Quality Provisions of the Medicaid/CHIP Managed Care Rules

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Thanks to a grant from the Robert Wood Johnson Foundation, CCF has teamed up with NHeLP to launch a series of explainer briefs that unpack the new Medicaid/Children’s Health Insurance Program (CHIP) managed care regulations. Three briefs in the series have been released already: Looking at the New Medicaid/CHIP Managed Care Regulations Through a Children’s LensMedicaid/CHIP Managed Care Regulations: Improving Consumer InformationMedicaid/CHIP Managed Care Regulations: Enhancing the Beneficiary Experience, and Medicaid/CHIP Managed Care Regulations: Network Adequacy and Access to Services. Today, we are releasing the fifth brief of the six-part series on “Assuring Quality.”

These rules are critical. Nearly nine out of ten children in Medicaid and CHIP receive care through some kind of managed care arrangement. And, over the past decade while the rules remained unchanged, there have been significant advances in assessing quality, access, and timeliness of care in health coverage programs. Meanwhile, managed care – and particularly mandatory managed care – has become the predominant model for delivering care in Medicaid and the Children’s Health Insurance Program (CHIP). During this time, there has been a growing recognition of the need to ensure that the care delivered in 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 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 the development of their strategies to improve quality. Importantly, the rule increases state and managed care accountability and promotes transparency by requiring states to provide quality-related information online and in paper and alternative formats upon request.

The rules also seek to align quality measure and improvement with other programs – namely private coverage through the health insurance marketplaces and Medicare. They extend certain quality requirements beyond managed care organizations (MCO) but fell short of extending the requirement for a comprehensive quality strategy that encompasses all delivery systems as proposed in the initial rule. All provisions are applicable to MCOs, PIHPs, and PAHPs, while a few provisions apply to certain PCCM entities as described below (see the appendix for definitions of different managed care arrangements). The rules also apply to dental PAHPs but do not apply to non-emergency medical transportation services (NEMT) PAHPs.

Implementation timelines of the rules varies from immediate for revisions to federal financing of external quality review activities that are conducted on non-MCO managed care entities (PHIPs, PAHPs, and PCCMs) to May 6, 2019 for the new quality rating system.

We’ll review the brief and explain the quality provisions in a webinar on Thursday, September 8th at 1:30pm. Click here to register for the webinar.

Our final brief in the series on accountability and transparency will be released later this month. If you missed the webinars featuring the first four briefs, you’ll find the slides and a recording here.

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

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