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About 2.8 percent of children on Medicaid get emergency or urgent care out of state nationally, but that varies wildly.
Families in rural areas face the starkest choices. For specialized care—cardiology for kids, neurology for kids, cancer treatment—these households often have no in-state options.
Intermountain Primary Children’s Hospital in Salt Lake City serves six states across 600,000 square miles.
Children with rare diseases benefit enormously. When only a handful of doctors in the country treat your child’s genetic disorder, you can’t shop local.
Remaining Barriers
States still control what they pay out-of-state providers, and payment rates vary dramatically. A doctor might get paid substantially less for treating a Medicaid patient from another state than for treating their own state’s Medicaid kids. Low payment means some doctors simply won’t accept out-of-state Medicaid patients, faster approval or not.
Transportation remains a massive barrier. Simpler paperwork doesn’t put gas in your tank or give you paid time off work to drive your kid to an appointment four hours away. For low-income households already stretched thin, the cost of repeated trips to distant doctors can be prohibitive even when the medical care itself is covered.
This rule addresses access to doctors who already exist. It does nothing about the underlying shortage of children’s doctors, particularly in rural areas. Pediatric inpatient services have declined significantly in the past decade, with hospital units treating children closing across the country, though the extent varies by region and type of facility.
Medical schools aren’t producing enough pediatricians, and the ones they do produce aren’t choosing rural practice or lower-paying specialized fields. Lower Medicaid payment compared to Medicare or private insurance, combined with massive medical school debt, makes medicine for children less attractive. You can’t streamline your way out of a workforce shortage.
State Implementation Challenges
Congress passed the requirement. States now have to figure out what it means.
The legislation says states must “set up a way to handle this” but doesn’t specify what that process should look like, what timeline states must follow, or what happens if they don’t comply.
States vary enormously in their capacity and willingness to help families access out-of-state care. Some states already have simpler processes; others make it deliberately difficult. Other states maintain cumbersome case-by-case review systems.
States are also managing multiple other Medicaid changes simultaneously—new work requirements, restrictions on how they pay providers, changes to enrollment policies. Adding another mandate without federal funding to support implementation creates strain, and states might reasonably prioritize other requirements over this one.
The absence of clear federal guidance during this transition period means states could adopt wildly different approaches, potentially creating new inconsistencies even as the federal mandate tries to reduce them.
Related Healthcare Changes
The bill also reforms companies that manage prescription drug benefits, restricting practices that drive up medication costs for people on Medicaid. For households whose kids need expensive medications in addition to care from doctors, lower drug costs matter.
The budget impact of simpler out-of-state care is probably modest—out-of-state care represents a small share of overall Medicaid spending. Removing barriers likely makes it easier to access care households were already seeking rather than creating massive new use of services. But states operating in a climate of fiscal pressure don’t always make decisions based on careful analysis.
What Happens Next
Families should watch for guidance from their state Medicaid programs about how the new process works. If your child needs ongoing care from an out-of-state doctor, ask your state Medicaid office whether the three-year authorization is available and what you need to do to get it.
Providers serving Medicaid patients across state lines should pay attention to CMS guidance when it arrives and communicate with state Medicaid programs about implementation. The legislation creates an opportunity to reduce paperwork and red tape, but only if states implement it effectively and providers know how to use the new processes.
Advocates should monitor whether states develop and implement adequate processes or whether they delay, create unnecessarily complex requirements, or otherwise work against what the law is trying to do. Federal requirements only work if someone checks whether states are following them.
For the households this affects, the change represents one less barrier between their child and needed medical care. Not the only barrier. Not even necessarily the biggest one. But one less fight with bureaucracy at a time when they have enough to worry about.
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