Quality rating systems are used to help beneficiaries understand performance differences within health plans. In April 2016, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that requires states to implement a Medicaid and State Children’s Health Insurance Program (CHIP) quality rating system (QRS) (42 CFR § 438.334). Although states are not yet required to use a QRS until CMS finalizes and releases specific guidance, 13 states are already using rating systems in their Medicaid managed care programs.
MACPAC contracted with Mathematica to explore the design of QRSs 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 report documents the use of QRSs in state Medicaid programs in Florida, Michigan, Ohio, Pennsylvania, and Texas and the systems used for the Medicare Advantage program and exchange plans.
Although QRSs are designed to help beneficiaries understand performance differences among health plans, the study found that it is unclear whether Medicaid beneficiaries are using quality ratings to select health plans. The 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. States included in the study generally support greater alignment of QRSs across states and programs but would like future CMS rulemaking to allow for flexibility.