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
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. • 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 Methodology | CMS 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 Methodology | States 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 plans | This 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 measures | These 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 status | These 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 content | Includes 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 CMS | May 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. |
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
CMIT#* | Measure Steward | Measure Name | Measure Description | Data Collection Method |
743 | NCQA | Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP) | The percentage of members who had a new prescription for an antipsychotic medication and had documentation of psychosocial care as first-line treatment. Ages: 1 to 17 | Administrative |
394 | NCQA | Initiation and Engagement of Substance Use Disorder Treatment (IET) | The percentage of new substance use disorder (SUD) episodes that result in treatment initiation and engagement. Two rates are reported: • Initiation of SUD Treatment. The percentage of new SUD episodes that result in treatment initiation through an inpatient SUD admission, outpatient visit, intensive outpatient encounter, partial hospitalization, telehealth, or medication treatment within 14 days. • Engagement of SUD Treatment. The percentage of new SUD episodes that have evidence of treatment engagement within 34 days of initiation. Ages: 13 and older | Administrative or EHR |
672 | CMS | Preventive Care and Screening: Screening for Depression and Follow-Up Plan (CDF) | The percentage of members screened for depression on the date of the encounter or 14 days prior to the date of the encounter using an age-appropriate standardized depression screening tool, and if positive, a follow-up plan is documented on the date of the qualifying encounter. Ages: 12 and older | Administrative or EHR |
268 | NCQA | Follow-Up After Hospitalization for Mental Illness (FUH) | The percentage of discharges for members who were hospitalized for treatment of selected mental illness or intentional self-harm diagnoses and who had a follow-up visit with a mental health provider. Two rates are reported: • The percentage of discharges for which the member received follow-up within 30 days after discharge. • The percentage of discharges for which the member received follow-up within 7 days after discharge. Ages: 6 and older | Administrative |
761 | NCQA | Well-Child Visits in the First 30 Months of Life (W30) | The percentage of members who had the following number of well-child visits with a primary care practitioner (PCP) during the last 15 months. The following rates are reported: • Well-Child Visits in the First 15 Months. Children who turned age 15 months during the measurement year: Six or more well-child visits. • Well-Child Visits for Age 15 Months to 30 Months. Children who turned age 30 months during the measurement year: Two or more well-child visits. Ages: 0 to 15 months | 15 to 30 months | Administrative |
123 | NCQA | Child and Adolescent Well-Care Visits (WCV) | The percentage of members who had at least one comprehensive well-care visit with a primary care practitioner (PCP) or an obstetrician/gynecologist (OB/GYN) during the measurement year. Ages: 3 to 21 | Administrative |
93 | NCQA | Breast Cancer Screening (BCS-E) | The percentage of members who were recommended for routine breast cancer screening and had a mammogram to screen for breast cancer. Ages: 50 to 74 | Electronic Clinical Data System (ECDS)w |
118 | NCQA | Cervical Cancer Screening (CCS, CCS-E) | The percentage of members who were recommended for routine cervical cancer screening who were screened for cervical cancer using any of the following criteria: • Members 21 to 64 years of age who were recommended for routine cervical cancer screening and had cervical cytology performed within the last 3 years. • Members 30 to 64 years of age who were recommended for routine cervical cancer screening and had cervical high-risk human papillomavirus (hrHPV) testing performed within the last 5 years. • Members 30 to 64 years of age who were recommended for routine cervical cancer screening and had cervical cytology/high-risk human papillomavirus (hrHPV) co-testing within the last 5 years. Ages: 21 to 64 | Administrative, hybrid, EHR, or ECDS |
139 | NCQA | Colorectal Cancer Screening (COL-E) | The percentage of members who had appropriate screening for colorectal cancer. Ages: 45 to 75 | ECDS |
897 | DQA | Oral Evaluation, Dental Services (OEV) | The percentage of members who received a comprehensive or periodic oral evaluation within the reporting year. Ages: 0 to 20 | Administrative |
166 | OPA | Contraceptive Care - Postpartum Women (CCP) | Among women who had a live birth, the percentage that: 1. Were provided a most effective or moderately effective method of contraception within 3 days of delivery and 90 days of delivery. 2. Were provided a long-acting reversible method of contraception (LARC) within 3 days of delivery and 90 days of delivery. Ages: 15 to 44 | Administrative |
581 | NCQA | Prenatal and Postpartum Care (PPC) | Percentage of deliveries of live births on or between October 8 of the year prior to the measurement year and October 7 of the measurement year. For these members, the measure assesses the following facets of prenatal and postpartum care: 1. Timeliness of Prenatal Care. The percentage of deliveries that received a prenatal care visit in the first trimester, on or before the enrollment start date, or within 42 days of enrollment in the organization. 2. Postpartum Care Rate. The percentage of deliveries that had a postpartum visit on or between 7 and 84 days after delivery. Ages: All Ages | Administrative or hybrid |
148 | NCQA | Glycemic Status Assessment for Patients with Diabetes (GSD) | The percentage of members with diabetes (types 1 and 2) whose most recent glycemic status (hemoglobin A1c [HbA1c] was at the following levels during the measurement year: • Glycemic Status <8.0%. • Glycemic Status >9.0%. Ages: 18 to 75 | Administrative or hybrid |
80 | NCQA | Asthma Medication Ratio (AMR) | The percentage of members who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year. Ages: 5 to 64 | Administrative |
167 | NCQA | Controlling High Blood Pressure (CBP) | The percentage of members who had a diagnosis of hypertension and whose blood pressure was adequately controlled (< 140/90 mm Hg) during the measurement year. Ages: 18 to 85 | Administrative, hybrid, or EHR |
151/152 | AHRQv | CAHPS – How people rated their health plan | The percentage of members who rated their health plan a 9 or 10, where 0 is the worst health plan possible and 10 is the best health plan possible. Ages: 0 to 17 | 18 and older | Consumer survey |
151/152 | AHRQv | CAHPS – Getting care quickly | Composite of the following items: • The percentage of members who indicated that they always got care for illness, injury, or condition as soon as they needed, in the last six months. • The percentage of members who indicated they always got check-up or routine care as soon as they needed, in the last six months. Ages: 0 to 17 | 18 and older | Consumer survey |
151/152 | AHRQv | CAHPS – Getting needed care | Composite of the following items: • The percentage of members who indicated that it was always easy to get necessary care, tests, or treatment, in the last six months. • The percentage of members who indicated that they always got an appointment with a specialist as soon as needed, in the last six months. Ages: 0 to 17 | 18 and older | Consumer survey |
151/152 | AHRQv | CAHPS – How well doctors communicate | Composite of the following items: • The percentage of members who indicated that their doctor always noted things in a way that was easy to understand. • The percentage of members who indicated that their doctor always listened carefully to enrollee. • The percentage of members who indicated that their doctor always showed respect for what enrollee had to say. • The percentage of members who indicated that their doctor always spent enough time with enrollee. Ages: 0 to 17 | 18 and older | Consumer survey |
151/152 | AHRQv | CAHPS – Health plan customer service | Composite of the following items: • The percentage of members who indicated that customer service always gave necessary information or help, in the last six months. • The percentage of members who indicated that customer service always was courteous and respectful, in the last six months. Ages: 0 to 17 | 18 and older | Consumer survey |