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Quality measures used in Medicaid and CHIP

Sources of quality of care data in state Medicaid programs include for example the core set measures, the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, and the managed long-term services and supports (MLTSS) measure set. These measures help to promote standardized data collection and measurement across states. Use of these measures is voluntary. Information about quality of care can also be found from state CMS-416 reporting for the Early and Periodic Screening Diagnostic and Treatment benefit, and Section 1115 demonstration reporting.

Core Set

The core sets allow states, the public, and the Centers for Medicare & Medicaid Services (CMS) to monitor trends in performance on standardized indicators of quality of care provided to Medicaid and CHIP beneficiaries under both fee-for-service (FFS) and managed care arrangements and examine performance across states (HHS 2011). The goals of the core sets are to facilitate standardized reporting by states on a uniform set of performance measures and encourage states to use results to drive quality improvement (CMS 2019). CMS has developed core sets for pediatric and adult care, health homes, maternity care, and behavioral health services.

Child Core Set

The Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA, P.L. 111-3) required CMS to develop a core set of children’s health care quality measures in Medicaid and CHIP (§ 1139A of the Social Security Act (the Act)). The Child Core Set was developed in 2009, and voluntary reporting began in 2010. It is reviewed and updated annually, and includes measures related to primary and preventive care, maternal and perinatal health, care of acute and chronic conditions, dental care and oral health, behavioral health care, and patients’ experiences of care. CMS is required to report to Congress every three years on the status of voluntary reporting on the core quality measures and on other efforts to advance quality of care in Medicaid and CHIP.

The Bipartisan Budget Act of 2018 (P.L. 115-123) requires states to report on the Child Core Set for Medicaid and CHIP beginning with reports for fiscal year (FY) 2024.

Click here for information regarding the core set of child health care quality measures for Medicaid.

Adult Core Set

The Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended) required the development of a core set of adult health care quality measures in Medicaid (§ 1139B of the Act) for voluntary use by states, managed care organizations, and providers. CMS and the Agency for Health Care Research and Quality (AHRQ) developed the Adult Core Set in 2011, and voluntary reporting of these measures began in 2014.

The Adult Core Set includes measures related to primary and preventive care, maternal and perinatal health, care of acute and chronic conditions, behavioral health care, and patients’ experience of care. The Adult Core Set is reviewed and updated annually.

The Substance-Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act, P.L. 115-271) required that states report behavioral health measures in the adult core set beginning with reports for FY 2024.  Moreover, states with Section 1115 research and demonstration substance use disorder (SUD) waivers are required to report performance measures on use of SUD treatment services and other SUD-related services.

Click here for information regarding the core set of adult health care quality measures for Medicaid.

Health Home Core Set

The ACA created the option for states to establish health homes to integrate and coordinate services for Medicaid beneficiaries with chronic conditions such as substance use disorder, asthma, diabetes, heart disease, and having body mass index over 25. Health home providers may be a designated provider, a team of health professionals, or a health team. Services include comprehensive care management, care coordination, health promotion, comprehensive transitional care and follow up, patient and family support, and referrals to community and social support services.

In 2013, CMS developed a core set of quality measures for voluntary use to help states monitor and measure quality in Medicaid health home programs (CMS 2013). The health home core set measures reflect key priority areas including behavioral health and preventive care (CMS 2021). CMS selected core set measures that aligned with the Medicaid Adult Core Set, the Medicaid Promoting Program Integrity measures, and the National Quality Strategy (CMS 2021).  Health home providers are required to report to the states on quality measures (§ 1945(g)).

Click here for the core set of health home program quality measures for Medicaid.

Other core sets

CMS has identified the maternity and behavioral core sets, drawing upon measures from the adult and child core sets.  CMS will use the core sets to measure and evaluate progress toward and improvement of maternal and perinatal health and behavioral health, respectively, in Medicaid and CHIP. Use of these core sets is voluntary.

Click here for the maternity core set measures for Medicaid.

Click here for the behavioral health core set measures for Medicaid.

Consumer Assessment of Healthcare Providers and Systems (CAHPS)

CAHPS is a set of beneficiary surveys designed to measure experience of care for children and adults. Use of CAHPS in Medicaid is currently optional, but required for CHIP (§ 2108(e)(4) of the Social Security Act).

States may also choose to report CAHPS for Medicaid-covered children, but data for Medicaid and CHIP must be sampled, collected, and reported separately (CMS 2012).

The CAHPS Medicaid health plan surveys are included in the Child and Adult Core Sets and include questions about access to and use of services, the ability to schedule appointments, communication with providers, and assistance sought and received from health plans. In addition, CAHPS offers a supplemental set of questions regarding the care experience of children with chronic conditions that can be incorporated into the health plan survey (AHRQ 2020).

CAHPS also includes surveys to measure beneficiary experience of care with long-term services and supports (LTSS) and nursing homes. Surveys for LTSS include those for both fee-for-service home and community-based services (HCBS) programs and managed long-term services and supports (MLTSS) programs. There are three CAHPS nursing home surveys for long-stay residents, discharged residents, and family members (AHRQ 2021).

Click here for information regarding CAHPS surveys.

Early and Periodic Screening Diagnostic and Treatment Participation Report (CMS-416)

State Medicaid programs are required to report performance annually on the early and periodic screening, diagnostic, and treatment (EPSDT) benefit using form CMS 416. Under EPSDT, all states must provide children under age 21 access to any Medicaid-coverable service in any amount that is medically necessary, regardless of whether the service is covered in the state plan.

The CMS 416 is used by states and CMS to assess whether states are effectively ensuring that EPSDT- eligible children are receiving the screening and services to which they are entitled. Beginning with reporting for fiscal year 2020, states may elect to have CMS generate the CMS 416 using state-reported data in the Transformed Medicaid Statistical Information System (T-MSIS). Only states that are up to date with T-MSIS data submissions and who meet certain data quality criteria may choose this option (CMS 2021).

Click here for more information on the CMS-416.

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