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Medicaid and CHIP Quality Rating System

In the 2016 Managed Care Final rule, we established the authority to require States to operate a Medicaid managed care quality rating system (QRS) and adopted the requirement for this provision, excluding provisions regarding consultation with the Medical Care Advisory Committee, to apply to separate CHIP at § 457.1240(d).

The Medicaid and Chip (MAC) QRS requirements currently include public posting of quality ratings on the State’s website, which is intended to provide beneficiaries and their caregivers with a web-based interface to compare Medicaid and CHIP managed care plans based on assigned ratings. The policy objectives of the MAC QRS are threefold: (1) to hold States and plans accountable for the care provided to Medicaid and CHIP beneficiaries; (2) to empower beneficiaries with useful information about the plans available to them; and (3) to provide a tool for States to drive improvements in plan performance and the quality of care provided by their programs.

2023 Proposed Rule

On May 3, 2023, CMS published the Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality Proposed Rule, which would advance CMS’ efforts to improve access to care, quality and health outcomes, and better address health equity issues for Medicaid and CHIP managed care enrollees. The proposed rule would establish a quality rating system for Medicaid and CHIP managed care plans, including new and updated requirements for the MAC QRS that build off previous rulemaking in the 2016 and 2020 managed care final rules. 

  • View the 2023 proposed rule
  • Register to attend the MAC QRS proposed rule webinar on May 25, 2023 at 3pm EST.
  • We encourage you to submit comments online prior to July 3 at: http://www.regulations.gov. When submitting comments, refer to file code CMS-2439-P.

Request for Public Comment

CMS is seeking comment on the proposed MAC QRS requirements.

MAC QRS Website Display Prototypes

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

Each proposed website implementation phase includes minimum requirements with which the state’s website display must comply. Under our proposal, all States must at least implement the first phase of features proposed 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, proposed in § 438.520(a)(6), during the first phase, but all states would be required to implement all features proposed in 438.520(a) by the end of the second phase, which would occur no sooner than six years following the final rule.

Prototype A 

Prototype A illustrates a simple version of the display requirements proposed in § 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 would be 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 proposed display features 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 would be required in the second phase of website implementation. States would have at least until the sixth year following the release of the final rule to implement phase two features, but would 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

Citation Map

The citation map cross-walks each website display feature in proposed § 438.520(a) with the display element number used to identify where the feature is illustrated in both prototypes as well as the the page number(s) in each prototype where the feature is portrayed. 

Citation Map PDF