New requirements for all state and territory Medicaid programs

 

Over the past year, federal agencies and Congress have enacted dozens of polices that will impact Medicaid programs. Many of these policies are focused on improving the quality of long-term care services, streamlining Medicaid eligibility processes, increasing access to services, and strengthening oversight of managed care organizations. NAMD has compiled a list of the most visible changes grouped by their implementation deadlines.

NEW IN 2025 

Justice-involved youth must receive services as they leave carceral settings.

Medicaid programs will be required to provide services to eligible juveniles who are re-entering communities from carceral settings, like jails and prisons. Specifically, Medicaid agencies will be required to provide certain screenings 30-days pre-release (or within one week, or as soon as practicable post-release) and targeted case management 30 days pre-release and 30 days post-release.

• Deadline: January 1, 2025
• Read the statutory language.

Medicaid programs must publish searchable and regularly updated provider directories. 

All Medicaid programs will be required to publish searchable and regularly updated provider directories on a public website.

• Deadline: July 1, 2025
• Read the statutory language.

Medicaid programs must establish Medicaid Advisory Committee and Beneficiary Advisory Council. 

All Medicaid programs will be required to transition their existing Medical Care Advisory Committees into Medicaid Advisory Committees and establish new Beneficiary Advisory Councils made up of Medicaid members and caregivers.

• Deadline: July 9, 2025
• Read the final rule.

NEW IN 2026 

Suspend, not terminate, Medicaid coverage during incarceration. 

All Medicaid agencies will be required to suspend, not terminate, Medicaid coverage when an individual becomes incarcerated.

• Deadline: January 1, 2026
• Read the statutory language.

Establish total minimum nurse staffing levels in long-term care facilities.

Long-term care facilities will be required to meet total minimum nursing staffing standards at a level of 3.48 hours of nurse staffing per resident day. They will also be required to have a registered nurse on-site 24/7.

• Deadline: June 21, 2026
• Read the final rule.

Publish reimbursement rates and rate comparisons for certain services.

Medicaid agencies will be required to disclose their reimbursement rates for personal care, home health aide, homemaker, and habilitation services. They will also be required to publish comparisons of Medicaid rates to Medicare rates for primary care, OB/GYN, and mental health/substance use services.

• Deadline: July 1, 2026, and then every 2 years
• Read the final rule.

Publish managed care reimbursement rate comparisons for certain services. 

Medicaid agencies will be required to publish payment analyses for their managed care organizations. These analyses must include total payments and comparisons to Medicare rates for primary care, OB/GYN, and mental health/substance use services, and total payments and comparisons to fee-for-service rates for homemaker services, home health aide services, personal care services, and habilitation services.

• Deadline: Managed care rating period beginning on or after July 9, 2026.
• Read the final rule.

NEW IN 2027 

Create a Provider Access API to share data between payers and providers. 

Medicaid agencies will be required to implement and maintain a Provider Access Application Programming Interface (API) which will allow payers and providers to exchange claims, encounter, and prior authorization data.

• Deadline: January 1, 2027 (Medicaid/CHIP FFS programs may request a one-time, one-year extension)
• Read the final rule here.

Create a Payer-to-Payer API to share data when a patient changes insurers. 

Medicaid agencies will be required to implement and maintain a Payer-to-Payer Access Application Programming Interface (API) which will allow payers to share data when a patient transitions between coverage sources.

• Deadline: January 1, 2027 (Medicaid/CHIP FFS programs may request a one-time, one-year extension)
• Read the final rule here.

Create a Prior Authorization API to automate prior authorization processes. 

Medicaid agencies will be required to implement and maintain a Prior Authorization Requirements, Documentation, and Decision Application Programming Interface (PARDD API) which will be used by providers to automate certain aspects of prior authorization processes.

• Deadline: January 1, 2027 (Medicaid/CHIP FFS programs may request a one-time, one-year extension)
• Read the final rule here.

Align Medicaid renewal processes across MAGI and non-MAGI eligibility groups.

Medicaid agencies will be required to extend enrollment simplifications that currently only apply to MAGI members to non-MAGI Medicaid and CHIP members. This includes requiring that states conduct eligibility renewals once, and only once, every 12 months; providing a pre-populated renewal form; providing a minimum of 30 calendar days to return the signed renewal form; and providing a 90-day reconsideration period.

• Deadline: June 3, 2027
• Read the final rule here.

Meet timeliness standards for determinations and redeterminations of Medicaid eligibility. 

Medicaid agencies will be required to meet timeliness standards for determinations and redeterminations of Medicaid eligibility and provide Medicaid members with minimum periods to provide additional information at application, changes in circumstance, and renewal.

• Deadline: June 3, 2027
• Read the final rule here.

Establish specific registered nurse and nursing aide minimum staffing levels at long-term care facilities.

Long-term care facilities will be required to meet specific minimum nurse staffing levels for registered nurses (.55 hours per resident day) and nursing aides (2.45 hours per resident day).

• Deadline: June 21, 2027
• Read the final rule here.

Establish appointment wait time standards for Medicaid managed care organizations. 

Managed care organizations will be required to meet maximum appointment wait time standards for primary care, OB/GYN, and mental health/substance use services.

• Deadline: Managed care rating period beginning on or after July 9, 2027
• Read the final rule here.

Conduct annual enrollee experience surveys for Medicaid managed care organizations.

Medicaid agencies will be required to conduct annual enrollee experience surveys for Medicaid managed care organizations. These surveys gauge Medicaid members’ experiences with their health care providers and plans.

• Deadline: Managed care rating period beginning on or after July 9, 2027
• Read the final rule here.

NEW IN 2028

Report on percentage of Medicaid payments to nursing facilities that go to compensation for direct care workers. 

Medicaid agencies will be required to report on the percentage of Medicaid payments to nursing facilities and intermediate care facilities for individuals with intellectual disabilities (ICFs/IID) that go to compensation for direct care workers.

• Deadline: June 21, 2028
• Read the final rule here.

Conduct annual “secret shopper” surveys of Medicaid managed care organizations. 

Medicaid agencies will be required to conduct annual “secret shopper surveys” to assess managed care organizations’ compliance with provider directory requirements and appointment wait time standards.

• Deadline: Managed care rating period beginning on or after July 9, 2028
• Read the final rule here.

Report on home and community-based services (HCBS) Quality Measure Set and payment adequacy. 

Medicaid agencies will be required to report on the new home and community-based services (HCBS) Quality Measure Set and on the percentage of Medicaid payments for homemaker, home health aide, personal care, and habilitation services spent on compensation to direct care workers.

• Deadline: July 9, 2028 (for managed care, the first rating period beginning on or after July 9, 2028)
• Read the final rule here.

Launch the Medicaid and CHIP Quality Rating System to compare managed care plans. 

Medicaid agencies will be required to launch “Phase 1” of the Medicaid and CHIP Quality Rating System, which will allow Medicaid members to compare managed care plans across key metrics.

• Deadline: December 31, 2028 (states may request a one-time, one-year extension for certain components)
• Read the final rule here.

NEW IN 2030

Ensure that at least 80 percent of Medicaid payments for home and community-based services are spent on compensation to direct care workers. 

Medicaid agencies will be required to ensure that least 80 percent of all Medicaid payments for homemaker, home health aide, and personal care services are spent on compensation to direct care workers (DCW).

• Deadline: July 9, 2030 (for managed care, the first rating period beginning on or after July 9, 2030)
• Read the final rule here.