What to know about new Medicaid rules addressing access to care

CMS issued final rules in April related to managed care, fee-for-service plans

The Centers for Medicare & Medicaid Services issued two final rules April 22 related to access to care within Medicaid managed care and fee-for-service plans.

The American Dental Association previously sent letters in June 2023 to CMS, commenting on both rules after they were proposed and offering suggestions.

Below are key takeaways from the final rules.

MANAGED CARE

State Medicaid programs have been expanding their use of managed care as an alternative service delivery and payment system to traditional fee-for-service systems. Managed care organizations are health plans that contract with states to provide comprehensive Medicaid benefits to enrolled beneficiaries. The state Medicaid agency pays the managed care organization a set amount of money per patient to cover the expected cost of health care services for that patient over a certain period of time.

The Medicaid and Children's Health Insurance Program Managed Care Access, Finance, and Quality final rule addresses access to care and other topics within managed care plans. Notable regulations include:

• Rate transparency: Managed care organizations must provide their rates for primary care, OB-GYN and behavioral health services in a report to states and the general public starting with the first rating period beginning on or after Sept. 9 of this year. States must select a fourth health care service for which managed care organizations will need to publicly provide their rates. This could be dental.

• Access monitoring: Managed care organizations will be required to actively perform access monitoring with the first rating period beginning on or after July 9, 2027. This will be done through secret shopper surveys overseen by an independent entity that is not a state or managed care organization. Detected errors from the surveys must be reported for correction to the managed care organizations in order to ensure accurate provider directories. Larger access issues that are discovered must be reported to CMS within 90 days of their discovery and include a 12-month remediation plan. This regulation does not specifically address dental care, but states must apply this oversight to an additional type of service — such as dental — outside primary care, OB-GYN and behavioral health services, which the regulation includes. Survey results must be published starting with the first rating period beginning on or after July 10, 2028.

• Wait time standards: While the rule proposes standard wait times of 10-15 days for routine primary care, OB-GYN and behavioral health appointments to help evaluate network adequacy, it leaves determining the wait time standard for another provider of the state’s choosing — potentially dental — to the state. However, CMS appears to suggest in the rule that states should take guidance from Medicare Advantage, which enforces 30 days for routine appointments and one week for urgent appointments. The wait time standards will be applicable after the first rating period beginning on or after July 9, 2026.

• Website improvements: The rule requires states to post managed care plan information and links, including enrollee handbooks, provider directories, network adequacy standards, secret shopper survey results and more, on a single webpage to make it easier to find for users. CMS will begin enforcing this regulation on or after July 9, 2026.

FEE FOR SERVICE

In a fee-for-service system, state Medicaid agencies establish the fee levels for covered services and pay participating providers directly for each service they provide. This is the payment model historically used by most state Medicaid programs.

The Ensuring Access to Medicaid Services final rule addresses access to care within fee-for-service models. Notable regulations include:

• Advisory groups: States are required to create both a beneficiary advisory council and a Medicaid advisory committee by April 22, 2025, to advise on issues related to the administration of Medicaid. The Medicaid advisory committee must include a practicing health care provider, such as a dentist, and a member from a state agency that focuses on health and human services. The state agency representative, who would be a nonvoting member, could be a state dental director.

• Rate transparency: States must publish all fee-for-service Medicaid payment rates on a publicly available and accessible website by July 1, 2026, and update them within 30 days of changes. While this is already done by most states for dental fees, some of the information is difficult to find and understand. States also must publish analyses every two years, beginning July 1, 2026, comparing their fee-for-service rates for primary care, OB-GYN and behavioral health services with Medicare rates. States are not required to choose an additional service type, such as dental, for analysis.

• Access monitoring: The rule requires states to demonstrate network sufficiency through an initial analysis if they submit a plan amendment that includes a rate reduction or restructuring in a way that could result in diminished access. If states do not meet the requirements of the initial analysis, they must perform an additional, more extensive analysis. The rule does not include a standard for patient appointment wait times.

For more information on Medicaid, including the ADA’s advocacy efforts related to it, visit ADA.org/Advocacy.