about Quality in Medicaid and CHIP

What are the current quality measurement requirements in the Medicaid program?
Federal quality measurement requirements vary substantially based on the delivery system used--Medicaid managed care, fee-for-service, or Primary Care Case Management. The following table illustrates a significant quality reporting infrastructure mandated by Federal requirements among Medicaid managed care, while fee-for-service and Primary Care Case Management have no Federal quality measurement requirements at all:

Federal Requirements for Quality Reporting by Sector of the Medicaid Program

Capitated Managed Care
(serves 29.1 million)1

Primary Care Case Management
(serves 8.9 million)

(serves 19.1 million)

- States contracting with Medicaid managed care organizations (MCO) must provide comparative information on quality and performance indicators for the benefits offered by the MCO.
- States must develop a "quality assurance and improvement strategy" that includes access measures and procedures to monitor the quality and appropriateness of care for the populations covered by the MCOs.
- The state's strategy must utilize quality information, using standards established by HHS and states. For states to implement the quality assessment and improvement strategy effectively, enhanced federal funding is available for external quality review organizations (EQROs) that conduct independent reviews of MCO activities.
- No Federal requirements.* - No Federal requirements.*

*CMS has established a core set of adult and pediatric quality measures which states can use to for voluntary reporting purposes. Depending on state approaches to this option, PCCM and FFS programs may report to states on some quality measures.

Why is there a need for mandatory quality reporting in Medicaid?
There is currently no nationwide, mandatory and standardized way to measure, report, or improve the quality of services across the entire Medicaid program. That means that CMS, federal and state governments, and taxpayers cannot systematically evaluate the quality of care that Medicaid beneficiaries are receiving nationwide, from state to state, or even through varying delivery systems within a state.

Why is not having a systematic quality improvement program a problem?
Without a system in place, efforts to reform the Medicaid program cannot effectively focus on improving quality of care. Instead, changes must rest on cuts to vital benefits or payments to plans and providers, none of which will improve the health of enrollees, access to care or participation of high-quality providers in the program. The establishment by Congress of a nationwide system to uniformly measure, report, and improve the quality of care to Medicaid enrollees--across all types of delivery systems--will be an important step forward.

Why is it important to compare quality among delivery systems?
The Medicaid program delivers most care and services through three delivery systems: capitated managed care, primary care case management and fee-for-service. New systems, such as Accountable Care Organizations and Continuing Care Organizations, are being introduced into the Medicaid program. The effectiveness of these delivery systems can and does vary. Congress, the states and policymakers must understand the differences in quality between these systems so that they can make informed decisions about how and where to best focus improvement efforts.

Is there a model that can used to improve quality reporting for Medicaid?
Yes. The importance of strengthening quality measurement systems in Medicaid has been recognized in recent legislation, including the Children's Health Insurance Program Reauthorization Act (CHIPRA) and the Affordable Care Act (ACA)2. These laws call for the establishment of core sets of health care measures and voluntary reporting by states on these measures.

Isn't voluntary reporting sufficient?
Voluntary reporting is insufficient. Experience with the CHIPRA Core Measures Set shows that there is great variability in the extent of state reporting. Under voluntary reporting, only two-thirds of states report at least one measure for both Medicaid and CHIP-and states are reporting, on average, on slightly more than half the measures. A systematic and standardized quality measurement, reporting and improvement program cannot be based on reporting which is not consistent from year-to-year, or from state-to-state. Data on state voluntary reporting on the Adult Core Measures Set shows similar results; only 34 states reported in 2015.

Are there other systemic issues that affect the ability to measure quality in the Medicaid and CHIP programs?
Yes. A significant roadblock to quality measurement in Medicaid and CHIP is the fact that individuals often do not retain their Medicaid or CHIP eligibility long enough to enable accurate measurement of quality. Data from 2012 show that the typical individual on Medicaid is covered for less than 10 months of the year. Coverage periods are lowest for non-elderly, non-disabled adults (about 8.6 months), but somewhat higher for those with disabilities (10.8 months), seniors (10.3 months), and children (10 months).3

This issue is known as "churning," an on-and-off-and-on pattern of enrollment that may be unrelated to actual eligibility status or arise from small, often short-term, changes in incomes.

How does churning impact measuring quality of care?
Most measures of quality require that all individuals included in the measures be enrolled continuously during a 12-month period with only a limited break in service. Since churning prevents significant numbers of enrollees from retaining continuous coverage for a 12-month period, it makes it more difficult to accurately and completely measure quality because many enrollees are excluded from the data set. Churning also leads to disruptions in health care and leads to higher average monthly health expenditures.

How can 12-month continuous eligibility in Medicaid and CHIP improve care?
A 2012 report from the Government Accountability Office found that Medicaid enrollees "reported low rates of difficulty obtaining necessary medical care and prescription medicine, similar to those with private insurance for a full year." By comparison, individuals "with partial year health insurance-coverage for between 1 and 11 months-were more likely to report difficulties obtaining needed care, whether covered by Medicaid or private health insurance. In calendar years 2008 and 2009, the percentage of Medicaid enrollees enrolled for a partial year who reported difficulties obtaining needed medical care was almost double that of full-year Medicaid enrollees."4

Medicaid and CHIP combined to provide health insurance coverage to 80 million people over the course of 2012. But the number of individuals enrolled in a typical month was just 58.8 million - about 20 percent lower.5 This suggests a difference of 15 million between the number of people who are ever covered in a given year and the number covered at any point in the year.

How many people who churn off Medicaid are still eligible?
A 2002 study demonstrated that in many cases, families lose Medicaid despite remaining eligible for the program. This study found that about 1 in 7 children from families below the poverty level lost their eligibility despite their families' incomes remaining below the poverty level. Because all children 14 or under from families with income below the poverty level are entitled to Medicaid coverage, this finding suggests that these children ought to have been Medicaid-eligible a year later.6

For what proportion of a year are Medicaid enrollees typically enrolled in the program?
Data from 2012 show that the typical individual on Medicaid is covered for less than 10 months of the year. Coverage periods are lowest for non-elderly, non-disabled adults (about 8.6 months), but somewhat higher for those with disabilities (10.8 months), seniors (10.3 months), and children (10 months).7 This data may overstate the length of time that individuals have ongoing coverage, since it does not account for short breaks in coverage.


1. Enrollment numbers reflect most recent data from CMS. U.S. Department of Health and Human Services: Centers for Medicare and Medicaid Services. "Medicaid Managed Care Enrollment Report." July 1, 2011. (Return)

2. Sections 1139A and 1139B of the Social Security Act, respectively, establish the requirements for the core set of quality measures for children and adults. (Return)

3. Leighton Ku, PhD, MPH, Erika Steinmetz, MBA, and Tyler Bysshe, MPH, George Washington University. Continuity of Medicaid Coverage in an Era of Transition. November 2015. (Return)

4. GAO 13-55, "MEDICAID: States Made Multiple Program Changes, and Beneficiaries Generally Reported Access Comparable to Private Insurance." (Return)

5. The 75 million includes 66.0 million individuals on Medicaid and 7.9 million children on CHIP. Medicaid and CHIP Access and Payment Commission. "Report to Congress on Medicaid and CHIP. June 2013, Table 19. (Return)

6. Ku, L., & Cohen Ross, D. (Dec 2002). Staying Covered: The importance of retaining health insurance coverage for low-income families. Washington, DC: Commonwealth Fund. (Return)

7. Ku, Steinmetz and Bysshe.(Return)