DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland   21244-1850 
 
 
 
CMCS Informational Bulletin  
 
DATE:  November 19, 2020 
 
FROM:  Anne Marie Costello, Acting Deputy Administrator and Director  
Center for Medicaid & CHIP Services  
 
SUBJECT:  2021 Updates to the Child and Adult Core Health Care Quality Measurement 
Sets  
 
This Center for Medicaid & CHIP Services (CMCS) Informational Bulletin describes the 2021 
updates to the Core Set of childrens health care quality measures for Medicaid and the 
Childrens Health Insurance Program (CHIP) (the Child Core Set) and the Core Set of health 
care quality measures for adults enrolled in Medicaid (the Adult Core Set).  
 
Background  
 
CMCS has worked with stakeholders to identify two Core Sets of health care quality measures 
that can be used to assess the quality of health care provided to children and adults enrolled in 
Medicaid and CHIP (see https://www.medicaid.gov/medicaid/quality-of-care/performance-
measurement/index.html). The Core Sets are tools states can use to monitor and improve the 
quality of health care provided to Medicaid and CHIP beneficiaries. Core Set reporting is also 
important because the State Health System Performance pillar of the Medicaid and CHIP (MAC) 
Scorecard uses Core Set data for several measures.1 
 
CMCS released the initial Child Core Set in 2010 and the initial Adult Core Set in January 2012.  
Currently, by statute, state reporting on these measure sets is voluntary.2,3 Since the inception of 
the Child and Adult Core Sets, CMCS has collaborated with state Medicaid and CHIP agencies 
to voluntarily collect, report, and use the core set measures to drive quality improvement. Since 
the Child and Adult Core Sets were established, states have made significant progress in 
reporting.4  
 
All states and the District of Columbia (DC) voluntarily reported at least one Child Core Set 
measure for Federal Fiscal Year (FFY) 2019, with 49 states reporting at least half (13) of the 
measures. States reported a median of 20 Child Core Set measures for FFY 2019, which was an 
increase from 18 for FFY 2017 and FFY 2018. Thirty-one states reported more Child Core Set 
measures for FFY 2019 than for FFY 2018.  
 
 
1 https://www.medicaid.gov/state-overviews/scorecard/index.html  
2 https://www.ssa.gov/OP_Home/ssact/title11/1139A.htm. 
3 https://www.ssa.gov/OP_Home/ssact/title11/1139B.htm.  
4 Core Set History Table: https://www.medicaid.gov/medicaid/quality-of-care/downloads/core-set-history-table.pdf   CMCS Informational Bulletin  Page 2 
 
The number of states reporting Adult Core Set measures has increased steadily from 30 states for 
FFY 2013 to 46 states for FFY 2019. The median number of Adult Core Set measures reported 
by states is 22.5 measures for FFY 2019, up from 20 measures reported for FFY 2018 and 17 
measures for FFY 2017. Forty states reported at least half (16) of the Adult Core Set measures 
for FFY 2019. In addition, 36 states reported more Adult Core Set measures for FFY 2019 than 
for FFY 2018.  
 
Reporting of the Child Core Set and the Behavioral Health measures on the Adult Core Set will 
become mandatory starting in FFY 2024.  Section 50102(b) of the Bipartisan Budget Act of 2018 
made state reporting of the Child Core Set mandatory starting in FFY 2024 while Section 5001 
of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for 
Patients and Communities Act (SUPPORT Act) 2018 made state reporting of the Behavioral 
Health Core Set for adults mandatory starting in FFY 2024. 5, 6 CMCS will provide further 
guidance to states regarding mandatory Core Set reporting in future years.  
 
Part of implementing an effective quality measures reporting program is to periodically reassess 
the measures that comprise it since many factors, such as changes in clinical guidelines and 
experiences with reporting and performance rates, may warrant modifying the measure set. 
Section 1139A of the Social Security Act, as amended by Section 401(a) of the Childrens 
Health Insurance Reauthorization Act (CHIPRA) of 2009, provides that, beginning annually in 
January 2013, the Secretary shall publish recommended changes to the core measures.i Section 
1139B of the Social Security Act, as amended by Section 2701 of the Affordable Care Act, 
provides that the Secretary shall issue updates to the Adult Core Set beginning in January 2014 
and annually thereafter.ii In fulfilling these statutory requirements, CMCS works with other 
federal partners to promote quality measurement alignment across programs in order to reduce 
burden and help to drive quality improvement across payers and programs.  
 
For the 2021 updates to the Child and Adult Core Sets, CMCS contracted with Mathematica to 
convene the 2021 Child and Adult Core Set Annual Review Stakeholder Workgroup 
(Workgroup) to identify ways to improve the Core Sets.7 The Workgroup included 28 members 
representing a diverse set of stakeholders, including state Medicaid and CHIP agency 
representatives, health care providers, health plans, patient advocates, and federal partners who 
review measures for potential use in federal public reporting. CMCS also obtained additional 
input from state Medicaid agencies through the Quality Technical Advisory Group (QTAG), 
internal Center for Medicare & Medicaid Services (CMS) stakeholder meetings, and interagency 
federal partners to ensure that the Core Set measures are evidence-based and promote measure 
alignment within CMS and across the federal government.8  
 
Additional information about the Child and Adult Core Set Annual Review process that occurred 
in 2020 and the recommendations to CMCS can be found at: 
 
5 Advancing Chronic Care, Extenders and Social Services (ACCESS) Act (P.L. 115-123 Sec. 50102) 
https://www.congress.gov/115/bills/hr1892/BILLS-115hr1892enr.xml  
6 The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and 
Communities Act (SUPPORT for Patients and Communities Act) https://www.congress.gov/115/bills/hr6/BILLS-
115hr6enr.pdf 
7 https://www.mathematica-mpr.com/features/maccoresetreview  
8 CMS Annual Review and Selection Process: https://www.medicaid.gov/medicaid/quality-of-
care/downloads/annual-core-set-review.pdf   CMCS Informational Bulletin  Page 3 
 
https://www.medicaid.gov/medicaid/quality-of-care/performance-measurement/child-core-
set/index.html. Based on the input received through this Annual Review process, CMCS will be 
making the following updates to the 2021 Core Sets.  
 
2021 Child Core Set Updates   
 
CMCS will retire one measure:  
  Dental Sealants for 6-9 Year-Old Children at Elevated Caries Risk (SEAL-CH) 
(NQF#2508  no longer endorsed) because this measure is being retired by the measure 
steward.9 
 
CMCS will add one new measure:  
  Sealant Receipt on Permanent 1st Molars.10  This measure provides data on the percentage 
of children who have ever received sealants on permanent first molar teeth by their 10th 
birthdate.   
 
The Sealant Receipt on Permanent 1st Molars measure will replace the SEAL-CH measure, 
which is being retired by the measure steward. This new measure will help states monitor 
appropriate preventive oral health care for childrens because it promotes sealing all molars by 
age 10 rather than evaluating sealant placement only during the measurement year. 
 
CMS Calculation on Behalf of States for Two Measures: 
  Live Births Weighing Less Than 2,500 Grams  
  Cesarean Delivery  
 
CMCS has been working to identify ways to reduce state burden and streamline Core Set 
reporting for states and to improve the completeness, transparency, and comparability of data 
reported across states.11 To that end, in 2020 CMCS completed a state pilot which leveraged 
CDC data calculated at the state-level for two measures on Child Core Set: Live Births Weighing 
Less Than 2,500 Grams (LBW-CH) and PC-02: Cesarean Birth (PC02-CH). Based on the 
success of this pilot, CMS will be calculating the LBW-CH and Cesarean Delivery on behalf of 
all states in 2021. 
 
LBW-CH 
Due to the challenges of accessing and using vital records data, state participation in calculating 
and reporting LBW-CH has remained relatively low, with around half of the states reporting 
each year. This relatively low number of states reporting has implications for public reporting 
and limits the feasibility of using the measure to assess performance across states and over time. 
As a result of this pilot, CMCS was able to publicly report the LBW-CH measure for all states 
for FFY 2019 without adding any additional burden on states by using a combination of state 
reported rates and National Vital Statistics System Natality data obtained through Centers for 
Disease Control and Prevention (CDC) Wide-ranging ONline Data for Epidemiologic Research 
 
9 Measure Steward: Dental Quality Alliance (American Dental Association), NQF#2508 
10 Measure Steward: American Dental Association (ADA)/Dental Quality Alliance (DQA)  
11 The term states includes the 50 states and the District of Columbia.  CMCS Informational Bulletin  Page 4 
 
(CDC WONDER) rates.12, 13 For FFY 2020, states will have the option of reporting the LBW-
CH measure or having CMS calculate their rates. CMCS will start calculating the LBW-CH 
measure for all states for FFY 2021 reporting.  
 
Cesarean Delivery  
The most severe complications of pregnancy, generally referred to as severe maternal morbidity, 
affect more than 50,000 women in the United States every year.14 Based on recent trends, this 
burden has been steadily increasing. One factor associated with rising maternal morbidity is the 
increased use of cesarean sections. Cesarean section for women with low-risk pregnancies is an 
overused procedure that has not led to better outcomes for infants or women.15,16 As such for 
FFY 2021, CMCS is also updating the existing Cesarean Birth measure from the current PC-02: 
Cesarean Birth (PC02-CH) to the CDCs Low-Risk Cesarean Delivery measure. The current 
measure is calculated using hybrid method (requiring chart review) and has never been publicly 
reported by CMS as we have not met the threshold of having 25 or more states reporting. Of the 
16 states that reported PC-02 in FFY 2019, 60 percent used vital records (equivalent to the CDC 
Low-Risk Cesarean Delivery Measure) and did not adhering to the technical specifications for 
PC-02. The updated cesarean delivery measure will also be calculated on behalf of states using 
data submitted by states to National Vital Statistics System Natality data obtained through CDC 
WONDER starting in FFY 2021. Updating this measure will allow CMS to calculate data for all 
states and enable CMS to publicly report a cesarean birth measure for the first time. 
 
2021 Adult Core Set Updates 
  
CMCS will retire one measure.  
  Adult Body Mass Index Assessment (ABA-AD) because this measure is being retired by 
the measure steward and up-to-date technical specifications required for reporting the 
measure are no longer available.17 
 
  Obesity is a major and growing public health problem in the U.S. with the prevalence of 
obesity in adults over 42% in 2017-2018.18 Adults with obesity are at higher risk for 
many chronic conditions including heart disease, stroke, type 2 diabetes and certain types 
of cancer that are some of the leading causes of preventable and costly premature death. 
The estimated annual medical cost of adult obesity in the United States was $147 billion 
in 2008. CMS recognizes that the removal of the ABA-AD measure leaves a gap in the 
Adult Core Set for a high-priority health area for Medicaid and CHIP. CMS will include 
obesity assessment and treatment in the list of identified measure gaps for consideration 
by the 2022 Workgroup. 
 
 
12 This data resource is publicly available at: https://wonder.cdc.gov/natality-expanded-current.html. 
13 FFY 2019 Child Core Set Chart Pack available at: https://www.medicaid.gov/medicaid/quality-of-
care/downloads/2020-child-chart-pack.pdf  
14 https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html  
15 Goer, H., A. Romano, and C. Sakala. Vaginal or Cesarean Birth: What Is at Stake for Women and Babies? New 
York: Childbirth Connections, 2012. 
16 Gregory, K.D., S. Jackson, L.M. Korst, and M. Friedman. Cesarean versus Vaginal Delivery: Whose Risks? 
Whose Benefits? American Journal of Perinatology, vol. 29, 2011, pp. 718. 
17 Measure Steward: National Committee for Quality Assurance 
18 https://www.cdc.gov/obesity/data/adult.html   CMCS Informational Bulletin  Page 5 
 
CMCS will not add any new measures. 
  The 2021 Annual Core Set Workgroup recommended the addition of two measures to the 
Core Set that rely on a proprietary electronic clinical data systems (ECDS) reporting 
method. While CMCS may consider adding them to the Adult Core Set in the future, we 
are deferring the decision to include these measures in the 2021 Adult Core Set in order to 
determine how the proprietary nature of this information impacts the feasibility and 
viability of including these measures.  
 
Effective Date of Revisions to the Core Sets 
 
The 2021 updates to the Core Sets will take effect in the FFY 2021 reporting cycle, which will 
begin in the early fall of 2021. To support states, CMCS will release updated technical 
specifications for both Core Sets in spring 2021 and make them available at: 
https://www.medicaid.gov/medicaid/quality-of-care/index.html.  
 
States with questions or that need further assistance with reporting and quality improvement 
regarding the Child and Adult Core Sets can submit questions or requests to: 
MACQualityTA@cms.hhs.gov.  
 
If you have questions about this bulletin, please contact Karen Matsuoka, PhD, at 
karen.matsuoka@cms.hhs.gov, or call (410)786-9726. 
 
 
i The first update was issued via a State Health Official Letter 2013 Childrens Core Set of Health Care Quality 
Measures, SHO #13-002. http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SHO-13-002.pdf . The 
2014 update was issued via a CMCS Informational Bulletin 2014 Updates to the Child and Adult Core Health Care 
Quality Measurement Sets http://medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-12-19-13.pdf as was the 
2015 Updates to the Child and Adult Health Care Quality Measurements Sets  http://www.medicaid.gov/federal-
policy-guidance/downloads/cib-12-30-2014.pdf,   2016 Updates to the Child and Adult Core Health Care Quality 
Measurement Sets https://www.medicaid.gov/federal-policy-guidance/downloads/cib-12-11-15.pdf,, 2017 
Updates to the Child and Adult Core Health Care Quality Measures Sets https://www.medicaid.gov/federal-policy-
guidance/downloads/cib120516.pdf and the 2018 Updates to the Child and Adult Core Health Care Quality 
Measurement Sets https://www.medicaid.gov/federal-policy-guidance/downloads/cib111417.pdf. The 2019 update 
was issued via a CMCS Informational Bulletin 2019 Updates to the Child and Adult Core Health Care Quality 
Measurement Sets. https://www.medicaid.gov/federal-policy-guidance/downloads/cib112018.pdf. The 2020 update 
was issued via a CMCS Informational Bulletin 2020 Updates to the Child and Adult Core Health Care Quality 
Measurement Sets. https://www.medicaid.gov/sites/default/files/Federal-Policy-
Guidance/Downloads/cib111919.pdf 
ii The first update was issued via a CMCS Informational Bulletin 2014 Updates to the Child and Adult Core Health 
Care Quality Measurement Sets. http://medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-12-19-13.pdf . The 
2015 update was issued via a CMCS Informational Bulletin 2015 Updates to the Child and Adult Core Health Care 
Quality Measurement Sets.http://www.medicaid.gov/federal-policy-guidance/downloads/cib-12-30-2014.pdf. The 
2016 update was issued via a CMCS Information Bulletin 2016 Updates to the Child and Adult Core Health Care 
Quality Measurement Sets. https://www.medicaid.gov/federal-policy-guidance/downloads/cib-12-11-15.pdf. The 
2017 update was issued via a CMCS Information Bulletin 2017 Updates to the Child and Adult Core Health Care 
Quality Measurement Sets. https://www.medicaid.gov/federal-policy-guidance/downloads/cib120516.pdf. The 
2018 update was issued via a CMCS Information Bulletin 2018 Updates to the Child and Adult Core Health Care 
Quality Measurement Sets. https://www.medicaid.gov/federal-policy-guidance/downloads/cib111417.pdf.. The 
2019 update was issued via a CMCS Informational Bulletin 2019 Updates to the Child and Adult Core Health Care 
Quality Measurement Sets. https://www.medicaid.gov/federal-policy-guidance/downloads/cib112018.pdf . The 
2020 update was issued via a CMCS Informational Bulletin 2020 Updates to the Child and Adult Core Health Care 
Quality Measurement Sets. https://www.medicaid.gov/sites/default/files/Federal-Policy-
Guidance/Downloads/cib111919.pdf