Medicaid/CHIP Managed Care Regulations: Assuring Quality


While the rules governing Medicaid/CHIP managed care remained unchanged for more than a decade, significant advances have been made in assessing quality, access, and timeliness of care in health coverage programs. During this time, there has been a growing recognition of the need to ensure that the care delivered through capitated managed care arrangements is focused not only on controlling costs by managing and coordinating care, but also on assuring high value, high quality care. To this end, the modernization of federal Medicaid and Children’s Health Insurance Program (CHIP) Managed Care regulations, released in May 2016, seek to advance state quality assurance efforts by ensuring the use of meaningful and reliable data and expanding requirements for external quality review of managed care plans.

The new rules require states to develop and maintain a comprehensive statewide quality strategy, and establish a quality rating system for managed care plans to aid beneficiaries in comparing plan performance. Noting that public reporting of quality is “a key tool for driving quality improvement,” the regulations require states to engage stakeholders in their quality strategy development. The new rules also seek to increases state and managed care accountability and promote transparency.

This brief reviews provisions of the new federal managed care rules that are intended to improve quality of care and is the fifth in a series of explainer briefs, funded by a grant from the Robert Wood Johnson Foundation.

For the full series, visit our Medicaid/CHIP Managed Care page.

The video recording of our webinar on this paper is available below.

Tricia Brooks
Tricia Brooks is a Senior Fellow at the Center for Children and Families