Chapter 1 focuses on improving the managed care external quality review process. Managed care is the primary health care delivery approach in Medicaid, with 73 percent of beneficiaries enrolled in a comprehensive, full-risk managed care organization (MCO). With the growth of managed care, federal and state stakeholders have increasingly prioritized the effective oversight of Medicaid managed care programs to ensure beneficiaries have appropriate access to needed services. State Medicaid agencies conduct an annual external independent review of the quality of and access to services under each managed care contract, known as the EQR process.
MACPAC examined how states implement federal EQR requirements, the role the Centers for Medicare & Medicaid Services (CMS) plays in overseeing the process, and if the EQR process supports accountability for states and MCOs and improves care for beneficiaries. The Commission makes three recommendations that are intended to improve the transparency and usability of findings included in the EQR annual technical reports.
From: March 2025 Report to Congress on Medicaid and CHIP