This document establishes requirements for mandatory annual State reporting of the Core Set of Children's Health Care Quality Measures for Medicaid and the Children's Health Insurance Program (CHIP), the behavioral health measures on the Core Set of Adult Health Care Quality Measures for Medicaid, and the Core Sets of Health Home Quality Measures for Medicaid.
These regulations are effective January 1, 2024. The initial round (2024) of Core Sets reporting must be submitted and certified by States by December 31, 2024.
Given the significant role that Medicaid and CHIP play in America's health care system, this rule requires—for the first time—States, the District of Columbia (DC) and certain territories to mandatorily report on measures of the quality of health care provided to Medicaid and CHIP beneficiaries.
The Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) (Pub. L. 111–3, enacted February 4, 2009), established Federal requirements regarding voluntary quality measurement to assess the care delivered to beneficiaries in both Medicaid and CHIP.
Section 401 of CHIPRA added new section 1139A to the Act, which required development of a Core Set of Children's Health Care Quality Measures for Medicaid and CHIP (Child Core Set), which could be voluntarily reported by States, and directed the Secretary to publish for general comment an initial recommended core set of child health quality measures based on existing quality of care measures for children not later than January 1, 2010. To assist the Federal Government in establishing priorities for the development and advancement of the Child Core Set, section 1139A of the Act also directed the Secretary to consult with a variety of specific interested parties in developing the initial measures and to work with interested parties annually to update the measures. CMS released the initial Child Core Set, consisting of 24 measures, in 2009, with voluntary State-level reporting beginning in Federal Fiscal Year (FFY) 2010.
Section 2701 of the Patient Protection and Affordable Care Act of 2010 (Pub. L. 111–148, enacted March 23, 2010) as amended and revised by the Healthcare and Education Reconciliation Act (Pub. L. 111–152, enacted March 30, 2010), referred to collectively as the Affordable Care Act (ACA), added a new section 1139B of the Act, extending the measurement of health care quality to Medicaid-eligible adults. While not required by statute, including separate CHIP enrollees in reporting on the Adult Core Set measures is encouraged; therefore, both Medicaid and CHIP populations are referenced in descriptions of the Adult Core Set (see additional discussion in section II.E. of the proposed rule). CMS issued the initial Adult Core Set consisting of 26 quality measures in 2012, and voluntary reporting of these measures began in FFY 2013.
This rule implements mandatory annual reporting of the Child Core Set and the behavioral health measures on the Adult Core Set using a standardized format, as required by section 50102 of the Bipartisan Budget Act of 2018 (Pub. L. 115–123, enacted February 9, 2018) and section 5001 of the Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act), (Pub. L. 115–271, enacted October 24, 2018).
In addition to requiring reporting on the Child Core Set and specified behavioral health measures on the Adult Core Set, this rule establishes reporting requirements for States that elect to implement one or both of the optional Medicaid health home benefits under sections 1945 or 1945A of the Act. . . .
Implementation of the Child and Adult Core Sets, and the sections 1945 and 1945A Health Home Core Sets, represents a major step in the development of a national, evidence-based system for measuring and improving the quality of care delivered to Medicaid and CHIP beneficiaries. The Core Sets include measures that, taken together, may be used to estimate the overall national quality of health care provided to beneficiaries. The ability to assess the quality of and access to care furnished by State Medicaid and CHIP programs is critical given that more than 93 million Americans receive coverage in Medicaid and CHIP, and the annual expenditures for the programs are over $600 billion. . . .
We received 93 public comments from individuals and organizations, including, but not limited to, State government agencies, non-profit health care organizations, advocacy groups, associations, law firms, managed care organizations, academic groups, tribal organizations, and private citizens. We thank the commenters for their consideration of the proposed requirements for mandatory reporting and appreciate the submission of all of the comments received. In general, commenters supported the proposed rule. In this section, arranged by subject area, we summarize the proposed provisions, the public comments received, and our responses. For a complete and full description of the proposed mandatory reporting requirements, see the 2022 proposed rule, “Medicaid Program and CHIP; Mandatory Medicaid and Children's Health Insurance Program (CHIP) Core Set Reporting” (87 FR 51303, August 22, 2022) hereafter referred to as the “proposed rule”. . . .
For the reasons set forth in the preamble, the Centers for Medicare & Medicaid Services amends 42 CFR chapter IV as set forth below: . . .
Adult and Child Health Care Quality Measures: https://www.medicaid.gov/medicaid/quality-of-care/performance-measurement/adult-and-child-health-care-quality-measures/index.html
Health Home Quality Reporting: https://www.medicaid.gov/resources-for-states/medicaid-state-technical-assistance/health-home-information-resource-center/health-home-quality-reporting/index.html