Managed care plays a crucial role in delivering health care services to Medicaid beneficiaries, with a majority (72%) enrolled in comprehensive managed care plans. To ensure the quality, timeliness, and accessibility of care provided by Medicaid managed care organizations (MCOs), states are required to engage qualified independent entities called external quality review organizations (EQROs) for periodic reviews. These reviews serve as a means for federal and state oversight, monitoring, and accountability of MCOs.
This issue brief provides background on the external quality review (EQR) process and how states and the Centers for Medicare & Medicaid Services (CMS) use EQR to conduct oversight of managed care programs and improve quality and outcomes for Medicaid beneficiaries.