Managed Care Quality Strategy

The Centers for Medicare & Medicaid Services (CMS), per regulation 42 CFR § 438.340(a) and 42 CFR 457.1240(e), requires states to have a quality strategy for their managed care programs. The intent of the regulation is to ensure members enrolled in Medicaid managed care programs have access to high quality health care services provided by the state's managed care organizations (MCOs) or entities.

The Managed Care Quality Strategy (MCQS) for Pennsylvania's Medical Assistance (MA) and Children's Health Insurance Program (CHIP), describes the managed care programs and structures, populations served, services offered, goals and objectives, quality-related initiatives, and strategies, as well as administrative processes used to assure and monitor quality.

The draft MCQS was published for public comment in the PA Bulletin on September 23, 2023.  The summary of public comments received and the Department of Human Service's response is available here.

• Final Medical Assistance and Children's Health Insurance Program Managed Care Quality Strategy - Sent to CMS December 22, 2023.  
  

Attachments referenced in the Medical Assistance and Children’s Health Insurance Program Managed Care Quality Strategy:

External Quality Review (EQR) Reports

• EQR Statewide Annual Technical Reports
• PH HealthChoices EQR reports
• BH HealthChoices EQR reports
• CHC HealthChoices EQR reports
  

Managed Care Program Annual Report (MCPAR)

CMS regulations at 42 CFR § 438.66(e) require states to submit a Managed Care Program Annual Report (MCPAR). Under the regulation, each state must submit to CMS, no later than 180 days after each contract year, a report on each managed care program administered by the state.

The annual report is part of CMS's overall strategy to improve access to services by supporting Federal and state access monitoring for Medicaid beneficiaries within a managed care delivery system.

The MCPAR report provides information in the following categories:

1. Program enrollment and service area expansions
2. Financial performance
3. Encounter data reporting
4. Grievances, appeals, and state fair hearings
5. Availability, accessibility, and network adequacy
6. Delegated entities
7. Quality and performance measures
8. Sanctions and corrective action plans
9. Beneficiary support system (BSS)
10. Program integrity

Each of the above categories have data indicators (data elements) that are organized by and will be reported at state, program, or plan levels. The blank excel workbook is available on Medicaid.gov and provides the exact indicators reported along with the instructions on how to report.  Each MCPAR report for the managed care program is provided below.  Based on questions received from stakeholders, the Department has prepared and posted a MCPAR Interpretation Document  which provides supplemental information to help interpret the data presented in each report submission. 

Network Adequacy and Assurance Report

States must provide documentation regarding the managed care plan's compliance with the requirements for availability and accessibility of services (including the adequacy of the provider network). 

Ownership and Controlling Interest Report

States are required to report individuals within managed care organizations that have ownership or a controlling interest in the organization. The following report includes names the individuals and entities with more than 5% controlling interest.

The Pennsylvania Department of Human Services (DHS or Department) MA and CHIP programs are administered through the following main programs: