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PA Bulletin, Doc. No. 23-1296



Managed Care Quality Strategy for the Commonwealth

[53 Pa.B. 6011]
[Saturday, September 23, 2023]

 The Department of Human Services (Department) is making available for public review and comment the Medical Assistance (MA) and Children's Health Insurance Program (CHIP) Managed Care Quality Strategy for the Commonwealth.


 The Centers for Medicare & Medicaid Services (CMS) requires states to draft and implement a written quality strategy for assessing and improving the quality of health care and services furnished by managed care organizations (MCO) that have an agreement with the Department (see 42 CFR 438.340(a) and 457.1240(e) (relating to managed care State quality strategy; and quality measurement and improvement)). As a result, the Department has developed the MA and CHIP Managed Care Quality Strategy (MCQS), which discusses the various initiatives the Department has implemented to improve the quality of care for individuals receiving services through its managed care programs. The MCQS for the Commonwealth is not intended to comprehensively describe all the activities the Department undertakes to assure the quality of care rendered to individuals who are receiving services through its managed care programs.

 The MCQS is an updated version of the previous quality strategy submitted to CMS in December 2020, and describes initiatives, strategies and processes to improve, evaluate and monitor member access to high quality, timely care through the Medicaid and CHIP managed care delivery system. The novel coronavirus (COVID-19) pandemic and ongoing post-pandemic delivery system pressures have affected and changed how the MCOs deliver care. As a result of these and other changes in how the MCOs deliver care, the Department has refocused and revised its quality goals, objectives and strategies.


 As the delivery system landscape continues to respond and evolve, this MCQS provides a roadmap for the Department to support improved quality for all MA managed care and CHIP members. Across the Department and as detailed throughout the MCQS, the Department strives to improve the health of members in each of its managed care programs through the implementation of strategic initiatives that support its three main goals:

 1. Increase access to health care services.

 2. Improve the health outcomes of populations.

 3. Promote efficient and effective use of taxpayer resources.

 The MCQS takes a broad view of opportunities to improve member health by focusing on domains of increasing value, supporting health equity and addressing Social Determinates of Health (SDOH) in its managed care programs using the MCO agreements and programmatic initiatives. The Department is working on a Value-Based purchasing strategy to align the program offices. The Department is also using several CMS-approved State directed payments to support the goals of increasing access, improving health outcomes and promoting the effective use of resources. At the same time the Commonwealth, MCOs, providers and members are all emerging from the COVID-19 pandemic with new approaches and opportunities, as well as facing ongoing challenges, including workforce and supply chain issues.

 The Office of Medical Assistance Programs' (OMAP) key initiatives continue to be centered around value-based purchasing and requiring the MCOs to incorporate the use of community-based organizations in their value-based purchasing strategies to address SDOH domains. OMAP is also encouraging expanded use of Opioid Use Disorder Centers of Excellence as well as using pay-for-performance to improve the health for the population in HealthChoices.

 The Office of Mental Health and Substance Abuse Services' (OMHSAS) key quality improvement initiatives include value-based purchasing arrangements, like OMAP, that incorporate the use of community-based organizations to address SDOH domains. OMHSAS continues to use Integrated Community Wellness Centers to increase SDOH screenings and promote integrated physical and behavioral health care for patients, as well as pay-for-performance to improve performance and outcomes.

 The Office of Long-Term Living quality improvement initiatives included requiring value-based purchasing models for long-term services and supports, requiring a pay-for-performance program to improve the quality of nursing facility services as well as Performance Improvement Program for performance around assessments, care plans reassessments and planning after discharge, Consumer Assessment of Healthcare Providers and Systems health plan satisfaction and meeting nursing home transition benchmarks.

 The CHIP key quality improvement initiatives include developing a pay-for-performance incentive for meeting or exceeding benchmarks on health care performance measures.

 Finally, key quality improvement initiatives for the Adult Community Autism Program include decreasing social isolation among members.

 The MCQS for the Commonwealth can be viewed at

Public Comment

 Interested persons are invited to submit comments regarding the MCQS for the Commonwealth to the Department at Comments received within 30 days will be reviewed and considered before the MCQS is submitted to CMS for review.

 Persons with a disability who require an auxiliary aid or service may submit comments using the Pennsylvania Hamilton Relay Service at (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).


Fiscal Note: 14-NOT-1591. No fiscal impact; recommends adoption.

[Pa.B. Doc. No. 23-1296. Filed for public inspection September 22, 2023, 9:00 a.m.]

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