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Medicaid Managed Care Quality

Many states deliver services to Medicaid beneficiaries via managed care arrangements. Federal regulations at 42 CFR 438 set forth quality assessment and performance improvement requirements for states that contract with managed care organizations (MCOs) and/or prepaid inpatient health plans (PIHPs). These requirements include the development and drafting of a managed care quality strategy and the performance of an external quality review (EQR).  

The following map displays which states currently contract with MCOs and/or PIHPs:

All states have MCO’s or PIHPs and therefore are subject to the quality provisions of 438 except: Alabama, Alaska, Arkansas, Connecticut, Maine, Montana, Oklahoma, South Dakota, U.S. Virgin Islands, Vermont, and Wyoming

State Quality Strategy

Federal regulations at 42 CFR Part 438, subpart D (Quality Assessment and Performance Improvement) lay the groundwork for the development and maintenance of a quality strategy to assess and improve the quality of managed care services offered within a state. This quality strategy is intended to serve as a blueprint or road map for states and their contracted health plans in assessing the quality of care that beneficiaries receive, as well as for setting forth measurable goals and targets for improvement. Learn more about State Quality Strategy.

External Quality Review

Federal regulations at 42 CFR Part 438, subpart E (External Quality Review) set forth the parameters that states must follow when conducting an EQR of its contracted MCOs and PIHPs. An EQR is the analysis and evaluation by an external quality review organization (EQRO) of aggregated information on quality, timeliness, and access to the health care services that an MCO or PIHP, or their contractors, furnish to Medicaid recipients. Learn more about External Quality Review.

Technical Assistance Requests

The Centers for Medicare & Medicaid Services (CMS) is available to provide individualized support for your state's technical assistance needs. Please submit requests for technical assistance related to the state quality strategy and/or the EQR process to ManagedCareQualityTA@cms.hhs.gov.