and health insurers that administer the program argue a new plan to speed up appointment wait times is unrealistic.

Why it matters: Low-income patients and people with disabilities served by Medicaid historically have faced longer wait times for appointments, partly because because providers are less willing to accept the program's typically lower reimbursement rates compared with private insurance.

  • The administration will soon mandate that most beneficiaries can see a primary care provider within 15 business days of booking an appointment.
  • "It doesn't matter how good your insurance is or how close your provider is if you can't actually get an appointment," said Naomi Fener, director of population health at Families USA.
  • The rule could put the onus on some states to raise rates to attract more providers into Medicaid, experts said.

How it works: The administration's new standards are for Medicaid managed care plans, which cover most program enrollees.

  • The 15-day limit, which also applies to OB-GYN services, would take effect starting July 2027, along with a 10-day requirement for mental health and substance use care.
  • Nearly identical requirements for Affordable Care Act marketplace plans kick in next year.

States will enforce Medicaid wait time requirements using "secret shopper" methods to verify patients can make timely appointments.

  • For insurers who don't meet the standards at least 90% of the time, states must create remedy plans that could include boosting provider pay, improving outreach to providers or expanding services that providers could offer.
  • In the most egregious cases, health insurers' Medicaid payments could be cut.

Friction point: Managed care plans and state Medicaid programs say the policy doesn't address the underlying problems of provider shortages.

  • "Our plans are going to do what it takes to comply. I just harbor some concerns that they will be held accountable for things that are outside of their control," said Jennifer McGuigan Babcock, senior vice president at the Association for Community Affiliated Plans.
  • Her group, which represents nonprofit safety net health insurers, and others unsuccessfully pushed for the administration to adopt a minimum 30-day wait time standard and provide more leeway for health plans to meet the requirements through telehealth.
  • The administration acknowledged in a final rule published last week that provider shortages "present challenges to ensuring timely access," but federal Medicaid officials said that's part of what makes wait time standards important.
  • They noted that states can grant managed care plans exceptions to the requirement.

Between the lines: Medicaid plans may increase provider payment as they try to attract more providers to meet wait time standards, said Families USA's Fener.

  • Raising Medicaid provider rates is not a silver bullet, said Jack Rollins, director of federal policy for the National Association of Medicaid Directors.
  • Rollins also said that Medicaid directors thought it was "premature" to set wait time limits before knowing how they work in the ACA marketplaces.

Reality check: States, which run Medicaid with the federal government, will take different approaches to enforcing wait times — meaning Medicaid enrollees in some states may get more relief from long waits for appointments than others.

  • "This is a great step and a great signal from [the Centers for Medicare and Medicaid Services]. It's gonna take a while before plans can actually get into compliance," Fener said.
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