Medicaid's New Appointment Wait-Time Standards

For years, Medicaid network adequacy was mostly about counts and distance. A 2024 federal rule added something closer to what patients actually experience: how long it takes to get a routine appointment. The limits are now in the regulation, the start date is set, and the enforcement method is a secret shopper survey. For a provider told that a Medicaid plan's network is full, these standards are a new way to show that it is not.

What do the new standards require?

States must "establish and enforce appointment wait time standards" for their Medicaid managed care plans (42 CFR 438.68(e)). For routine appointments, the state's limits may be no longer than:

• 10 business days from the date of request for outpatient mental health and substance use disorder services, adult and pediatric;
• 15 business days for primary care, adult and pediatric;
• 15 business days for obstetrics and gynecology;
• a state-chosen limit for one additional service type the state selects "in an evidence-based manner."

Each applies "if covered in the" plan's contract. States can set shorter limits. Plans "will be deemed compliant" when secret shopper results show appointments available within the standard at a rate "of at least 90 percent" (438.68(e)(2)).

When do they take effect?

The wait-time paragraph "applies to the first rating period for contracts with MCOs, PIHPs, or PAHPs beginning on or after 3 years after July 9, 2024" (438.68(h)), which is the first rating period beginning on or after July 9, 2027. A state whose rating period starts on January 1 would reach it on January 1, 2028; one that starts July 1 would reach it on July 1, 2028. Check your state's contract year. The related requirement that plans meet state timely access standards "as well as appointment wait times specified in § 438.68(e)" follows the same three-year schedule (438.206(c)(1)(i) and (d)).

The secret shopper surveys that measure compliance apply one year later, from the first rating period beginning on or after July 9, 2028 (438.68(h)). These dates are as the regulation reads in October 2026; federal rules can change, so confirm them before relying on them.

How will compliance be checked?

States must contract with an entity independent of the state Medicaid agency and of the plans to run annual secret shopper surveys of each plan's appointment availability and directory accuracy (438.68(f)). The surveys must use a random sample, cover every area of the state the plan serves, and use a statistically valid sample of providers for wait times (438.68(f)(4)). Results must be reported to CMS and posted on the state's website within 30 calendar days of submission (438.68(f)(5)).

Telehealth appointments count toward the wait-time standard only if the surveyed provider also offers in-person appointments to the plan's enrollees, and they must be reported separately (438.68(f)(2)(ii)).

How can a provider use the standards now?

Before the effective date, the federal limits are not yet enforceable against a plan. They are still useful:

1. Your state may already have a wait standard. States have long been required to set timely access standards. Your state's existing limits, published under 438.68(g), apply today.
2. The federal numbers are a benchmark. A dated call log showing that members of a plan wait 30 business days for a first outpatient therapy appointment, against a federal ceiling of 10 that the plan will soon have to meet, makes a clear point in a network adequacy letter. See documenting an access gap.
3. Plans are preparing. A plan that expects to be surveyed in 2028 has a reason to look at its behavioral health and primary care capacity before then. A ready, willing provider who is accepting new patients is part of the answer.

After the effective date, the standards add weight to a complaint to the state Medicaid agency, which "must develop and enforce network adequacy standards" (438.68(a)) and certify each plan's network to CMS (438.207(d)).

Where do the standards stop?

They are obligations on the state and the plan, not a right of any provider to a contract. Federal rules still allow a Medicaid plan to decline providers "beyond the number necessary to meet the needs of its enrollees" (438.12(b)(1)). What changes is how "necessary" is measured: by whether members can get timely appointments, not only by whether a provider's office exists within a certain distance.

And they apply only to Medicaid managed care. Medicare Advantage has its own primary care and behavioral health wait standards in 42 CFR 422.112(a)(6)(i). Commercial plans depend on state law; Texas, for example, sets PPO limits of three weeks for routine medical care and two weeks for routine behavioral health care (Tex. Ins. Code 1301.00555).

Can we help you use them?

A Payer Network Dispute ($799 per payer) for a Medicaid plan includes the state's published standards, a wait-time audit of the plan's directory and a letter for your signature, plus, where the facts support it, a complaint draft for the state Medicaid agency that you review, sign and send. See pricing and Medicaid MCO network adequacy. We are not a law firm and do not give legal advice; questions about your legal rights go to a healthcare attorney.