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Medicaid and CHIP Quality Rating System

Overview

The Medicaid and CHIP Quality Rating System (MAC QRS) websites will be one-stop shops that empower beneficiaries and their caregivers to make choices about their health care and increase transparency into Medicaid and CHIP managed care plan performance. Requiring States to publicly display this information will hold States and plans accountable for the care provided to beneficiaries and will be a tool for States to drive improvements in plan performance and the quality of care provided by their programs.

Regulations at 42 CFR Part 438 Subpart G and 42 CFR § 457.1240(d), promulgated in the Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality Final Rule, 89 FR 41002 published on May 10, 2024 (2024 Final Rule) require each state that contracts with managed care organizations (MCOs), prepaid inpatient health plans (PIHPs), or prepaid ambulatory health plans (PAHPs) to deliver Medicaid or CHIP services to establish a MAC QRS. A MAC QRS is a state-run public website that provides quality information about Medicaid and CHIP managed care plans (MCPs).  These regulations implement requirements under sections 1932(c)(1) and 1932(a)(5)(C) of the Social Security Act (the Act). Medicare Advantage Dual Eligible Special Needs Plans contracts that provide only Medicaid coverage of Medicare cost sharing are excluded from this requirement.

All applicable States (each state that contracts with MCOs, PIHPs, or PAHPs for the delivery of services covered under Medicaid or CHIP) must implement a MAC QRS by December 31, 2028. However, states that are unable to fully comply with certain methodology and website display requirements have the option to request a one-time, one-year implementation extension for these specific requirements. This flexibility provides an additional year (until December 31, 2029) to integrate the requirements for which the extension is granted into state’s existing MAC QRS (implemented no later than December 31, 2028).

Required Components of a MAC QRS

Each state’s MAC QRS must include the following three components:

1. Quality Measures

Each MAC QRS is required to include a mandatory set of quality measures established by CMS.
Mandatory Measure Set•    In the Final Rule CMS established an initial mandatory measure set  consisting of 16 measures, which was developed and refined based on feedback received through engagement with states, health plans, beneficiaries, and other interested parties. 
•    On July 31, 2025, CMS released the Measurement Year 2026 Technical Resource Manual (TRM) finalizing the initial mandatory measure set.  
•    Quality ratings for every mandatory measure applicable to a state’s Medicaid and/or CHIP program must be displayed no later than December 31, 2028.
Measure Set Updates•    CMS will assess the mandatory measure set at least every other year through a public engagement process. 
•    CMS will make updates to the mandatory measure set based on the application of the measure selection criteria established in the final rule, input received during the subregulatory process, and other relevant information.
•    States will have no less than two years to implement new measures once they are announced.
Additional Measures not in the Mandatory Set•    States can include additional measures but must obtain and document input on the intended additional measure(s) from prospective users. 
•    The documentation must include: any modifications made to the additional measures based on the feedback from prospective users, the timeline for implementing those modifications, and the rationale for not accepting or implementing specific recommendations or feedback submitted during the consultation process. 


2. Methodology

States must develop quality ratings that comply with CMS requirements for the collection, validation, and use of health plan data to calculate performance rates for each measure.
Rating MethodologyCMS has established a methodology that identifies both the plan enrollees that must be included in the quality ratings and the level at which quality ratings must be issued to health plans.
Alternative MethodologyStates also have the option to request CMS approval for the implementation of an alternative rating methodology. 

Technical Assistance		Guidance and technical assistance on these topics are forthcoming, and CMS intends to release an alternative QRS request form in early 2025.


3. Website Display

CMS established standard requirements for state websites to support the creation of a one-stop shop with a broad range of information that Medicaid and CHIP beneficiaries indicated would be meaningful to them when identifying a managed care plan that meets their needs and preferences.  
Information that compares the cost and coverage of available plansThis information allows beneficiaries to easily see relevant comparisons among available managed care plans based on their cost and benefits provided. 
Health plan ratings for a standardized set of quality of care and patient and consumer experience measuresThese ratings are calculated using data from beneficiaries enrolled in the same health plan who received the care assessed by each measure. These quality ratings allow individuals to compare health plans’ quality of services provided to the plan’s enrollees.
Health plan ratings for the standardized set of measures stratified by race and ethnicity, sex, and dual eligibility statusThese ratings are calculated using data only from beneficiaries enrolled in the health plan who received the care assessed by the measure and share one of the identified characteristics. These quality ratings allow individuals to compare health plans by identifying the group with “people like them” and comparing the quality of a service when it is provided to this specific group, as opposed to all enrollees in a health plan. 
Information that provides transparency into the displayed contentIncludes when, how, and by whom the quality ratings are validated, the time period that the quality ratings reflect, and plain language descriptions of each quality measure and how the care measured may impact an enrollee’s overall health and well-being.
Other health plan information reported to CMSMay include metrics of managed care plan performance reported to CMS including metrics of the accessibility of care via secret shopper surveys and provider network adequacy reports and health plan appeals and grievance data.

Contact Information

Questions? Email the MAC QRS team at MAC_QualityRatingSystem@cms.hhs.gov