CMS Finalizes Rules to Improve Access across Medicaid, CHIP, and Home and Community-Based Service Programs

On April 22, the Centers for Medicare & Medicaid Services (CMS) released two final rules: Ensuring Access to Medicaid Services and Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality. These rules aim to improve care access, promote transparency and accountability, streamline data collection and monitoring, and increase opportunities to promote Medicaid and CHIP beneficiary engagement. CMS also published a Fact Sheet for each of the rules in addition to a chart outlining the applicability dates for all of the changes:

Ensuring Access to Medicaid Services: Fact Sheet , Applicability Date Chart
Medicaid and CHIP Managed Care Access, Finance, and Quality: Fact Sheet , Applicability Date Chart

The rules align with President Biden’s executive orders directing federal agencies to take action to expand affordable, quality health coverage issued in January 2021 and April 2022. The rules will take effect July 9, 2024.

The final rules aim to improve care access and health outcomes and address health equity considerations for Medicaid and CHIP managed care enrollees and across Medicaid fee-for-service (FFS) programs, managed care delivery systems, and home and community-based services (HCBS) by:

Ensuring Access to Medicaid Services:

adding new federal requirements for Medicaid home and community-based services,
standardizing rate information and increase rate transparency, and
enhancing beneficiary and stakeholder engagement through Medicaid Advisory Committees (MACs) and Beneficiary Advisory Councils (BACs)

Medicaid and CHIP Managed Care Access, Finance, and Quality:

enhancing beneficiary access and care quality through the establishment of certain standards and data transparency improvements,
making several Changes to State directed payment arrangements,
changing medical loss ratio reporting requirements, and
establishing a Medicaid and CHIP Managed Care Quality Rating System website to promote transparency and enable comparison of plans based on quality, drug formularies, and provider networks.

BACKGROUND

Beneficiary care access remains a principal focus of the Medicaid program. While Access to health coverage increased significantly due to the enactment of the Patient Protection and Affordable Care Act (ACA), which, among other things, expanded Medicaid eligibility and simplified Medicaid and CHIP enrollment processes – CMS is concerned that there continue to be care access challenges due to inconsistent regulations and a lack of transparency across different delivery systems. This is particularly important given that 74.6 percent of Medicaid beneficiaries were enrolled in a managed care plan in 2021,[1] and many regulations governing care access, service payment, and provider participation apply only to Medicaid FFS programs, not to managed care.

Managed care is the primary delivery system for Medicaid and CHIP in the United States. As of September 2023, more than 88 million individuals were enrolled in Medicaid or CHIP,[2] and the Medicaid program accounted for 18 percent of national health expenditures in 2021.^[3]

States may implement a Medicaid managed care delivery system using one or more Federal authorities: Section 1915(a), 1915(b), and 1115(a) waivers and 1932(a) State plan amendments.^[4] These authorities permit States the flexibility to operate their programs without complying with three major tenets of Medicaid law, such as implementing delivery systems in specific areas of a State, providing different benefits to individuals enrolled in a managed care delivery system, or requiring individuals to receive Medicaid services from a managed care plan.

However, regardless of the authority used, States must still comply with Federal regulations that govern Medicaid managed care delivery systems.

To this end, CMS aims to strengthen Federal regulations to increase access and quality of care. CMS assesses the sufficiency of health care access through a three-dimensional framework: (1) enrollment in coverage; (2) coverage maintenance; and (3) access to services and supports. CMS previously released a request for information (RFI) in the Spring of 2022 regarding Medicaid and CHIP eligibility and enrollment challenges. In response, stakeholders largely expressed a need for cultural competency to address language and enrollment and retention barriers, observed that reimbursement rates often serve as a driver of Medicaid and CHIP provider participation, and that setting standards and aligning payment practices could promote consistent and improved care access across beneficiary groups, delivery systems, and Medicaid programs.

To address coverage maintenance considerations, on March 27, 2024, CMS published a final rule, ‘Streamlining the Medicaid, Children’s Health Insurance Program, and Basic Health Program Application, Eligibility, Determination, Enrollment, and Renewal Processes,’[5] to reduce, simplify, and streamline administrative processes to encourage more health care coverage through Medicaid and CHIP for children, older adults, people with disabilities, and people from underserved communities. See the fact sheet here.

These final rules address the last dimension, service and support access, with policies that would standardize HCBS reporting mechanisms, increase beneficiary engagement opportunities, promote rate transparency and care access, and advance health equity.

CMS recognizes that States faced challenges transitioning out of the COVID-19 public health emergency, particularly with the expiration of continuous Medicaid enrollment authorized by the Families First Coronavirus Response Act. Accordingly, to allow sufficient time for States to implement required changes, CMS implements an effective date of 60 days following the final rules publication, with separate compliance dates for certain provisions.

ENSURING ACCESS TO MEDICAID SERVICES

Ensuring that Medicaid recipients can access covered services is a focus of the Department of Health and Human Services, specifically within the Centers for Medicare & Medicaid Services (CMS). Executive Order 14009 in 2021 established a policy goal to enhance Medicaid and the Affordable Care Act (ACA), with the aim of making quality healthcare more accessible and affordable across the United States. Following this, Executive Order 14070 in 2022 tasked agencies with identifying ways to expand affordable healthcare coverage, improve the quality of coverage, strengthen benefits, and facilitate enrollment in quality health insurance.

The Ensuring Access to Medicaid Services final rule seeks to improve access and the quality of care, aiming to enhance health outcomes for those in both fee-for-service and managed care systems, including home- and community-based services (HCBS).

CMS has made efforts to improve access to care for Medicaid enrollees, within the constraints of existing regulations. The Access rule focuses on enhancing transparency, standardizing data collection, and promoting state-led engagement of beneficiaries in Medicaid programs to improve overall access to care.

CMS Finalizes Changes to Promote HCBS Payment Adequacy and Transparency

Access to most HCBS generally requires hands‑on and in‑person services to be delivered by direct care workers. However, direct care worker shortages are impacting beneficiaries’ access to services. To address direct care workforce shortages, CMS finalizes the proposal to require that at least 80 percent of Medicaid payments in a State for homemaker, home health aide, and personal care services be spent on compensation for direct care workers. The agency makes a number of modifications to the proposal.

To avoid penalizing States for paying for the essential functions of direct care workers jobs, CMS is excluding the following costs from the compensation percentage calculation:

Costs of required trainings for direct care workers,
Travel costs for direct care workers provided to direct care workers, and
Costs of personal protective equipment for direct care workers.

These costs would be deducted from the total Medicaid payments States receive before the compensation percentage is determined. This would avoid disincentivizing States from serving members in rural areas, as travel costs would not lower the percentage of total payment spent on direct care worker compensation.

As reflected in the Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting final rule, CMS modifies the definition of direct care workers to include staff such as nurses who provide clinical supervision.

This final rule also allows States flexiblities and exemptions for small providers and providers facing extraordinary circumstances that prevent compliance with the 80 percent minimum. In regard to small providers, the State could set a different minimum percentage for these providers so long as said percentage were based on an objective, transparent process that included public notice and comment opportunities. The hardship exemption requirements for certain providers facing extraordinary circumstances would need to be established under a similar process. Any providers who qualified for this exemption would be excluded from the State’s minimum percentage calculations. States would need to report their criteria for these provisions as well as their utilization to CMS.

CMS also modifies the proposal to exempt Indian Health Service (IHS) and Tribal health programs from this requirement. Lastly, CMS pushes back the timeline for this requirement, which will go into effect six years after the effective date of the final rule, as opposed to the four years originally proposed.

CMS also finalizes the requirement for States to report annually, in the aggregate for each service, on the percent of payments for homemaker, home health aide, personal care, and habitation services that are spent on compensation for direct care workers, and separately report on payments for such services when they are self‑directed or delivered in a provider-operated physical location for which facility-related costs are included in the payment rate. Habitations services and the separate reporting for facility-related costs were added to these reporting requirements in the final rule in response to comments.

To better provide assistance to States that are struggling to comply with these requirements, CMS is adding a provision that States must report on their readiness to comply with the reporting requirements one year prior to their effective date, which will be four years after the effective date of this final rule.

To ensure that HCBS stakeholders have increased awareness of how states establish Medicaid payment rates for personal care, homemaker, home health aide, and habitation services, CMS will require states to publish the average hourly Medicaid FFS rate paid to direct care workers delivering these services every two years starting July 1, 2026. This information would separately compare rates for individual direct care providers and direct care provider agencies.

In addition, this rule will require the establishment of an interested parties advisory group, to advise and consult with the State on payment rates for direct care workers. This group will include, at a minimum, direct care workers, beneficiaries and their authorized representatives, and other interested parties, will hold their first meeting within two years of the effective date of this final rule, and after this, will hold meetings at least once every two years.

CMS Finalizes Grievance Systems in Fee-For-Service HCBS Programs

As proposed, CMS establishes general requirements for state grievance procedures in Medicaid HCBS waiver programs. These rules allow a beneficiary or their authorized representative to file a grievance.

CMS also require states to:

Establish written policies for their grievance processes that comply with these new regulations.
Assist beneficiaries in filling out grievance forms and navigating the grievance process.
Ensure no punitive actions are taken against individuals filing grievances.
Accept and process grievances and requests for quick resolutions or time extensions.
Provide beneficiaries with information about how to file a grievance and their rights within the grievance system, making sure this information is accessible to those with disabilities or limited English proficiency.
Review grievances where the beneficiary is dissatisfied with the resolution.
Inform providers and subcontractors about the grievance system.

Furthermore, the procedures for handling grievances must:

Allow grievances to be filed either orally or in writing.
Acknowledge every grievance received.
Ensure that the person deciding on a grievance has not previously dealt with the issue and has the right expertise.
Give beneficiaries a fair chance to present their case through various means, including face-to-face or virtual meetings.
Provide beneficiaries with access to their case files and any new evidence considered in the grievance, free of charge.
Offer free language services to help beneficiaries participate in the grievance process effectively.

States must comply with these requirements beginning two years from the effective date of the final rule. Importantly, these requirements do not apply to managed care delivery systems.

CMS Finalizes HCBS State Reporting Requirements and Improvements to Patient-Centered Planning

To enhance the consistency of person-centered service plan requirements across states, and to ensure the health and welfare of participants in section 1915 (c) waiver programs[6], CMS finalizes new regulatory measures.[7] The new HCBS requirements apply to section 1915(c) waiver programs and to section 1915(i), (j), and (k) state plan services, with some exceptions for certain services. The requirements apply to services delivered through both FFS and managed care delivery services and would also apply to services included in demonstration projects unless waived or not applicable.

CMS aims to ensure a consistent application of person-centered service plan requirements across states and protect the health and welfare of individuals receiving HCBS. Specifically, states are required to ensure that at least 90 percent of individuals continuously enrolled in the waiver for at least one year have their functional needs reassessed annually. Additionally, states would need to demonstrate that they have reviewed and, as necessary, revised the person-centered service plans following these reassessments for at least 90 percent of these individuals annually.

The intention behind these minimum performance levels is to improve the reporting requirements for person-centered planning, while acknowledging that there may be valid reasons for occasional delays in assessment and care planning. The agency does not offer exceptions for good causes, such as natural disasters or public health emergencies, to these performance levels. CMS asserts that the 90 percent threshold should accommodate various disruptions, and existing disaster authority allows states to seek waivers from these requirements in emergency situations. The performance levels and reporting requirements are effective three years after the effective date of the final rule.

CMS Finalizes Requirements for States to Maintain Incident Management Systems

CMS finalizes a new requirement to mandate states to operate an incident management system that can identify, report, assess, investigate, resolve, and analyze critical incidents. This system is intended to ensure consistent standards across states for addressing incidents that could harm or pose a risk to beneficiaries, based on experiences from the section 1915(c) waiver program and informed by previous surveys.

If an entity other than the State investigates critical incidents, States must have an information-sharing agreement and must investigate separately if the investigating entity fails to report on a resolution within state-specified timeframes. States must report results of an incident management system assessment every 24 months to demonstrate compliance, with some exceptions.[8] This requirement is effective three years after the effective date of this final rule.

CMS Extends Initial Reporting Requirement and Requires Performance Targets for the HCBS Quality Measure Set

States are required to report biennially on the HCBS Quality Measure set, adhering to a format and schedule determined by the secretary. This frequency was chosen to balance the burden of survey-based measures with the opportunity for states to use the data for significant quality improvements over time. In this final rule, CMS mandates that States establish performance targets for both mandatory and non-mandatory measures and describe their quality improvement strategies.[9]

In response to concerns about the operational feasibility of more frequent reporting, the final rule extends the initial reporting requirement from three to four years after the rule’s effective date, giving states more time to prepare for compliance. This adjustment also allows for more input into the measures, ensuring that states have adequate resources and support to meet the new reporting requirements. The rule also affirms that states with section 1115 demonstrations must comply with these requirements unless specific exemptions are granted.

CMS Standardizes HCBS Reporting Requirements

To enhance transparency in the administration of Medicaid-covered HCBS, states must compile and post required reporting data to a dedicated public HCBS webpage that meets specific availability and accessibility requirements. The information reported by states would also be reported on CMS’s website. This policy is effective three years after the effective date of this rule, except for the payment adequacy provision, which is effective four years after the final rule’s effective date.

CMS Strengthens Medical Care Advisory Committees and Beneficiary Advisory Groups

Current federal regulations require States to maintain a Medical Care Advisory Committee (MCAC) to provide feedback to the State’s Medicaid agencies about health and medical care services. Recognizing a need for more effective and broad-based feedback mechanisms that better integrate beneficiary perspectives, CMS updates regulations under various sections of the Act.

The final rule introduces a new framework, replacing the MCAC with a Medicaid Advisory Committee (MAC) and a Beneficiary Advisory Council (BAC), previously proposed as the Beneficiary Advisory Group (BAG). States will now have clear directives to regularly rotate MAC and BAC members, develop and publish member recruitment processes, and maintain transparency by posting governance bylaws, membership lists, and meeting minutes online. These changes are designed to facilitate bi-directional feedback on Medicaid administration and enhance the alignment of services with the needs and best interests of beneficiaries.

The MAC and BAC will enable more inclusive and effective participation and communication between Medicaid stakeholders and the state. The changes will also maintain Federal Financial Participation (FFP) for administrative activities related to these advisory bodies. Moreover, the new structure requires states to publish an annual report on the activities of the MAC and BAC, enhancing transparency and accountability.

It is anticipated that all states will be required to make significant updates to their advisory committee operations. The total burden under the high estimate for all requirements is 17,340 hours across all states, with a total cost of $1,665,354, of which states would be responsible for $832,676 after accounting for the Federal administrative match.

In response to comments, CMS extends the applicability date for MAC and BAC annual reporting to the State to be effective two years from the effective date of this final rule.

MEDICAID AND CHIP MANAGED CARE ACCESS, FINANCE, AND QUALITY

Ensuring timely and high-quality access to services in a fair and consistent manner is crucial to the success of Medicaid and CHIP programs. The rule outlines guidelines for timely access to care, as well as State monitoring and enforcement efforts. CMS finalizes changes related to managed care programs, including State directed payments (SDPs) arrangements, medical loss ratio requirements, and specifying the scope of in lieu of services and settings to more effectively address health-related social needs. The rule also requires separate CHIP programs to conform to the majority of the access and quality provisions for Medicaid.

CMS finalizes the following access-related provisions:

The establishment of national standards for maximum appointment wait times for routine primary care, including pediatric primary care, obstetric/gynecological services, outpatient mental health and substance use disorder services for adults and children, as well as a State-chosen services. This requirement will be effective for the first rating period beginning on or after 3 years after the effective date of the final rule.
A State requirement to use an independent entity to conduct annual secret shopper surveys to verify compliance with appointment wait time standards and provider directory accuracy, as well as identify errors and network providers that do not offer appointments. This requirement will take effect by the first rating period beginning on or after 4 years after the effective date of the final rule.
A State requirement to conduct an annual enrollee experience survey for each Medicaid managed care plan and post the results on States’ websites, while also reporting them to CMS. This requirement will take effect by the first rating period beginning on or after 2 years after the effective date of the final rule. CMS also finalized a proposed rule to permit States to use a CAHPS survey as required for Medicare Advantage D-SNPs.
The required submission of an annual payment analysis comparing managed care plan payment rates for certain services as a proportion of Medicare’s payment rate and, for certain HCBS, the State’s Medicaid State plan payment rate. This requirement will take effect the first rating period beginning on or after 2 years after the effective date of the final rule.
For any managed care plan with access issues requiring improvement, States will be required to implement a remedy plan. This requirement will take effect by the first rating period beginning on or after 3 years after the effective date of the final rule.
A requirement that States maintain a single web page that is easily accessible to the public, containing all required information, for transparency. This requirement will take effect by the first rating period beginning on or after 2 years after the effective date of the final rule.

CMS Finalizes Several Changes to State Directed Payment Arrangements

Federal regulations set forth the parameters under which States may direct expenditures in connection with Medicaid managed care contracts. State directed payments (SDPs) must advance at least one objective in a State’s managed care quality strategy and be based on service delivery and utilization under the managed care contract. Examples of permissible SDP arrangements include requirements for managed care plan providers to participate in value-based purchasing models, in Medicaid-specific delivery system reform or performance improvement initiatives, or for managed care organizations to abide by certain fee schedule requirements.

CMS has issued guidance to States regarding SDPs on several occasions over the past several years.[10]^,[11]Most recently, on February 17, 2023, CMS issued an informational bulletin concerning health care-related taxes and hold harmless arrangements in the redistribution of Medicaid payments.[12]

CMS indicates that there has been an increasing number of SDPs from States, and that SDPs also account for a significant amount of spending. In 2020, the Medicaid and CHIP Payment and Access Commission noted that SDP arrangements in 37 states accounted for more than $25 billion in spending.[13] In recognition of increasing expenditures and to promote Medicaid quality goals and objectives, CMS finalizes several changes in this rule to clarify and add existing requirements for State directed payments. Specifically, CMS intends these provisions to ensure access to high quality care for Medicaid managed care enrollees under SDP arrangements, appropriately align SDPs with Medicaid quality goals and objectives for participating providers, and establish fiscal and program integrity guardrails to promote accountability and transparency for SDP payment arrangements.

CMS finalizes the proposal to allow States to direct payments under managed care contracts to non-network providers. The agency believes this will increase access to care. For example, when States transition benefits from FFS to managed care, the ability to direct payments to non-network providers would allow states to require providers are paid a rate high enough to ensure access is not compromised while plans and providers negotiate rates for these new services. This provision will be applicable beginning on the effective date of the final rule.

Additionally, all payments made under SDPs will now be required to be based on utilization under the managed care contract for the applicable rating period, preventing states from basing SDP payment on historic utilization. CMS is concerned that allowing SDPs to be based on historic utilization undermines the integrity of risk-based managed care by not allowing plans to effectively manage risk under their contract. States will also be prohibited from requiring plans to make interim payments under SDPs and reconciling these payments at the end of the rating period. SDPs based on value-based purchasing would be allowed to tie performance to one year preceding the applicable rating period. These provisions will go into effect beginning with the first rating period on or after three years after the effective date of the final rule.

The final rule establishes a payment limit for SDPs covering the following services: inpatient hospital services, outpatient hospital services, nursing facility services, or qualified practitioner services at an academic medical center. This limit will be set at the average commercial rate (ACR) defined by CMS as “the average rate paid for services by the highest claiming third-party payers for specific services as measured by claims volume.” This provision will be effective for the first rating period beginning on or after the effective date of the final rule. While CMS considered setting this limit at the Medicare rate, they ultimately believed that doing so would be too limiting to States and would hurt their ability further their Medicaid program goals and objectives. CMS is not finalizing an overall SDP expenditure limit in this final rule.

To ensure that States comply with existing Federal requirements for funding the non-Federal share of Medicaid payments, CMS is adding new language to § 438.6(c)(2)(ii) explicitly stating that SDPs must comply with relevant legal requirements. Additionally, providers in an SDP arrangement must attest that they do not participate in any hold harmless arrangements for health-care related taxes. This attestation must be made available to CMS upon request beginning with the first rating period beginning on or after January 1, 2028.

In addition, among other SDP related provisions, this final rule will establish the following requirements:

establish new timeframes and procedures for the submission of SDPs and documentation requirements,
establish a process for states to appeal SDP disapprovals through the HHS Appeals Board,
remove written prior approval requirements for SDPs consisting of minimum fee schedules at the Medicare payment rate,
require States to submit total dollars spent on SDPs by each MCO, PIHP, and PAHP to CMS within one year after each rating period, and
increase SDP evaluation requirements.

The Agency believes these provisions will provide greater clarity and direction to Medicare Managed care plans to manage contracts and ensure that capitation rates are actuarially sound.

CMS Changes Medical Loss Ratio Requirements

Federal regulations set forth medical loss ratio reporting requirements for Medicaid managed care plans. The medical loss ratio (MLR) generally represents a percentage of revenue used for beneficiary care and quality improvement activities, rather than spending on administrative expenses. In general, Medicaid and CHIP managed care medical loss ratio requirements align with Qualified Health Plans (QHP) and Medicare Advantage Organization standards, but there were some changes to QHP MLR reporting requirements the Agency finalized in recent rulemaking.[14]

Accordingly, CMS finalizes several changes to Medicaid managed care medical loss ratio requirements to maintain alignment with QHP standards, and to ensure that capitation rates are actuarially sound. CMS finalizes the proposal to, among other things, require Medicaid managed care plans to submit SDP expenditures and revenues to States as part of their medical loss ratio. CMS also requires States to report these amounts as separate line items on annual medical loss ratio reports to the Agency. These requirements will become effective for the first rating period on or after July 9, 2024.

CMS finalizes changes specifying when managed care plans must resubmit medical loss ratio reports, makes technical revisions for quality improvement expenditures, requires states to provide medical loss ratios for each managed care plan, and specifies contractual requirements for provider incentive payments. Based on public comment, the provisions related to the Standards for Provider Incentives will become effective for the rating period beginning on or after one year following the effective date of the final rule.

CMS Streamlines Managed Care in the Medicaid and CHIP Managed Care Quality Rating System

The Medicaid and CHIP Managed Care Quality Rating System (MAC QRS) is a quality rating system for Medicaid and CHIP managed care plans that holds States and plans accountable for the care provided to beneficiaries. It is intended to provide beneficiaries and their caregivers with a web-based interface to compare managed care plans based on assigned performance indicators and ratings.

The final rule contains several provisions that would hold States to a minimum Federal standard for their rating systems. These provisions would enable Medicaid and CHIP beneficiaries in every State contracting with a managed care plan to access quality and other performance data at the plan level and support the ability of beneficiaries to select plans that meet their needs. The policies build upon existing data and information that States are already required to report publicly and to the Federal government.

CMS establishes the MAC QRS website as a seamless and uniform resource for beneficiaries to access information about eligibility, managed care, and compare plans based on quality, drug formularies, and provider networks. States will be required to comply by the end of the fourth calendar year following July 9, 2024.

Additionally, CMS finalizes the establishment of an Agency framework along with State requirements for the MAC QRS, including an initial set of mandatory measures (a reduced amount of mandatory measures from the proposed rule to reduce burden) and methodology for quality ratings, with a process for updating these measures in the future. States must establish the methodology for quality ratings starting on the effective date of the final rule. Additionally, States will need to publicly present quality ratings for the first set of required measures by December 31, 2028. Based on concerns from commenters on the burden that this rule could cause, CMS is adding an option for a one-year extension to fully comply with the requirements. States granted an extension for the first phase of requirements will have until December 31, 2029, to fully comply. These ratings must correspond to the data collected in the performance year January 1, 2026, to December 31, 2026. Further, from the effective date of the final rule, States would also be granted flexibility to implement an alternative QRS outside the CMS framework, if granted approval from CMS.

CMS Finalizes Changes to Quality Strategy and External Quality Review

CMS finalizes changes to the current regulations governing the annual External Quality Review (EQR) technical reports for managed care delivery systems. The changes include expanding the type of data that must be included in the reports to include quantitative assessments and outcomes data from performance improvement projects (PIPs) and mandatory network adequacy validations. Additionally, CMS is adding guidance for States to stratify performance measures collected and reported in the EQR technical reports under the performance measure validation activity. The revisions to the regulations would apply to separate Children’s Health Insurance Program (CHIP) programs through an existing cross-reference.

Specifically, CMS finalizes the following actions and applicability dates:

Increase public engagement around States managed care quality strategies from one year following the effective date of the final rule.
Eliminate EQR requirements from primary care case managers (PCCM) providers and simplify the use of accreditation reviews for EQR by States, applicable from the effective date of the final rule. Based on public comments on the proposed rule, CMS adds a revision to allow for validation of performance measures and performance improvement projects conducted by PCCM entities.
Beginning December 31, 2025, establish uniform review periods of 12 months for the yearly EQR activities to guarantee that the reports include the most up-to-date data and information.
Mandate the inclusion of comprehensive and valuable data and information in the yearly EQR reports within 1 year of the release of the associated protocol.

CMS did not finalize the deadline change for EQR technical reports and decided to keep the posted date April 30^th instead of December 31, as proposed.

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This Applied Policy® Summary was prepared by April Gutmann with support from the Applied Policy team of health policy experts. If you have any questions or need more information, please contact her at agutmann@appliedpolicy.com or at (202) 558-5272.

[1] https://www.medicaid.gov/medicaid/managed-care/enrollment-report/index.html

[2] https://www.medicaid.gov/sites/default/files/2023-10/september-2023-medicaid-chip-enrollment-trend-snapshot.pdf.

[3] https://www.cms.gov/data-research/statistics-trends-and-reports/national-health-expenditure-data/nhe-fact-sheet

[4] https://www.medicaid.gov/medicaid/managed-care/managed-care-authorities/index.html

[5] 89 FR 22780

[6] https://www.medicaid.gov/federal-policy-guidance/downloads/cib-03-20-14.pdf

[7] Under the authority of sections 1915(c)(1) SSA and section 2402(a)(1) and (2) of the ACA

[8] Unless CMS determines the system meets the requirements at § 441.302(a)(6), at which point the assessment

must be made every 60 months

[9] CMS released a voluntary set of nationally standardized quality measures for Medicaid-covered HCBS, the HCBS Quality Measure Set on July 21, 2022.

[10] https://www.medicaid.gov/sites/default/files/Federal-Policy-Guidance/Downloads/cib051420.pdf

[11] https://www.medicaid.gov/Federal-Policy-Guidance/Downloads/smd21001.pdf

[12] https://www.medicaid.gov/federal-policy-guidance/downloads/cib021723.pdf

[13] https://www.macpac.gov/wp-content/uploads/2022/06/MACPAC_June2022-WEB-Full-Booklet_FINAL-508-1.pdf

[14] 88 FR 25740

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