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Medicaid Eligibility Quality Control Program

Update: May 13, 2021

As a result of the Coronavirus Disease 2019 (COVID-19) public health emergency (PHE), on April 2, 2020, CMS exercised its enforcement discretion to adopt a temporary policy of relaxed enforcement regarding activities related to the Medicaid Eligibility Quality Control (MEQC) program. This temporary relaxed enforcement was to be in effect until CMS issued additional guidance to states. Upon resumption of the MEQC program, CMS released supplemental guidance on August 17, 2020, titled “Medicaid Eligibility Quality Control (MEQC) Program: Supplemental Guidance in Effect during the COVID-19 Public Health Emergency” (hereafter called the August 2020 MEQC supplemental guidance). That supplemental guidance included modified reporting requirements and a deadline extension for the Cycle 1 and 2 states, whose MEQC pilots were directly impacted by the COVID-19 PHE.

On May 13, 2021, CMS released a revised version of the August 2020 MEQC supplemental guidance (see link below). Under this revised supplemental guidance, CMS is extending the prior Cycle 1 and Cycle 2 states’ reduced program requirements to the Cycle 3 states because the COVID-19 PHE remains in effect. This updated guidance is supplemental to the “Medicaid Eligibility Quality Control (MEQC) Phase 1 Sub-Regulatory Guidance, August 2020 Update,” also provided below, which describes the complete MEQC program requirements.

Effective May 13, 20201, this revised supplemental guidance establishes the following reduced requirements for Cycle 1, Cycle 2, and Cycle 3 states, which have been conducting MEQC pilots from January 1, 2019 – December 31, 2019, January 1, 2020 – December 31, 2020, and January 1, 2021 – December 31, 2021, respectively:

  • Cycle 2 and Cycle 3 states only: A reduction in the number of required case reviews
  • All Cycles: Summary reporting instead of comprehensive case level and corrective action plan (CAP) reporting, as well as an extension of the deadline for the summary reports
  • All Cycles: Suspension of payment reviews and associated CMS-64 and CMS-21 adjustments
Note: At this time, this supplemental guidance does not apply to the next MEQC pilot conducted by the Cycle 1 states, which will be undertaken during the review year January 1, 2022 – December 31, 2022. The Cycle 1 states should continue to follow the guidance in the “MEQC Phase 1 Sub-Regulatory Guidance, August 2020 Update” document. However, CMS will continue to monitor the COVID-19 PHE and make any necessary changes for the Cycle 1 states, as appropriate.

Medicaid Eligibility Quality Control - History and Background

Since 1978, the Medicaid Eligibility Quality Control (MEQC) program has gone through several iterations. On July 5, 2017, the Centers for Medicare & Medicaid Services (CMS) issued a final regulation entitled Changes to the Payment Error Rate Measurement (PERM) and Medicaid Eligibility Quality Control (MEQC) Programs (CMS-6068-F). This regulation restructured the MEQC program into an ongoing series of pilots that are closely coordinated with CMS’s Payment Error Rate Measurement (PERM) program.

Under the MEQC program, states design and conduct projects, known as pilots, to evaluate the processes that determine an individual’s eligibility for Medicaid and Children’s Health Insurance Program (CHIP) benefits. States have great flexibility in designing pilots to identify vulnerable or error-prone areas. In addition, states conduct MEQC pilots during the two-year intervals (“off-years”) that occur between their triennial PERM review years. The MEQC program does not generate an error rate.

When an MEQC pilot concludes, the state must submit to CMS both a case-level report on the results of their pilots and payment reviews, as well as a corrective action plan (CAP) to address the errors and deficiencies identified through the pilot work.

MEQC program guidance documents are included in the section below. This guidance provides states with information about the general requirements in the regulation and detailed specifications regarding the MEQC pilot planning documents that each state is required to submit on November 1 of the year in which their PERM review is completed. Additional guidance regarding details about case-level reports, payment reviews, and CAPs will be released in the future.

MEQC Guidance

Historical Documents