Medicaid and Children’s Health Insurance Program (CHIP) Quality and Managed Care

Oct 31st, 2024

Broadly speaking, managed care is a healthcare delivery system designed to control costs, improve quality, and manage how services are provided to enrollees. It integrates healthcare providers, hospitals, and insurers to coordinate patient care in a cost-effective way. Managed care often emphasizes preventive care, streamlined service delivery, and coordinated treatment plans.

Federal regulations require Medicaid and CHIP to provide “quality assessment and performance improvement requirements for states contracting with any of the four types of managed care entities: managed care organizations (MCOs), prepaid inpatient health plans (PIHPs), prepaid ambulatory health plans (PAHPs) and/or primary care case management entities (PCCM-Es). These requirements include the development and drafting of a managed care state quality strategy and the performance of an external quality review (EQR).”

It should be noted that in 2024, CMS published a Final Rule regarding the improvement of quality and care for Medicaid and CHIP managed care enrollees.

Resource: CLICK HERE to go to the Medicaid.gov page regarding these programs.

Resource: CLICK HERE to read about Managed Care for other types of health insurance programs.