Protocol Changes

SUMMARY OF CHANGES TO THE 2022 EXTERNAL QUALITY REVIEW
PROTOCOLS
Changes to Title Page and Table of Contents

Updated release date on cover page
Added Protocol 4, Validation of Network Adequacy
Changes to Introduction

•

Added background on the November 2020 revisions to the 2016 final rule, including:
•

Required states to identify MCOs exempt from EQR annually on its website in the
same location where EQR technical reports are posted. State must include the
name(s) of the MCO(s) exempt from EQR, including the beginning date of the
current exemption period, or that no MCOs are exempt from EQR.

•

Clarified standards for the EQR compliance review activity in 42 CFR
438.358(b)(1)(iii) by referencing the full set of subpart B, C, and D standards that
comprise the compliance review. The rule made further modifications to the
standards subject to EQR in each of these subparts, and CMS encourages states and
EQROs to familiarize themselves with these changes.

•

Inserted several technical revisions to CHIP regulations that cross-reference Medicaid
EQR standards to align CHIP and Medicaid EQR standards, and those quality
standards relevant to EQR reporting requirements.

•

Updated text and citations based on 2016 Medicaid and CHIP managed care final rule.

•

Updated information on managed care quality tools and the EQR process.

•

Clarified circumstances for federal financial participation for EQR.

•

Noted that several protocols are organized around site visits by the EQRO; indicated that due
to changing practices related to the COVID-19 pandemic, site visits may be conducted onsite
or virtually to obtain the information specified in the protocols.

•

Updated guidance on report content and structure.

•

Updated tips for drafting compliant and effective EQR technical reports, tips for state review
of EQR technical reports, and tips for posting and submitting EQR technical reports.

1

Changes to Protocols

Protocol 1. Validation of Performance Improvement Projects
•

•

Clarified that the EQRO should determine the appropriateness of the PIP topic, including
how it was selected, input from enrollees or providers, and alignment with CMS-identified
priorities and the aims of the National Quality Strategy.
•

Added reference to the National Quality Strategy and CMS priorities and initiatives
when developing PIP study topics

•

Added suggestion that states review performance on child and adult Core Set
performance measures to identify opportunities to improve performance through a
managed care PIP

Indicated that due to changing practices related to the COVID-19 pandemic, site visits may
be conducted onsite or virtually to obtain the information specified in the protocol.

Protocol 2. Validation of Performance Measures
•

Indicated that due to changing practices related to the COVID-19 pandemic, site visits may
be conducted onsite or virtually to obtain the information specified in the protocol.

Protocol 3. Review and Compliance with Medicaid and CHIP Managed Care Regulations
•

•

Added three activities to the Compliance Review from the 2020 Final Rule:
•

Disenrollment Requirements and Limitations 438.56

•

Enrollee Rights Requirements 438.100

•

Emergency and Post-Stabilization Services 438.114

Indicated that due to changing practices related to the COVID-19 pandemic, site visits may
be conducted onsite or virtually to obtain the information specified in the protocol.

Protocol 4. Validation of Network Adequacy
•

Inserted new protocol for validation of network adequacy.

Protocol 5. Validation of Encounter Data Reported by the Medicaid and CHIP Managed
Care Plan
•

Clarified that before initiating Activity 1, EQROs should request all available encounter data
guidance from states, including encounter reporting requirements and standards, data
dictionary, edit checks, and other documents.

Protocol 6. Administration or Validation of Quality of Care Surveys
•

Updated Table 6.1, Examples of Validated Survey Instruments, including CAHPS
Behavioral Health Care Surveys and Long-terms Services and Supports Surveys
2

•

For Activity I.4. Develop the Sampling Plan, clarified the target number of completed
surveys and recommended initial sample sizes for the CAHPS® Medicaid Health Plan
Survey.

Protocol 8. Implementation of Additional Performance Improvement Projects
•

Indicated that PIPs can be conducted in conjunction with CMS and state quality
improvement priorities or to align with national quality improvement initiatives.

•

Clarified that these activities are eligible for enhanced Federal financial participation at a 75
percent rate under certain circumstances.

Appendices

Appendix A. Information Systems Capabilities Assessment (ISCA)
•

Indicated that in the event that onsite activities are not feasible due to the COVID-19
pandemic, site visits may be conducted virtually.

Appendix D. Glossary
•

Added terms from Protocol 4, Validation of Network Adequacy.

3