Quality Rating Systems in Medicaid Managed Care

Managed care has become the dominant form of service delivery for Medicaid and CHIP beneficiaries. In April 2016, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that requires states to implement a Medicaid and CHIP quality rating system (QRS). MACPAC partnered with Mathematica to explore the design of quality rating systems in use on a voluntary basis by state Medicaid programs, how the systems work, how they compare with systems developed for other federal programs, and how they might evolve to comply with federal requirements. The primary goal of this study was to examine how states use QRSs to inform beneficiaries, incentivize health plan performance, and increase health plan accountability. A secondary goal of the study was to explore how state Medicaid programs align their QRSs with other quality initiatives and financial incentives to improve health plan performance.

This report profiles the quality rating systems of five state Medicaid managed care programs—in Florida, Michigan, Ohio, Pennsylvania, and Texas—and compares them with the rating systems used in the Medicaid Advantage program and for Marketplace qualified health plans.