(a) General rule. Each State contracting with an MCO, PIHP or PAHP to furnish services to Medicaid beneficiaries must -
(1) Adopt the Medicaid managed care quality rating system developed by CMS in accordance with paragraph (b) of this section; or
(2) Adopt an alternative Medicaid managed care quality rating system in accordance with paragraph (c) of this section.
(3) Implement such Medicaid managed care quality rating system within 3 years of the date of a final notice published in the Federal Register.
(b) Quality rating system.
(1) CMS, after consulting with States and other stakeholders and providing public notice and opportunity to comment, will develop a framework for a Medicaid managed care quality rating system (QRS), including the identification of the performance measures, a subset of mandatory performance measures, and a methodology, that aligns where appropriate with the qualified health plan quality rating system developed in accordance with 45 CFR 156.1120, the Medicare Advantage 5-Star Rating System described in subpart D of part 422 of this chapter, and other related CMS quality rating approaches.
(2) CMS, after consulting with States and other stakeholders and providing public notice and opportunity to comment, may periodically update the Medicaid managed care QRS framework developed in accordance with paragraph (b)(1) of this section.
(c) Alternative quality rating system.
(1) A state may implement an alternative Medicaid managed care quality rating system that utilizes different performance measures or applies a different methodology from that described in paragraph (b) of this section provided that -
(i) The alternative quality rating system includes the mandatory measures identified in the framework developed under paragraph (b) of this section;
(ii) The ratings generated by the alternative quality rating system yield information regarding MCO, PIHP, and PAHP performance which is substantially comparable to that yielded by the framework developed under paragraph (b) of this section to the extent feasible, taking into account such factors as differences in covered populations, benefits, and stage of delivery system transformation, to enable meaningful comparison of performance across States.
(iii) The State receives CMS approval prior to implementing an alternative quality rating system or modifications to an approved alternative Medicaid managed care quality rating system.
(2) Prior to submitting a request for, or modification of, an alternative Medicaid managed care quality rating system to CMS, the State must -
(i) Obtain input from the State's Medical Care Advisory Committee established under § 431.12 of this chapter; and
(ii) Provide an opportunity for public comment of at least 30 days on the proposed alternative Medicaid managed care quality rating system or modification.
(3) In requesting CMS approval, the State must include the following:
(i) The alternative quality rating system framework, including the performance measures and methodology to be used in generating plan ratings; and,
(ii) Documentation of the public comment process specified in paragraphs (c)(2)(i) and (ii) of this section, including discussion of the issues raised by the Medical Care Advisory Committee and the public. The request must document any policy revisions or modifications made in response to the comments and rationale for comments not accepted; and,
(iii) Other information specified by CMS to demonstrate compliance with paragraph (c) of this section.
(4) The Secretary, after consulting with States and other stakeholders, shall issue guidance which describes the criteria and process for determining if an alternative QRS system is substantially comparable to the Medicaid managed care quality rating system in paragraph (b) of this section.
(d) Quality ratings. Each year, the State must collect data from each MCO, PIHP, and PAHP with which it contracts and issue an annual quality rating for each MCO, PIHP, and PAHP based on the data collected, using the Medicaid managed care quality rating system adopted under this section.
(e) Availability of information. The State must prominently display the quality rating given by the State to each MCO, PIHP, or PAHP under paragraph (d) of this section on the Web site required under § 438.10(c)(3) in a manner that complies with the standards in § 438.10(d).
[81 FR 27853, May 6, 2016, as amended at 85 FR 72841, Nov. 13, 2020]