Medicaid and CHIP Quality Rating System

On May 10, 2024, CMS published the Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality Final Rule, which advances CMS’ efforts to improve access to care, quality and health outcomes, and better address health equity issues for Medicaid and CHIP managed care enrollees by requiring each state to establish a quality rating system for Medicaid and CHIP managed care plans (Medicaid and CHIP Quality Rating System or MAC QRS). These requirements build off of previous rulemaking in the 2016 and 2020 managed care final rules.

Overview

By December 31, 2028, each state that contracts with MCOs, PIHPs, or PAHPs for the delivery of services covered under Medicaid or CHIP is required to establish a MAC QRS—a state-run public website that provides quality information about those plans established in the final rule. Medicare Advantage Dual Eligible Special Needs Plans contracts that provide only Medicaid coverage of Medicare cost sharing are excluded from this requirement.

The MAC QRS websites will be one-stop shops that empower beneficiaries and their caregivers by providing useful and meaningful information that can be used to compare available plans and identify a Medicaid or CHIP managed care plan that aligns with their personal needs and preferences. 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.

All applicable States 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

2. Methodology

3. Website Display

CMS intends to release additional website display guidance, technical assistance, and best practices on implementation of the MAC QRS website display.

MAC QRS Prototypes

Given the visual nature of the website display requirements at § 438.520, CMS developed two sample prototypes, one simple and one interactive, in Portable Document Format (PDF) to provide examples of how States may choose to comply with the website display requirements.  They are not intended to prescribe exactly what a display of a MAC QRS must look like. 

Each website implementation phase includes minimum requirements with which the state’s website display must comply. Under the final rule, all States must at least implement the first phase of features finalized in § 438.520(a)(1)-(5) by the end of the fourth calendar year following the final rule. States may choose to implement one or more features required in phase two, described in § 438.520(a)(6), during the first phase, but all states are required to implement all features described in 438.520(a) by the end of the second phase, which would occur no sooner than six years following the final rule. 

CMS is not updating the prototypes to reflect the modifications to the proposed website display requirements that are finalized in the 2024 rule because these modifications do not substantively affect the content displayed in either prototype. However, the prototype citation map published with the proposed rule has been replaced with an updated prototype citation map  that maps the prototype design elements to both the proposed and finalized website display requirement citation.  CMS intends to provide additional guidance, technical assistance, and best practices on implementing a MAC QRS website display through the release of design guide modules.

Prototype A 

Prototype A illustrates a simple version of the display requirements in proposed § 438.520(a)(1)-(5) and discussed in section I.6.B.g.1 through 4 of the proposed rule. These display features represent the minimum that States are required to display in their MAC QRS website in the first phase of website implementation, by the end of the fourth year following the release of the final rule. States would retain the flexibility to display the required features in a more interactive format, or include additional display features during this initial phase. The display features required for this phase include:

• Information necessary for users to understand and navigate the contents of the QRS website display proposed at § 438.520(a)(1);
• Information that allows beneficiaries to identify the managed care plans available to them and that align with their coverage needs and preferences proposed at § 438.520(a)(2);
• Standardized information identified by CMS that allows users to compare available managed care plans and programs proposed at § 438.520(a)(3);
• Information on quality ratings for mandatory measures identified in the technical resource manual displayed in a manner that promotes beneficiary understanding of and trust in the ratings proposed at § 438.520(a)(4); and
• Information or hyperlinks directing users to resources on how and where to apply for Medicaid and enroll in a Medicaid or CHIP plan proposed at § 438.520(a)(5).

Prototype A PDF
Video walk-though of Prototype A

Prototype B

Prototype B illustrates an interactive version of the MAC QRS website that includes the display features proposed in § 438.520(a)(1)-(5) represented in Prototype A, as well as the interactive features proposed in § 438.520(a)(6). Prototype B represents the minimum display features that are required in the second phase of website implementation. CMS has not announced a date by which States must implement the second phase, but the final rule establishes that States will be required to implement the phase two features no earlier than the sixth year following the release of the final rule, but have the flexibility to implement these interactive features sooner. These features include: 

• A search tool that enables users to identify available managed care plans that provide coverage for a drug identified by the user proposed at § 438.520(a)(6)(i);
• A search tool that enables users to identify available managed care plans that include a provider identified by the user in the plan’s network of providers proposed at § 438.520(a)(6)(i); and 
• An interactive tool that enables users to view the quality ratings for mandatory measures identified in the technical resource manual stratified by dual eligibility status, race and ethnicity, sex, age, rural/urban status, disability, language, or other factors specified by CMS proposed at § 438.520(a)(6)(i).

Prototype B PDF
Video walk-though of Prototype B

Contact Information

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

Resources

MAC QRS Measure Set

The table below lists the Mandatory MAC QRS Measure Set established in the final rule. 

TABLE 1: MAC QRS MANDATORY MEASURE SET