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Medicaid Eligibility Quality Control

PLEASE NOTE:

Pursuant to the Robert T. Stafford Disaster Relief and Emergency Assistance Act, President Trump declared on March 13, 2020 that, as a result of the effects of the Coronavirus Disease 2019 (COVID-19), a national emergency exists nationwide, retroactive to March 1, 2020. On January 31, 2020, Secretary Azar of the Department of Health & Human Services (HHS) declared a nationwide public health emergency, retroactive to January 27, 2020. Accordingly, the Centers for Medicare & Medicaid Services (CMS) is taking the steps below to allow states to focus their resources on combatting COVID-19.

Effective immediately CMS is exercising its enforcement discretion to adopt a temporary policy regarding the Payment Error Rate Measurement (PERM) program. Accordingly, CMS is suspending all improper payment-related engagement/communication or data requests to providers and state agencies, until further notice. This includes calls and communications regarding existing PERM corrective action plans.

Additionally, CMS is exercising its enforcement discretion to adopt a temporary policy of relaxed enforcement regarding activities related to the Medicaid Eligibility Quality Control (MEQC) program until further notice to state agencies from CMS.

Additional guidance regarding the administration of the PERM and MEQC programs will be provided in the coming weeks. Please reach out to your CMS PERM state liaison or CMS MEQC state liaison if you have any questions.

We believe that this guidance is a statement of agency policy not subject to the notice and comment requirements of the Administrative Procedure Act (APA). 5 U.S.C. § 553(b)(A). For the same reasons explained above, the CMS additionally finds that, even if this guidance were subject to the public participation provisions of the APA, prior notice and comment for this guidance is impracticable, and there is good cause to issue this guidance without prior public comment and without a delayed effective date. 5 U.S.C. § 553(b)(B) & (d)(3).

Medicaid Eligibility Quality Control

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 review report on the results of their pilots and a corrective action plan to address the errors and deficiencies identified through the pilot work.

On August 29, 2018, CMS released a guidance document to assist states in implementing the final regulation. CMS released updated guidance on October 22, 2018. The guidance document 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.

MEQC Guidance