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Examining the Role of External Quality Review in Managed Care Oversight and Accountability

External Quality Review (EQR) requirements are one of the few statutory tools that the federal
government and states have to engage in oversight of Medicaid managed care.

EQR is the annual process by which an independent external quality review organization (EQRO) reviews and validates the performance of a state’s contracted Medicaid managed care plans. EQR is also one part of an interrelated set of compliance and quality requirements that apply to Medicaid and the State Children’s Health Insurance Program (CHIP) managed care.

This session continued the Commission’s broader work addressing oversight and accountability of managed care. Given that managed care has become the dominant delivery approach in Medicaid, the Commission is interested in examining how states and the federal government are using available oversight tools to hold plans accountable. This presentation provided an overview of the EQR process and shared insights from MACPAC’s review of federal policy and an environmental scan of states executing EQR. Staff also highlighted some emerging themes gleaned from the work to date.