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CMS Releases Proposed Rule to Improve Medicaid & CHIP Quality Reporting Across States

The Centers for Medicare & Medicaid Services (CMS) released a notice of proposed rulemaking to promote consistent use of nationally standardized quality measures in Medicaid and the Children’s Health Insurance Program (CHIP). This will help identify gaps and health disparities among the millions of people enrolled in these programs.

This rule proposes requirements for mandatory annual state reporting of three different quality measure sets:

  • the Core Set of Children’s Health Care Quality Measures for Medicaid and CHIP;
  • the behavioral health measures on the Core Set of Adult Health Care Quality Measures for Medicaid; and
  • the Core Sets of Health Home Quality Measures for Medicaid.

These Core Sets are designed to measure the overall national quality of care for beneficiaries, monitor performance at the state level, and improve the quality of health care.

“The Medicaid and CHIP Core Sets of quality measures for children, adults, and health home services are key to promoting health equity. They will allow us not only to identify health disparities but also to implement interventions based on the very data that make those disparities clear,” said CMS Administrator Chiquita Brooks-LaSure. “CMS will use every lever available to ensure a high quality of care for everyone with Medicaid and CHIP coverage. By requiring states to report the core sets of quality measures, we can ensure that our policies are supported by data representing all of our beneficiaries.”

Quality measures help evaluate or quantify processes, outcomes, patient perceptions, and even organizational structures associated with providing high-quality health care. The Core Sets include a range of measures key to determining how well Medicaid and CHIP meet their missions of providing affordable, high-quality, person-centered health coverage to low-income people, including children and families. In doing so, the Core Sets can help CMS and partners evaluate Medicaid and CHIP nationally and across the 54 programs run by states and territories. Specifically, the Core Sets will evaluate how Medicaid and CHIP coverage is meeting the needs of individuals and communities, including where health disparities persist, and how the quality of care can be improved.

In addition to the Child and Adult Core Sets, CMS is establishing reporting requirements for states that elect to implement one or both of the optional Medicaid health home benefits under sections 1945 or 1945A of the Social Security Act, which will measure health care quality for states that choose to establish “health homes.” Health homes integrate and coordinate all primary, acute, behavioral health, and long-term services and supports for one of Medicaid’s most at-risk populations: people with significant chronic conditions and/or serious mental health concerns. The Health Home Core Sets will allow CMS to monitor the impact of these optional state plan benefits, thereby improving the quality of health care for the more than 1 million Medicaid beneficiaries with chronic conditions. Currently, 19 states and the District of Columbia have at least one health home program.

While currently voluntary, under this new rule, reporting for the full Child Core Set, behavioral health measures in the Adult Core Set, and the two Medicaid Health Home Core Sets becomes mandatory in federal fiscal year 2024. Data reported in 2024 will reflect care delivered in calendar year 2023. Nationwide reporting of the measure sets will create opportunities to develop a national view of quality in the Medicaid and CHIP programs – a long-sought goal for public health advocates.

There will be a 60-day comment period, and comments on the notice of proposed rulemaking must be submitted to the Federal Register no later than October 21, 2022. For more information, or to review the rule in its entirety, visit the Federal Register.

Centers for Medicare & Medicaid Services, CHIP, CMS, hildren’s Health Insurance Program, quality measures

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