External quality review (EQR) is one of the few statutory tools that the federal government and states have to engage in oversight of Medicaid managed care. EQR is also one part of an interrelated set of compliance and quality requirements that apply to Medicaid and CHIP managed care. Given the growth in Medicaid managed care, the Commission is interested in examining how states and the federal government are using available oversight tools.
Continuing the Commission’s work on EQR at the January 2023 meeting, staff shared findings from an environmental scan, a detailed examination of selected states, and interviews with key stakeholders.
These findings address several important policy questions, including how states structure their approaches to EQR, how states use EQR findings to hold plans accountable and improve care for beneficiaries, and how the Centers for Medicare & Medicaid Services engages in oversight of the EQR process.