Quality Rating Systems in Medicaid Managed Care

Quality Rating Systems in Medicaid Managed Care

Published: Feb 19, 2021
Publisher: Mathematica

Ruth Hsu

Télyse Masaoay

Stephanie Parver

Key Findings
  • Quality rating systems (QRSs) are designed to help beneficiaries understand performance difference among health plans. Their primary goal is to help inform beneficiaries about their health plan choices.
  • Even so it is unclear whether Medicaid beneficiaries use quality ratings to select health plans.
  • A secondary goal of QRSs is to improve health plan performance, and most study states reported aligning key quality measures in the QRS with financial incentives to further these efforts.
  • The study states generally support greater alignment of QRSs across state and federal programs, but would like future CMS rulemaking to allow for flexibility.

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.

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