Quality and Consumer Protection in Medicaid


As required by the Affordable Care Act, the Department of Health and Human Services (HHS) published a recommended core set of health quality measures for Medicaid-eligible adults in December 2014. In consultation with states, HHS is also required to develop a standardized format for reporting information based on these measures. They must also create procedures that encourage states to use and voluntarily report on these measures.

In addition, the Affordable Care Act authorized and funded demonstration projects that aim to improve the quality of Medicaid services, including:

  • a demonstration to evaluate integrated financing for care involving a hospital stay by studying the use of bundled payments for hospital and physician services under Medicaid;
  • a Medicaid Global Payment System demonstration conducted with the Center for Medicare & Medicaid Innovation—this demonstration will allow participating states to adjust their payment structure for safety-net hospitals from a fee-for-service model to a global capitated payment structure; and
  • a Medicaid Emergency Psychiatric demonstration, in which participating states will be required to pay certain institutions for services provided to Medicaid beneficiaries age 21–65 who need medical assistance to stabilize an emergency psychiatric condition.




Federal and state efforts to restructure Medicaid should ensure that:

  • long-term services and supports reflect the needs and preferences of beneficiaries and their families and provide a choice between home- and community-based support services and nursing facilities services;
  • quality protections are given the same priority as cost and access issues; and
  • consumers have a strong voice.

Fraud and abuse

In addressing fraud, waste, and abuse, federal and state governments should identify and implement strategies that do not threaten access to program benefits for people with low incomes and direct savings back into the program.

Disease management programs and Medicare Part D

Congress should require Medicaid and Medicare program administrators to collaborate to ensure that Medicaid disease management programs continue to function effectively for Medicaid beneficiaries receiving Medicare prescription drug coverage. Both programs should be required to evaluate their impact on health outcomes. They should also ensure the protection of beneficiaries’ privacy rights.