Significance of Recently Proposed CMS Changes for Medicaid and CHIP Managed Care Quality Rating System

The proposed Medicaid and CHIP Quality Rating System from the CMS has a significant impact on all of Medicaid managed care. Learn about the implications the new federal rating system.

Medicaid managed care remains the top delivery method of Medicaid in the country. Today, 41 states use a risk-based managed care health plan for some (if not all) of their Medicaid beneficiaries.

Today, over 70% of the total nearly 94 million individuals enrolled in Medicaid and Children’s Health Insurance Programs (CHIP) nationwide are enrolled in managed care plans.

Despite these incredible enrollment figures, there has been minimal control over the regulation of access quality and standardization at the federal level.

This year, as part of the Medicaid and Children’s Health Insurance Program Managed Care Access, Finance, and Quality Notice of Proposed Rulemaking, the Center for Medicare and Medicaid Services (CMS) has outlined a new Medicaid and CHIP Quality Rating System (MAC QRS) to standardize and improve the quantification of quality measurements and improve access to this information nationwide.

While states have created their own Medicaid and CHIP managed care rating system over the past few years, this is a notable shift to establish the MAC QRS as a federal standard and comparison point for all managed care plans. This makes the MAC QRS the comprehensive authority for all parties.

The new proposed MAC QRS framework contains three pillars:

  1. Mandatory measures (of quality)
  2. A quality rating methodology using either the CMS-developed methodology or an alternative methodology approved by CMS
  3. A mandatory website display format

Unlike previous iterations of rating systems from states, the mandatory website display is a huge, newly proposed step to provide clarity of the quality measures at hand.

Rather than provide Medicaid beneficiaries with an arbitrary plan performance number, the websites will provide data from the state to give a deeper level of understanding. Plus, beneficiaries would be able to read key plan factors such as what prescriptions are covered and the provider network when weighing what plan to select for themselves or a loved one.

If approved, this shift toward the MAC QRS will not happen overnight. With states at varying levels of experience in implementing their own rating system, there will be a multi-year catchup period allowing states to get their website and framework structured up to the end of the fourth calendar year from the effective final rule date.

By aligning Medicaid managed care health plans on an annual basis with this revamped MAC QRS, Medicaid state agencies, Managed Care Organizations (MCOs), Medicaid beneficiaries, and care providers will all have equal access to understanding the performance data and trends of their current and potential managed care health plans.

Along with some of the other rules in the proposed rulemaking including maximum appointment wait times, secret shopper surveys, member experience surveys, and more, this proposed change has a significant impact for every Medicaid stakeholder. This proposed rule brings a greater level of accountability, transparency, access to care and care information, health literacy, and more—all important components for taking care of some of the country’s most vulnerable patient populations.

SafeRide Health is excited for these proposed changes as we continue to support our Medicaid managed care health plan partners. Our technology-first approach delivers real-time, rich performance data to Medicaid managed care health plans for maximum transparency and understanding of program performance.

This enables health plans and members alike to have greater trust in their transportation benefit and getting to the care they need. SafeRide is also well-positioned to continue to help Medicaid beneficiaries by providing a member-centric experience every step of the way to help plan performance scoring as well as drive better health outcomes.

As Medicaid and Medicare Advantage health plans continue to focus on optimal member experience and delivering greater access to care, SafeRide will be there to support. To learn more about SafeRide Health’s ability to remove roadblocks in pursuit of more equitable care for all patient populations, visit our Access page.

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