Strengthening Quality Measurement in Medicaid and CHIP Through the Access and Managed Care Rules

On April 22, 2024, the Centers for Medicare & Medicaid Services (CMS) released three final rules, including the Ensuring Access to Medicaid Services final rule (Access Rule) and theMedicaid and Children’s Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality final rule (Managed Care Rule). Both rules contain provisions aimed at driving improvements in Medicaid and CHIP through quality measurement and reporting. CMS has posted an Access Rule fact sheet and effective dates chart, and a Managed Care Rule fact sheet and effective dates chart to aid implementation.This fourth entry in our Aurrera Health blog series on the Access and Managed Care final rules focuses on provisions specific to quality measurement to help states and partners digest the new requirements and consider their next steps.

What are the New Requirements Focused on Quality Measurement?

Access Rule, HCBS Measure SetIn July 2022, CMS released the first-ever Home- and Community-Based Services (HCBS) Quality Measure Set for voluntary state reporting. Comprised of 97 measures, the HCBS set is designed to promote consistent quality measurement within and across state Medicaid HCBS programs and provide opportunities to understand and improve health care quality and outcomes for people utilizing long-term services and supports (LTSS) across a range of key areas. 

To promote transparency, the Access Rule requires states to report on a subset of mandatory measures, establish performance targets for the measures, and determine the quality improvement strategies they will use to achieve those targets. To aid in the identification of health disparities to promote health equity, the Access Rule also calls for a phased-in approach to stratifying the measures by demographic characteristics; states will stratify 25% of the measures within four years of the final rule, and 100% of the measures within eight years. HCBS set measures will be reported every other year — this biennial reporting recognizes that several of the measures in the set are drawn from surveys, which are costlier than other quality measures and burdensome for both states and surveyed respondents.

Similar to the processes used for the CMS Medicaid/CHIP Child, Adult, and Health Home Core Sets, the Access Rule also details a process for updating the HCBS Quality Measure Set, beginning December 31, 2026. However, unlike the other Medicaid and CHIP quality measure sets, which are updated annually, the HCBS set will be updated no more frequently than every other year, with technical updates made annually, as appropriate. 

Managed Care Rule, Annual Experience of Care Survey
The Managed Care Rule requires that states conduct an annual enrollee experience survey for each managed care plan. States have the flexibility to determine which survey to conduct, for example, the Consumer Assessment of Healthcare Providers and Systems (CAHPS), one of the most widely used experience of care surveys in health care, or the National Core Indicators-Aging and Disabilities survey (NCI-AD), which is designed to measure the impact of publicly-funded services on quality of life and outcomes.

The Managed Care Rule also includes survey provisions specific to separate CHIPs. Separate CHIPs, like other programs funded under Title XXI, have existing requirements for conducting the CAHPS survey, but previously had no requirements to make survey data publicly available or use the data to evaluate network adequacy. Now, separate CHIPs must post summary survey data annually, by plan, on their state website and review CAHPS results in the state’s annual network adequacy analysis within two years of the final rule effective date.

Managed Care Rule, Medicaid and CHIP Quality Rating System
The 2024 Managed Care Rule establishes a quality rating system (QRS) for Medicaid and CHIP managed care plans (MAC QRS), building upon the 2016 and 2020 Managed Care final rules. As described by CMS, the MAC QRS will give states that contract with managed care plans a tool to drive improvements in plan performance and health care quality, and provide Medicaid and CHIP beneficiaries with plan-level information they can use to support informed decision-making. While some states already have rating systems for Medicaid and CHIP managed care, the MAC QRS holds states to a federal minimum standard for their rating systems.CMS will work with states to develop a MAC QRS framework that includes the measures used to assess plan performance and the methodology for calculating quality ratings. States have the option to use this framework or establish an alternative QRS.CMS defined three standards that a measure must meet to be included in the mandatory MAC QRS measure set.

• The measure must satisfy five of the following six inclusion criteria that consider if the measure:

  • is meaningful and useful for beneficiaries and caregivers.

  • aligns with other CMS rating programs, to the extent appropriate.

  • assesses health plan performance in at least one of the following areas; customer experience, access to services, health outcomes, quality of care, health plan administration, and health equity.

  • provides an opportunity for plans to influence their performance.

  • is based on data that is available and feasible to report by most states and plans.

  • demonstrates scientific acceptability.

  • The measure contributes to balanced representation of beneficiary subpopulations, age groups, health conditions, services, and performance areas within the mandatory measure set.

  • The burdens of including a measure do not outweigh the benefits to the overall QRS framework.

The Managed Care Rule includes an initial set of 16 mandatory measures that encompass physical and behavioral health, including measures focused on primary and preventive care, acute and chronic conditions, maternal and perinatal health, dental and oral health services, and experience of care. All measures in the MAC QRS set align with those included in CMS Medicaid and CHIP Core Sets, allowing for comparisons among states. States must display in the MAC QRS a quality rating for any mandatory measure that assesses a service or action covered by one or more of their managed care contracts. States also can include additional measures in the QRS that are not included in the mandatory measure set, permitting that they meet certain requirements.

What Are Implementation Considerations for States?

When considering implementation of the Access Rule and Managed Care Rule quality measurement provisions, states can glean insights from years of experience reporting CMS Medicaid and CHIP Core Sets and other reporting efforts.

• Collecting and reporting the measures may require significant technical assistance (e.g., understanding technical specifications and applying them to the specific populations) and potentially, system improvements to support data collection, reporting, and analysis.

• Administering experience of care surveys, which are found across all three provisions detailed above, may require new resources, and states also may have to contend with low survey response rates, especially as the survey sample population narrows. 

• Stratifying data by beneficiary characteristics may require states to substantially improve the completeness and accuracy of their demographic data.

At the same time, implementation of the HCBS Quality Measure Set presents unique implementation considerations, especially given that the measure set focuses on a smaller subset of the Medicaid population. In announcing the HCBS Quality Measure Set, CMS encouraged oversampling by beneficiary demographic and other characteristics to help yield the sample size necessary for measure stratification. Oversampling involves important considerations related to survey planning, methodology, implementation, and cost, and these factors may be heightened in HCBS experience of care surveys which can already yield low response rates. Some states, such as those that are smaller and/or with less diverse Medicaid populations, may face substantial challenges oversampling — if the survey sample effectively comprises the entire population group of interest, the same individuals may be surveyed continuously. This could compound survey fatigue, which is an ongoing challenge in many states.As per the Access and Managed Care Rules, CMS will provide technical assistance to support implementation of these provisions.

Aurrera Health Blog Series on Access and Managed Care Final Rules

Strengthening quality measurement and reporting in Medicaid and CHIP can promote transparency and more effective oversight while yielding improvements in access, quality, and equity. Aurrera Health will continue this blog series to synthesize major provisions of the Access and Managed Care final rules, consider state experiences to identify lessons learned, and provide insights that can inform implementation plans; the final blog of this series will look at the Managed Care Rule provisions more broadly, focused on improving access, quality, and health outcomes.We stand ready to help states navigate the new quality measurement requirements in the Access and Managed Care Rules and use the data to drive improvements in quality and outcomes. Our expertise includes managed care, data collection and analysis, performance measurement, disparities/equity analysis, and systems development, services that may be particularly helpful with respect to implementation of these quality provisions. If you would like to discuss how we can help your state, please reach out to Aurrera Health Managing Principals Megan Thomas or Kristal Vardaman. Please visit our Aurrera Health Group blog to read other entries in the series. 

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Megan Thomas [Managing Principal]