60278 Federal Register / Vol. 88, No. 168 / Thursday, August 31, 2023 / Rules and Regulations 

1February 2023 Medicaid and CHIP Enrollment 

data: https://www.medicaid.gov/medicaid/nationalmedicaid-chip-program-information/downloads/ 

april-2023-medicaid-chip-enrollment-trendsnapshot.pdf. 

2 Initial Child Core Set: https://

downloads.cms.gov/cmsgov/archived-downloads/ 

SMDL/downloads/SHO11001.pdf. 

3 Initial Adult Core Set: https://

www.medicaid.gov/sites/default/files/FederalPolicy-Guidance/Downloads/cib-01-04-12.pdf. 

4Public Law 116–16, enacted April 18, 2019. 

5On November 16, 2010, we issued State 

Medicaid Director (SMD) letter #10–024, which 

provided States with guidance on implementing the 

section 1945 health home benefit. See https://

www.medicaid.gov/federal-policy-guidance/ 

downloads/SMD10024.pdf. 

6On August 1, 2022, we issued SMD letter #22– 

004, which provides States with guidance on 

implementing the section 1945A health home 

benefit. See https://www.medicaid.gov/federalpolicy-guidance/downloads/smd22004.pdf. 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

42 CFR Parts 433, 437, and 457 

[CMS–2440–F] 

RIN 0938–AU52 

Medicaid Program and CHIP; 

Mandatory Medicaid and Children’s 

Health Insurance Program (CHIP) Core 

Set Reporting 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: Final rule. 

SUMMARY: This document establishes 

requirements for mandatory annual 

State reporting of the Core Set of 

Children’s Health Care Quality 

Measures for Medicaid and the 

Children’s Health Insurance Program 

(CHIP), the behavioral health measures 

on the Core Set of Adult Health Care 

Quality Measures for Medicaid, and the 

Core Sets of Health Home Quality 

Measures for Medicaid. 

DATES: 

Effective Date: These regulations are 

effective January 1, 2024. 

Applicability Date: The initial round 

(2024) of Core Sets reporting must be 

submitted and certified by States by 

December 31, 2024. 

FOR FURTHER INFORMATION CONTACT: 

Virginia Raney, (410) 786–6117, 

Children and Adults Health Care 

Quality Measurement. 

Sara Rhoades, (410) 786–4484, Health 

Home Quality Measurement. 

Candace Anderson, (410) 786–1553, 

Health Care Quality Measurement for 

Dually Eligible (Medicaid and Medicare) 

Beneficiaries. 

SUPPLEMENTARY INFORMATION: 

I. Background 

A. Quality Measurement in Medicaid 

and CHIP 

Medicaid was enacted in 1965 as Title 

XIX of the Social Security Act (the Act) 

to provide health coverage for certain 

groups of people with lower incomes. In 

1997, upon enactment of the Balanced 

Budget Act of 1997 (Pub. L. 105–33, 

enacted August 5, 1997), the Children’s 

Health Insurance Program (CHIP) was 

enacted as Title XXI of the Act. 

Combined, as of April 2023, the two 

programs provided health coverage to 

more than 94 million people, nearly half 

of whom are children (more than 42 

million).1

Given the significant role that 

Medicaid and CHIP play in America’s 

health care system, this rule requires— 

for the first time—States, the District of 

Columbia (DC) and certain territories to 

mandatorily report on measures of the 

quality of health care provided to 

Medicaid and CHIP beneficiaries. 

The Children’s Health Insurance 

Program Reauthorization Act of 2009 

(CHIPRA) (Pub. L. 111–3, enacted 

February 4, 2009), established Federal 

requirements regarding voluntary 

quality measurement to assess the care 

delivered to beneficiaries in both 

Medicaid and CHIP. 

Section 401 of CHIPRA added new 

section 1139A to the Act, which 

required development of a Core Set of 

Children’s Health Care Quality 

Measures for Medicaid and CHIP (Child 

Core Set), which could be voluntarily 

reported by States, and directed the 

Secretary to publish for general 

comment an initial recommended core 

set of child health quality measures 

based on existing quality of care 

measures for children not later than 

January 1, 2010. To assist the Federal 

Government in establishing priorities 

for the development and advancement 

of the Child Core Set, section 1139A of 

the Act also directed the Secretary to 

consult with a variety of specific 

interested parties in developing the 

initial measures and to work with 

interested parties annually to update the 

measures. CMS released the initial 

Child Core Set, consisting of 24 

measures, in 2009, with voluntary Statelevel reporting beginning in Federal 

Fiscal Year (FFY) 2010.2

Section 2701 of the Patient Protection 

and Affordable Care Act of 2010 (Pub. 

L. 111–148, enacted March 23, 2010) as 

amended and revised by the Healthcare 

and Education Reconciliation Act (Pub. 

L. 111–152, enacted March 30, 2010), 

referred to collectively as the Affordable 

Care Act (ACA), added a new section 

1139B of the Act, extending the 

measurement of health care quality to 

Medicaid-eligible adults. While not 

required by statute, including separate 

CHIP enrollees in reporting on the Adult 

Core Set measures is encouraged; 

therefore, both Medicaid and CHIP 

populations are referenced in 

descriptions of the Adult Core Set (see 

additional discussion in section II.E. of 

the proposed rule). CMS issued the 

initial Adult Core Set consisting of 26 

quality measures in 2012, and voluntary 

reporting of these measures began in 

FFY 2013.3

This rule implements mandatory 

annual reporting of the Child Core Set 

and the behavioral health measures on 

the Adult Core Set using a standardized 

format, as required by section 50102 of 

the Bipartisan Budget Act of 2018 (Pub. 

L. 115–123, enacted February 9, 2018) 

and section 5001 of the Substance Use– 

Disorder Prevention that Promotes 

Opioid Recovery and Treatment for 

Patients and Communities Act 

(SUPPORT Act), (Pub. L. 115–271, 

enacted October 24, 2018). 

B. Quality Measurement of the Medicaid 

Health Home Benefits Under Sections 

1945 and 1945A of the Act 

In addition to requiring reporting on 

the Child Core Set and specified 

behavioral health measures on the Adult 

Core Set, this rule establishes reporting 

requirements for States that elect to 

implement one or both of the optional 

Medicaid health home benefits under 

sections 1945 or 1945A of the Act. 

Section 1945 of the Act (added by 

section 2703 of the ACA and later 

amended by section 1006(a) of the 

SUPPORT Act) and section 1945A of the 

Act (added by section 3 of the Medicaid 

Services Investment and Accountability 

Act of 2019) 4 give States options for 

implementing two different Medicaid 

health home State plan benefits. The 

section 1945 health home benefit is for 

Medicaid-eligible individuals who have 

(1) two or more chronic conditions, as 

defined in section 1945(h)(2) of the Act, 

(2) at least one chronic condition, as 

defined in section 1945(h)(2) of the Act, 

and who are at risk for a second, or (3) 

at least one serious and persistent 

mental health condition.5 The section 

1945A health home benefit is for 

Medicaid-eligible children with 

medically complex conditions, as 

defined in section 1945A(i)(1) of the 

Act.6 States were able to begin covering 

the section 1945 health home benefit on 


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Federal Register / Vol. 88, No. 168 / Thursday, August 31, 2023 / Rules and Regulations 60279 

7Center for Medicaid and CHIP Services (CMCS) 

Informational Bulletin, ‘‘New Reporting Measures 

for Substance Use Disorder (SUD)-focused Health 

Homes,’’ November 27, 2019, at https://

www.medicaid.gov/federal-policy-guidance/ 

downloads/cib112719.pdf. 

8Under section 1945(c)(1) of the Act, State 

payments for section 1945 health home services 

provided during the first 8 fiscal year quarters that 

a section 1945 SPA is in effect are Federally 

matched at a 90 percent Federal Medical Assistance 

Percentage (FMAP). Section 1006(a) of the 

SUPPORT Act, ‘‘Extension of Enhanced FMAP for 

Certain Health Homes for Individuals with 

Substance Use Disorders,’’ amended section 1945(c) 

of the Act to permit an extension of this period of 

90 percent FMAP for certain section 1945 health 

home SPAs for individuals with substance use 

disorders (SUD) for two additional quarters (such 

that there could be a total of 10 quarters for the 90 

percent FMAP). CMS provided guidance to States 

about this amendment to section 1945 in a May 7, 

2019, Center for Medicaid and CHIP Services 

(CMCS) Informational Bulletin (CIB), ‘‘Guidance for 

States on the Availability of an Extension of the 

Enhanced Federal Medical Assistance Percentage 

(FMAP) Period for Certain Medicaid Health Homes 

for Individuals with Substance Use Disorders 

(SUD),’’ https://www.medicaid.gov/federal-policyguidance/downloads/cib050719.pdf. We released 

further guidance on the section 1945(c)(4)(B) 

reporting requirements in a CIB entitled ‘‘New 

Reporting Measures for Substance Use Disorder 

(SUD)-Focused Health Homes’’ on November 27, 

2019, https://www.medicaid.gov/federal-policyguidance/downloads/cib112719.pdf. 

9SUD Health Home reporting CIB at https://

www.medicaid.gov/Federal-policy-guidance/ 

downloads/cib112719.pdf. 

10 Initial section 1945 Health Home Core Set: 

https://www.medicaid.gov/federal-policy-guidance/ 

downloads/smd-13-001.pdf. 

11https://www.medicaid.gov/federal-policyguidance/downloads/cib112719.pdf. 

January 1, 2011. States were able to 

begin covering the section 1945A health 

home benefit on October 1, 2022. 

As a condition for receiving payment 

for section 1945 health home services, 

section 1945(g) of the Act requires 

section 1945 health home providers to 

report to the State, in accordance with 

such requirements as the Secretary shall 

specify, on all applicable measures for 

determining the quality of health home 

services. Section 1945(c)(4)(B) of the Act 

also requires certain States with an 

approved substance use disorder (SUD)- 

focused section 1945 health home State 

plan amendment (SPA) to report 

information to the Secretary on certain 

topics, including on the quality of 

health care provided to SUD-eligible 

individuals receiving health home 

services under the SUD-focused health 

home SPA.7 Section 1945(c)(4)(B) of the 

Act further provides that the Secretary 

shall specify all applicable quality 

measures that would be included in the 

reporting required under that provision. 

Per section 1945(c)(4)(B) of the Act, 

States must submit the required report 

at the end of the period of such SPA. We 

have interpreted this language to mean 

that the report should provide data 

relating to the enhanced Federal 

medical assistance percentage (FMAP) 

period available to the State under 

section 1945(c)(4) of the Act and that 

States should submit the report within 

6 months after the enhanced FMAP 

period ends.8

Apart from the one-time-only required 

report under section 1945(c)(4)(B) of the 

Act, section 1945 of the Act does not 

require States to submit quality measure 

reporting to CMS or the Secretary 

related to the section 1945 health home 

benefit. However, since 2013, we have 

encouraged States (including States 

subject to the one-time-only report 

specified at section 1945(c)(4)(B) of the 

Act) to report annually on a set of 

section 1945 health home quality 

measures (section 1945 Health Home 

Core Set).9 We published an initial core 

set of section 1945 health home quality 

measures in 2013, with updates issued 

annually. We also explained when 

publishing the initial core set of section 

1945 health home quality measures that 

reporting on the section 1945 Health 

Home Core Set would be voluntary until 

regulations were promulgated to require 

it. However, to ease the reporting 

burden, all but one of the recommended 

measures was aligned with measures in 

the Adult Core Set.10 Subsequent 

updates to the section 1945 Health 

Home Core Set have been made on an 

annual basis. In developing and 

updating the section 1945 Health Home 

Core Set, we have generally tried to 

align it with the Child and Adult Core 

Sets. In November 2019, we released a 

Center for Medicaid and CHIP Services 

(CMCS) Informational Bulletin (CIB), 

which added two additional measures 

specific to SUD-focused health home 

programs to the 2020 section 1945 

Health Home Core Set on which States 

could consider reporting as part of the 

required reporting under section 

1945(c)(4)(B) of the Act.11

Section 1945A(g)(1)(B) of the Act 

requires section 1945A health home 

providers to report information to the 

State on all applicable measures for 

determining the quality of health home 

services provided by the provider, 

including, to the extent applicable, 

child health quality measures and 

measures for centers of excellence for 

children with complex needs developed 

under Title XIX, Title XXI, and section 

1139A of the Act (which would include 

the Child Core Set). Additionally, unlike 

section 1945 of the Act, which requires 

States to report on quality measures to 

the Secretary only if the State is subject 

to section 1945(c)(4)(B) of the Act, 

section 1945A of the Act requires all 

States implementing that benefit to 

submit reports to the Secretary on a 

range of topics. Under section 

1945A(g)(2)(A)(i) of the Act, these 

reports must include all information 

reported by providers to the State under 

section 1945A(g)(1) of the Act, 

including the quality measure reporting 

required under section 1945A(g)(1)(B) of 

the Act. We interpret the language in 

section 1945A(g)(2)(A)(i) of the Act to 

refer to reporting on core measures 

developed for purposes of evaluating 

the quality of section 1945A health 

home services, because that provision 

cross-references the language in section 

1945A(g)(1)(B) of the Act that mentions 

quality measures developed under 

various provisions of the Act, including 

the Child Core Set. 

This rule establishes the following 

requirements for States electing to 

implement the benefit under sections 

1945 or 1945A of the Act. Under the 

provisions of this rule, States that have 

implemented the section 1945 and/or 

1945A health home benefit must report 

annually on the mandatory measures in 

the section 1945 Health Home Core Set 

and/or a proposed section 1945A Health 

Home Core Set (depending on which of 

the two benefits the State has opted to 

cover) and must require their health 

home providers to report to the State on 

those measures. Annual CMS reporting 

guidance will provide information on 

specific measures for which reporting is 

mandatory for the section 1945 and 

section 1945A Health Home Core Sets 

(including any specific measures that 

would be mandatory for States with a 

SUD-focused section 1945 health home). 

For States covering the section 1945 

health home benefit, this requirement is 

based on section 1902(a)(6) of the Act, 

which requires State Medicaid agencies 

to make such reports, in such form and 

containing such information, as the 

Secretary may from time to time require, 

and to comply with such provisions as 

the Secretary may from time to time find 

necessary to assure the correctness and 

verification of such reports. For 

measures specific to States with SUDfocused health home SPAs subject to 

section 1945(c)(4)(B) of the Act, this 

requirement is also authorized by the 

language in section 1945(c)(4)(B) of the 

Act stating that the Secretary shall 

specify all applicable measures for 

determining quality for purposes of 

section 1945(c)(4)(B) of the Act, but this 

rule does not otherwise address the 

reporting requirements under section 

1945(c)(4)(B) of the Act. Requiring 

States to require their section 1945 

health home providers to report to the 

State on the Health Home Core Set is 

further supported by the language in 


ddrumheller on DSK120RN23PROD with RULES2
60280 Federal Register / Vol. 88, No. 168 / Thursday, August 31, 2023 / Rules and Regulations 

12 January 2023 Medicaid and CHIP Enrollment 

data: https://www.medicaid.gov/medicaid/nationalmedicaid-chip-program-information/downloads/ 

january-2023-medicaid-chip-enrollment-trendsnapshot.pdf; and https://www.medicaid.gov/stateoverviews/scorecard/annual-medicaid-chipexpenditures/index.html. 

13Annual Review and Selection Process: https:// 

www.medicaid.gov/medicaid/quality-of-care/ 

downloads/annual-core-set-review.pdf. 

section 1945(g) of the Act providing that 

section 1945 health home providers 

shall report to States on all applicable 

measures for determining the quality of 

section 1945 health home services, in 

accordance with such requirements as 

the Secretary shall specify. For States 

covering the section 1945A health home 

benefit, these requirements are 

authorized by section 1945A(g)(1) and 

(2) of the Act (see discussion of those 

provisions above), as well as by section 

1902(a)(6) of the Act. While this rule 

implements section 1945A(g)(2)(A)(i) of 

the Act, section 1945A(g)(2)(A) of the 

Act requires States to report to the 

Secretary on several additional topics 

that are not addressed in this rule. CMS 

expects to provide information to States 

about the rest of the reporting 

requirements under section 

1945A(g)(2)(A) of the Act in the future. 

C. Building a System of Reporting To 

Improve the Quality of Care Delivered 

Implementation of the Child and 

Adult Core Sets, and the sections 1945 

and 1945A Health Home Core Sets, 

represents a major step in the 

development of a national, evidencebased system for measuring and 

improving the quality of care delivered 

to Medicaid and CHIP beneficiaries. The 

Core Sets include measures that, taken 

together, may be used to estimate the 

overall national quality of health care 

provided to beneficiaries. The ability to 

assess the quality of and access to care 

furnished by State Medicaid and CHIP 

programs is critical given that more than 

93 million Americans receive coverage 

in Medicaid and CHIP, and the annual 

expenditures for the programs are over 

$600 billion.12

1. Development of Core Sets 

To ensure that the measures included 

in the Child and Adult Core Sets reflect 

the needs of Medicaid and CHIP 

beneficiaries and provide the types of 

information necessary to assess the 

overall national quality of health care, 

sections 1139A and 1139B of the Act 

establish a number of specific 

parameters for the development of these 

core sets. For a complete and full 

description of these requirements see 

sections 1139A and 1139B of the Act. 

The initial section 1945 Health Home 

Core Set was established in 2013 as a 

recommended set of health care quality 

measures for assessing the section 1945 

health home service delivery model. We 

have updated the section 1945 Health 

Home Core Set annually since 2013, and 

in 2021 we established a Health Home 

Annual Review Workgroup to align this 

update process with the CMS process to 

annually update the Child and Adult 

Core Sets (as further discussed below). 

We formed a joint Child and Adult 

Core Sets Annual Review Workgroup in 

2019, consolidating what had 

previously been two separate 

workgroups, to implement the statutory 

requirements and to ensure that 

measures in the Core Sets are 

meaningful for States and interested 

parties and feasible for State-level 

reporting.13 In 2021, the Health Home 

Annual Review Workgroup was 

implemented, following the same 

structure and guidelines as the 

workgroup for the Child and Adult Core 

Sets, to develop and update section 

1945 and section 1945A Health Home 

Core Sets. The joint Child and Adult 

Core Sets Annual Review Workgroup 

and the Health Home Annual Review 

Workgroup (‘‘Workgroups’’) develop 

recommendations on how to revise, 

strengthen, and improve the applicable 

Core Sets measures, and every year the 

Workgroups’ recommended changes are 

published for public comment and then 

submitted to CMS. All meetings are 

open to the public, and public comment 

is invited during each meeting. 

D. Shifting From Voluntary to 

Mandatory Reporting 

In 2018, Congress passed two laws 

that mandate State reporting of the 

Child Core Set and the behavioral health 

measures on the Adult Core Set. These 

laws help address the limitations of 

voluntary reporting and significantly 

strengthen the ability of the Core Sets to 

drive quality improvements for 

Medicaid and CHIP beneficiaries 

nationwide. 

First, section 50102(b) of the 

Bipartisan Budget Act of 2018 (Pub. L. 

115–123, enacted February 9, 2018) 

added a new subparagraph (B) to section 

1139A(a)(4) of the Act to mandate 

annual reporting of the Child Core Set 

beginning with the annual State report 

on FFY 2024. Specifically, section 

1139A(a)(4)(B) of the Act provides that 

beginning with the annual State report 

on FFY 2024, the Secretary shall require 

States to use the initial core 

measurement set and any updates or 

changes to that set to report information 

regarding the quality of pediatric health 

care under titles XIX and XXI. 

Additionally, section 1139A(a)(4)(B) of 

the Act requires, once mandatory 

reporting begins, that States submit such 

information using the standardized 

format for reporting information and 

procedures developed by CMS in 

consultation with States in accordance 

with section 1139A(a)(4)(A) of the Act. 

Second, section 5001 of the SUPPORT 

Act (Pub. L. 115–271, enacted October 

24, 2018), added a new subparagraph 

(B) to section 1139B(b)(3), to make 

mandatory the annual reporting of 

behavioral health measures in the Adult 

Core Set. The SUPPORT Act 

requirement also becomes effective 

beginning with the annual State report 

on FFY 2024. Per section 1139B(b)(3)(B) 

of the Act, States are required to report 

on all behavioral health measures 

included in the core set of adult health 

quality measures and any updates or 

changes to such measures, and as with 

the Child Core Set, reporting of the 

behavioral health measures must be 

submitted using the standardized format 

for reporting information and 

procedures developed by CMS in 

consultation with States. 

As discussed previously, this final 

rule also implements certain statutory 

requirements in sections 1902(a)(6), 

1945, and 1945A of the Act to require 

States that have opted to implement the 

section 1945 or section 1945A health 

home benefit to report on the section 

1945 or 1945A Core Sets, as applicable, 

and also to require their health home 

providers to report on the applicable 

health home core set. 

II. Summary of the Proposed Provisions 

and Analysis of and Responses to the 

Public Comments 

We received 93 public comments 

from individuals and organizations, 

including, but not limited to, State 

government agencies, non-profit health 

care organizations, advocacy groups, 

associations, law firms, managed care 

organizations, academic groups, tribal 

organizations, and private citizens. We 

thank the commenters for their 

consideration of the proposed 

requirements for mandatory reporting 

and appreciate the submission of all of 

the comments received. In general, 

commenters supported the proposed 

rule. In this section, arranged by subject 

area, we summarize the proposed 

provisions, the public comments 

received, and our responses. For a 

complete and full description of the 

proposed mandatory reporting 

requirements, see the 2022 proposed 

rule, ‘‘Medicaid Program and CHIP; 

Mandatory Medicaid and Children’s 

Health Insurance Program (CHIP) Core 

Set Reporting’’ (87 FR 51303, August 22, 


ddrumheller on DSK120RN23PROD with RULES2
Federal Register / Vol. 88, No. 168 / Thursday, August 31, 2023 / Rules and Regulations 60281 

2022) hereafter referred to as the 

‘‘proposed rule’’. 

A. Basis, Scope, Purpose and 

Applicability 

As discussed in section II.A. of the 

proposed rule, we proposed in § 437.1 

to specify the basis and scope of the 

proposed requirements and to establish 

the purpose of the Child Core Set, Adult 

Core Set, and the Health Home Core 

Sets. We also proposed in § 437.10 to 

implement a process through which we 

would develop and update the Child 

Core Set, Adult Core Set, and the Health 

Home Core Sets (sections 1945 and 

1945A) and proposed in § 437.10 the 

process through which we would 

establish requirements that State 

agencies would have to meet when 

reporting on the measures included in 

these Core Sets. We also proposed in 

§§ 437.10 and 437.15 the form, 

reporting, time, and manner 

requirements for reporting the Core Sets. 

We proposed that the requirements for 

Child and Adult Core Sets reporting 

would apply to the 50 States, DC, Puerto 

Rico, the Virgin Islands, and Guam; and 

throughout the rule the term ‘‘States’’ is 

used to collectively refer to these States 

and territories when we are referring to 

the Child and Adult Core Sets. 

American Samoa and the Mariana 

Islands could, but would not be 

required to, report Child and Adult Core 

Set measures. We also proposed 

requirements for State reporting of 

health home quality measures in 

§§ 437.10 and 437.15 and noted the 

Secretary has the authority under 

sections 1945(g) and 1945A(g) of the Act 

to require States to require their health 

home providers to report on the Home 

Health Core Sets measures. The 

requirement for reporting on one or both 

of the Health Home Core Sets would 

apply to any State (as defined under 

section 1101 of the Act for purposes of 

Title XIX) with an approved Medicaid 

Health Home SPA under section 1945 or 

1945A of the Act. We also proposed, in 

§ 437.15(a)(1), to set the deadline to 

meet these requirements for State 

reporting on the 2024 Core Sets as no 

later than December 31, 2024. 

In general, commenters who 

submitted public comments on the 

proposed general requirements for 

mandatory reporting supported the 

proposed scope, purpose, and process. 

We are finalizing those provisions in 

§§ 437.1, 437.10 and 437.15 with 

revisions to § 437.10 to specify timelines 

for Child and Adult Core Sets updates 

and timelines for CMS reporting of 

Child and Adult Core Sets data. We 

added § 437.15(a)(1)(i) to specify 

timelines for the first year of mandatory 

reporting of the Child Core Set and 

behavioral health measures on the Adult 

Core Set. The addition of this new 

provision shifted the numbering of the 

remainder of the provisions in 

§ 437.15(a)(1), redesignating 

§ 437.15(a)(1)(i) to § 437.15(a)(1)(ii), etc. 

We also edited § 437.15(a)(1)(iv), 

originally proposed as § 437.15(a)(1)(iii), 

to include only the measures on the 

Adult Core Set that are not included in 

§ 437.15(a)(1)(i) and (ii) as optional for 

states to report, removing the reference 

to the Health Home Core Sets to align 

with changes in other sections. Below is 

a summary of the public comments we 

received related to the scope, purpose, 

and applicability of the requirements as 

proposed and our responses. 

Comment: Several commenters 

supported the proposed rule in its 

entirety or specifically indicated their 

support for reporting of a specific 

component such as the behavioral 

health measures on the Adult Core Set. 

Many of the comments referred to the 

positive outcomes that CMS expects 

from finalization of these proposals. The 

commenters generally expressed 

support for these proposals and noted 

that the proposed changes to the 

requirements for reporting the Core Sets 

will support the improvement of health 

outcomes for Medicaid and CHIP 

beneficiaries overall in addition to 

addressing health disparities and 

inequities. 

Response: We appreciate the support 

for our proposal and thank those who 

took the time to give us feedback. 

Comment: Several commenters 

recommended the following revisions 

(indicated below in bold typeface) to the 

proposed § 437.1(c)(1): ‘‘The purpose of 

the Medicaid and CHIP Child Core Set 

and the Medicaid Adult Core Set is to 

measure the overall national quality of 

care for beneficiaries; monitor 

performance and promote comparative 

analysis at multiple levels, including 

the State, program, plan and provider 

levels; and eliminate health disparities 

across populations; and improve the 

quality of health care.’’ They cite the 

following statutes: 

• Section 1139A(a)(8) of the Act to 

support the definition of the Child Core 

Set as a ‘‘group of valid, reliable, and 

evidence-based quality measures.’’ 

• Section 1139A(b) of the Act 

established the Pediatric Quality 

Measures program to advance the 

development of evidence-based quality 

measures for children which, per 

sections 1139A(b)(2)(B) and (C) of the 

Act, ‘‘shall, at a minimum, be . . . 

designed to identify and eliminate racial 

and ethnic disparities in child health 

and the provision of health care’’ and 

‘‘ensure that the data required for such 

measures is collected and reported in a 

standard format that permits 

comparison of quality and data at a 

State, plan, and provider level.’’ 

• Section 1139A(a)(3)(D) of the Act to 

highlight health disparities and 

comparative analysis in its requirement 

that the initial Child Core Set ‘‘taken 

together, can be used to estimate the 

overall national quality of health care 

for children, including children with 

special needs, and to perform 

comparative analyses of pediatric health 

care quality and racial, ethnic, and 

socioeconomic disparities in child 

health and health care for children.’’ 

• Sections 1139B(a) and (b)(5) of the 

Act that direct the Secretary to develop 

the Adult Core Set ‘‘in the same 

manner’’ as the Child Core Set. 

Response: We appreciate the 

suggestion to revise this section of the 

regulation and agree with the 

commenters on the importance of 

aligning quality measurement across 

multiple levels and measure sets, as 

feasibility and applicability allow. We 

consider measuring and reporting health 

disparities to be a cornerstone of CMS’ 

approach to advancing health equity 

and improving quality as outlined in the 

proposed rule. The public comment 

recommending that the purpose of the 

Child and Adult Core Sets include 

‘‘comparison of quality and data at a 

State, program, plan, and provider 

level’’ cites the statutory requirement as 

section 1139A(b)(2)(C) of the Act. That 

statutory requirement applies to 

measures developed under the pediatric 

quality measures program and does not 

refer to the reporting requirements for 

the Child Core Set, which are 

established in section 1139A(c) of the 

Act and require ‘‘Annual State Reports 

Regarding State-Specific Quality of Care 

Measures Applied Under Medicaid or 

Chip.’’ Section 1139A(c) of the Act 

requires reporting of State-level Child 

Core Set data, and does not require 

program-, plan- or provider-level 

reporting. In addition, it does not 

necessarily require comparative analysis 

of such data. There is similar language 

in section 1139B(d) of the Act, which 

requires reporting of Adult Core Set data 

at the State-level. Given these 

considerations, we are finalizing 

§ 437.1(c)(1) as proposed, with the 

purpose of the Medicaid and CHIP 

Child Core Set and the Medicaid Adult 

Core Set to measure the overall national 

quality of care for beneficiaries, monitor 

performance at the State-level, and 

improve the quality of health care. 

Comment: Several commenters 

recommended that CMS add a provision 

to the final rule to require CMS to 


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collect, analyze, and make publicly 

available Child and Adult Core Sets data 

annually by September 30th. Other 

commenters recommended that CMS 

add a provision to the final rule to 

require CMS to publish recommended 

changes to the Child and Adult Core Set 

measures by January 1 of each year. 

Response: The statutory authority for 

the Core Sets at sections 1139A(c)(2) 

and 1139B(d)(2) of the Act requires the 

Secretary to collect, analyze, and make 

publicly available, by September 30th of 

each year, the information reported in 

the annual State reports described in 

sections 1139A(c)(1) and 1139B(d)(1) of 

the Act. Similarly, sections 1139A(b)(5) 

and 1139B(b)(5)(B) of the Act require 

the Secretary to publish recommended 

changes to the Child and Adult Core 

Sets by January 1st annually. We have 

historically followed this timeline for 

updating Core Sets. To address the 

recommendations received in public 

comments regarding the Child and 

Adult Core Sets to add these provisions 

to the final rule, we added these 

requirements at § 437.10(a)(1) and (4). 

Although the comment is not specific to 

Health Home Core Sets, we are 

specifying at § 437.10(a)(5) that the 

Secretary shall collect, analyze, and 

make publicly available data from the 

Health Home Core Sets annually. 

Comment: One commenter 

recommended that because most of the 

current Health Home Core Sets 

measures have continuous enrollment 

periods of ‘‘no gaps in coverage,’’ ‘‘no 

more than 45-day gap in coverage,’’ and 

‘‘no more than 90-day gap in coverage,’’ 

CMS should alter § 437.15(a)(1)(ii) in 

the proposed rule from ‘‘the applicable 

health home program has an effective 

date and has been implemented more 

than 6 months prior to the December 

31st reporting deadline’’ to ‘‘. . . 

implemented for nine or more months 

. . .’’ 

Response: In an effort to include as 

many active health home programs as 

possible in quality measurement 

reporting, we believe it is preferable to 

maintain the minimum requirement as 

it was proposed, even if this means a 

health home program may lack 

sufficient data to report on certain 

measures, as what a health home 

program can report will still be useful 

to help us and the State to understand 

the quality of care provided in the 

health home program. Specifically, the 

requirement states that a health home 

program must report if it has been 

implemented for more than 6 months 

prior to the December 31st reporting 

deadline. Therefore, we are finalizing 

the proposed § 437.15(a)(1)(ii) at 

§ 437.15(a)(1)(iii) (to accommodate 

addition of a new provision at 

§ 437.15(a)(1)(i), as discussed previously 

in this final rule) without other changes. 

Comment: A few commenters 

expressed support for the proposed 

changes but provided feedback on areas 

that were not addressed in the proposed 

rule. One commenter noted that it is 

critical that health plans reporting on 

Core Set quality measures have effective 

tools to communicate with enrollees in 

order to ensure that enrollees 

understand plan benefits and 

recommended health care screenings 

and services, and that these plans can 

also address barriers to higher quality 

care. This commenter requested that 

CMS issue guidance to States to help 

improve communication with 

beneficiaries due to confusion regarding 

the Telephone Consumer Protection Act 

(TCPA) (Pub. L. 102–243, enacted 

December 20, 1991). Another 

commenter recommended that CMS 

work with State Medicaid programs to 

remove undue pharmacy scope of 

practice restrictions, and to adopt 

payment pathways that recognize 

pharmacists as eligible providers and 

enable pharmacies to provide and be 

reimbursed for clinical care 

interventions that improve the health 

and wellbeing of beneficiaries. Another 

commenter suggested CMS consider a 

pilot to apply the pediatric measures to 

all payers, starting with States with allpayer claims databases as this would 

help demonstrate the impact of different 

interventions on children’s health more 

broadly and may address some of the 

‘‘small numbers’’ challenges when 

looking at subgroups of children, such 

as children with special health care 

needs. Lastly, one commenter 

recommended the development of 

national standards for assessing access 

to Medicaid and CHIP services to 

include at minimum: time and distance 

standards, coverage of reimbursement 

for a variety of health care services, and 

consistent standards across fee-forservice (FFS) and managed care. 

Response: We thank the commenters 

for their support of the proposed 

requirements for mandatory reporting 

and appreciate the submission of these 

comments but note that these areas are 

outside of the scope of this rulemaking. 

Comment: One commenter requested 

confirmation that States with section 

1115 demonstrations are included in 

mandatory reporting. 

Response: States are required to report 

mandatory Core Set measures for all 

required populations, even if those 

beneficiaries are enrolled in a section 

1115 demonstration. States with section 

1115 demonstrations are required under 

demonstration Special Terms and 

Conditions (STCs) to monitor their 

demonstration’s performance. Section 

1115 demonstration monitoring and 

reporting requirements are in addition 

to and not in lieu of requirements for 

State-level Core Set reporting as 

outlined in this final rule. As part of the 

demonstration monitoring process, we 

may require that States report a select 

set of Core Set measures that support 

assessing performance and progress 

toward specific goals and objectives of 

the demonstration. This reporting, 

which may be adapted for 

demonstration populations, is in 

addition to mandatory Core Set 

reporting. Additionally, States may 

leverage Core Set measures as part of 

their section 1115 demonstration 

evaluation. 

Comment: Several commenters 

recommended that CMS streamline the 

language in § 437.15(a) to remove 

references to the specific sets of 

measures (that is, the Child Core Set or 

behavioral health measures on the Adult 

Core Set) that will become mandatory 

under this final rule as redundant, 

noting that section 1139B of the Act 

does not preclude CMS from using its 

authority under section 1902(a)(4) of the 

Act to require reporting on additional 

measures if necessary to ensure the 

proper and efficient administration of 

the Medicaid program. Other 

commenters encouraged CMS to 

consider its independent authority, 

outside of sections 1139A and 1139B of 

the Act to require mandatory reporting 

of additional measures to advance 

quality in Medicaid through section 

1902(a)(6) of the Act. 

Response: We believe the 

Congressional intent is for mandatory 

reporting to apply to the Child Core Set 

and the behavioral health measures of 

the Adult Core Set, and not to apply to 

the remaining quality measures. For the 

Child and Adult Core Sets, this 

rulemaking is not proposing to make 

mandatory any measures beyond those 

under sections 1139A and 1139B of the 

Act. Therefore, we are maintaining the 

proposed scope of mandatory reporting 

and are not making any changes to 

§ 437.15(a) in response to this comment. 

Comment: One commenter urged 

CMS to consider ways to help address 

any burden that new data collection 

efforts may cause for States by exploring 

funding opportunities to assist States in 

conducting the necessary activities to 

implement these important provisions 

effectively. 

Response: We appreciate the 

submission of this comment but note 

that this issue is outside of the scope of 

this rulemaking. As noted in the 

proposed rule, in Medicaid, enhanced 


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14See section 1903(a)(3)(A)(i) and (B) of the Act, 

§ 433.15(b)(3) and (4), and subpart C of 42 CFR part 

433. 

15 42 CFR 433.112 and 42 CFR 433.116. 

16See 42 CFR 457.618(e)(1). 

17CMS Behavioral Health Strategy: https://

www.cms.gov/cms-behavioral-health-strategy. 

18 2022 Core Set CIB: https://www.medicaid.gov/ 

sites/default/files/2022-11/cib111522_0.pdf. 

19 2023–2024 Behavioral Health Core Set: https:// 

www.medicaid.gov/sites/default/files/2022-11/ 

2023-bh-core-set.pdf. 

Federal Financial Participation (FFP) is 

available at 90 percent for the design, 

development, and installation 

(including of enhancements) of 

mechanized claims processing and 

information retrieval systems, and 75 

percent enhanced FFP is available for 

operations of such systems, in 

accordance with applicable Federal 

requirements.14 Receipt of these 

enhanced Federal Medicaid matching 

rates is conditioned upon States meeting 

a series of standards and conditions.15

Additionally, under section 

1903(a)(3)(A)(iii) of the Act, the FFP for 

State expenditures on systems 

development or modifications necessary 

for efficient collection and reporting on 

the Child Core Set is at the State’s 

FMAP under section 1905(b) of the Act. 

We also note that under section 

1903(a)(7) of the Act, Federal Medicaid 

matching funds may be available at a 50 

percent Federal match rate for staffing 

and contracting related to implementing 

Core Set reporting requirements, as 

these activities might, subject to certain 

conditions, be necessary for the proper 

and efficient administration of the State 

plan. To the extent these system 

expenditures are attributable to a State’s 

CHIP (Medicaid Expansion CHIP 

(MCHIP), or separate CHIP), costallocation methodologies set forth in 45 

CFR part 75 apply. For the CHIP-funded 

portion of the expenditure, States can 

claim at a State’s CHIP enhanced FMAP 

(eFMAP) available under section 

2105(b) of the Act. We note that systems 

expenditures are administrative 

expenditures, and CHIP administrative 

funding is limited to 10 percent of either 

a State’s total computable allotments for 

a FFY or its total expenditures reported 

for a FFY, whichever is lower.16

B. Definitions 

As discussed in section II.B. of the 

proposed rule, in § 437.5 we proposed 

the definitions related to quality 

measurement and reporting. 

Commenters generally supported the 

proposed definitions, and we are 

finalizing these provisions with a 

revision to the definition of behavioral 

health in § 437.5 and other minor 

wording changes to clarify crossreferences within the same subpart. 

Below is a summary of the public 

comments we received regarding this 

section and our responses. 

Comment: Several commenters 

recommended that CMS revise (with 

revisions indicated in boldface type 

below) the definition of ‘‘behavioral 

health’’ proposed at § 437.5: ‘‘Behavioral 

health means a beneficiary’s whole 

emotional and mental well-being, which 

includes, but is not limited to, the 

prevention, treatment and recovery 

from mental disorders and substance 

use disorders.’’ The commenters 

recommended adding ‘‘and recovery’’ to 

the meaning of behavioral health and 

replace ‘‘including’’ with ‘‘and’’ 

regarding the inclusion of substance use 

disorders in this definition. 

Response: We agree with the 

recommendation to add ‘‘and recovery,’’ 

as recovery is a key part of improving 

the health outcomes for individuals 

with behavioral health conditions, and 

are revising the definition of behavioral 

health in § 437.5 of this final rule.17

Regarding the second suggestion, we 

will retain the language as originally 

proposed, ‘‘mental disorders including 

substance use disorders,’’ as that aligns 

with the American Psychiatric 

Association’s position, reflected in the 

Diagnostic and Statistical Manual of 

Mental Disorders (DSM–5), that 

substance use disorders are included in 

the definition of mental disorders. 

Comment: Several commenters 

supported CMS’ proposal to broadly 

define ‘‘behavioral health’’ and 

‘‘behavioral health measures.’’ Some 

commenters recommended additional 

guidance on the potential scope of 

conditions and quality measures 

included in the definition to ensure a 

shared understanding of such 

definitions and help prepare for 

reporting. 

Response: We appreciate the support 

for the proposed ‘‘behavioral health’’ 

definition, which aligns with the 

behavioral health conditions included 

in the American Psychiatric 

Association’s DSM–5. We plan to use 

the DSM–5 as a resource in determining 

which measures on the Adult Core Set 

should be considered behavioral health 

measures and thus subject to mandatory 

reporting requirements and will specify 

these measures in annual reporting 

guidance. In November 2022, we issued 

the annual CIB updating the Core Sets, 

the 2023–2024 Core Sets measure lists, 

to include a subset of measures 

identified as the Behavioral Health Core 

Set, which includes all the behavioral 

health measures on the Adult Core 

Set.18 19 As noted, we are finalizing the 

definition in § 437.5 with one revision, 

to add ‘‘and recovery.’’ 

C. The Child, Adult, and Health Home 

Core Sets 

As discussed in section II.C. of the 

proposed rule, in § 437.10 we proposed 

to continue the existing annual process 

of identifying and updating the 

measures comprising the Child, Adult, 

and Health Home Core Sets through 

annual consultation with States and 

other interested parties to establish 

priorities for the development and 

advancement of the Child, Adult, and 

both Health Home Core Sets. We 

proposed in § 437.10(a)(2) to identify 

any gaps in the measures included in 

each Core Set; to identify measures 

which should be removed because they 

no longer strengthened the Core Sets; 

and to ensure that all measures included 

in the Core Sets would reflect an 

evidence-based process (including 

testing, validation, and consensus 

among interested parties). The 

measure(s) selected would be 

meaningful for States and feasible for 

State-level and/or health-home program 

level reporting, as appropriate. 

Commenters generally supported the 

process proposed in § 437.10(a) and (e) 

by which we would update the Core 

Sets and publicly report data on such 

measures. Commenters also asked 

several questions about specific 

measures on the Core sets. We will be 

finalizing these provisions in this final 

rule with a revision to § 437.10(a)(iv), 

where we describe measure criteria for 

the Core Sets, and with revisions to 

§§ 437.10(b) and 437.15(a), where we 

have provided additional detail on 

reporting requirements, and we discuss 

these changes further in sections II.D.2. 

and II.D.3. of this final rule. Below is a 

summary of the public comments we 

received regarding this section and our 

responses. 

Comment: Several commenters 

provided feedback on areas that were 

not addressed in the proposed rule such 

as: proposing specific changes to the 

Core Sets, proposing measure additions 

or removals, identifying measure gaps 

on the Core Sets, adding non-behavioral 

health measures to the list of Adult Core 

Set measures required in mandatory 

reporting, and measure development 

and testing. Specifically, a few 

commenters recommended a ‘‘duration 

of coverage’’ measure as called for by 

existing statute (section 1139A(a)(3)(A) 

of the Act) to assess the negative impact 

of churn on the quality of care that 

children receive and recommended that 

this measure be added to the Child Core 

Set no later than mandatory reporting 

for 2024. 


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20https://www.medicaid.gov/medicaid/quality-ofcare/downloads/annual-core-set-review11102022.pdf. 

21https://www.mathematica.org/features/ 

maccoresetreview. 

22https://www.medicaid.gov/medicaid/accesscare/index.html. 

23https://opa.hhs.gov/research-evaluation/title-xservices-research/contraceptive-care-measures. 

24Annual Reporting on the Child Core Set: 

https://www.medicaid.gov/medicaid/quality-ofcare/performance-measurement/adult-and-childhealth-care-quality-measures/childrens-health-carequality-measures/index.html#AnnualReporting. 

25https://opa.hhs.gov/sites/default/files/2020-07/ 

interpreting-rates-for-contraceptive-caremeasures.pdf. 

Response: We appreciate the 

submission of these comments, and we 

will consider these comments as part of 

the measure adoption subregulatory 

process. We encourage the commenters 

to attend meetings of the joint Child and 

Adult Core Sets Annual Review 

Workgroup and the Health Home 

Annual Review Workgroup 

(Workgroups), which are convened 

annually to develop recommendations 

on how to revise, strengthen, and 

improve the applicable Core Sets 

measures.20 All meetings are open to the 

public, public comment is invited 

during each meeting, and every year the 

Workgroup recommendations are 

published for public comment.21

We agree with the commenters 

regarding the importance of 

understanding the continuity of 

coverage among Medicaid and CHIP 

beneficiaries, recognizing that 

disruptions in coverage can lead to 

periods of uninsurance, delayed care, 

and reduced access to preventive care 

and other essential care for 

beneficiaries. Beneficiaries moving on 

and off Medicaid and CHIP coverage 

(sometimes called ‘‘churning’’) can lead 

to higher administrative costs, less 

predictable State expenditures, and 

higher monthly health care costs due to 

pent-up demand for health care 

services. To help address this issue, 

section 5112 of subtitle B of title V of 

division FF of the Consolidated 

Appropriations Act, 2023 (CAA, 2023) 

(Pub. L. 117–328), which was signed 

into law December 29, 2022, requires all 

States to provide 12 months of 

continuous eligibility for most children 

under the age of 19 in Medicaid and 

CHIP, effective January 1, 2024. There 

are no existing standardized quality 

measures in this area; however, we 

published a data brief in November 

2022 on Medicaid and CHIP Access: 

Coverage and Behavioral Health Data 

Spotlight, which provides in depth data 

on continuity of coverage.22 We will 

consider the best venue for continued 

reporting of these important metrics. 

Comment: One commenter 

encouraged CMS to consider making the 

National Core Indicators Survey 

(NCIDD–AD) within the Adult Core Set 

a voluntary component, because they 

believe that there would be a low 

response rate to this survey, which is 

administered in person. 

Response: While we appreciate the 

submission of this comment, the issue 

of which specific measures will be 

voluntary versus mandatory will be 

considered in the subregulatory measure 

revision process described previously in 

this final rule. The NCIDD–AD measure 

is an experience of care survey that was 

added to the Adult Core Set to address 

a gap in measures for long-term services 

and supports. It has not been identified 

as a behavioral health measure and will 

not become mandatory for State 

reporting in 2024. Measure 

administration and technical 

specifications are set by the measure 

steward, the National Association of 

State Directors of Developmental 

Disabilities Services and Human 

Services Research Institute. 

Comment: One commenter 

encouraged CMS to work with States to 

ensure that contraceptive care measures 

are used appropriately in the Child Core 

Set without reference to an external 

benchmark that may suggest an 

appropriate level of contraceptive use, 

and without provider incentives that 

could promote forms of coercion. 

Response: This comment is outside 

the scope of rulemaking. However, we 

appreciate this comment identifying 

potential issues related to the 

appropriate use and interpretation of the 

contraceptive care measure results. 

Specific to the Contraceptive Care 

measure, we note that we do not publish 

a benchmark for this measure, which 

examines provision of a most or 

moderately effective method of 

contraception and provision of a longacting reversible method of 

contraception. The lack of benchmark 

reflects that some individuals will make 

informed decisions to choose methods 

in the lower tier of efficacy even when 

offered the full range of methods.23 To 

help ensure that data users understand 

that the goal is not prescribing 

contraceptives to 100 percent of women, 

we include language in public reporting 

(that is, the Child Core Set Chart Pack) 24

indicating the estimated percentage in 

need of contraceptive services. 

Additionally, we cite resources from 

Office of Population Affairs (OPA) with 

language about the goal and guidance 

for how to interpret the measure.25

Comment: Several commenters 

recommended that CMS not use the 

Core Set data for State comparisons 

without accounting for State variation, 

including program and benefit design, 

geography and resources, and 

beneficiary characteristics. 

Response: We appreciate the 

submission of these comments and will 

take this feedback into consideration 

when developing Core Set reporting 

guidance and materials for public 

reporting. 

Comment: One commenter requested 

that the Secretary require managed care 

organizations (MCOs) to deliver 

stratified data in a timely manner to 

Federally Qualified Health Centers 

(FQHCs), facilities, and providers. 

Response: While we appreciate the 

submission of this comment, this issue 

is outside the scope of this rulemaking. 

Comment: Several commenters 

provided recommendations on our 

publication of Core Set data, including 

that CMS limit phasing-in the 

publication of State-level data to no 

more than 3 years; that CMS publish all 

State-level data even if not enough 

States have reported for CMS to conduct 

comparative analysis and to report 

quartile rankings; that CMS reconsider 

its policy to limit public reporting of 

voluntary Core Set measures to 

measures that are reported by at least 25 

States; and that CMS publish 

standardized core measures data with 

national benchmarks that would permit 

comparisons across States and over 

time. 

Response: We will continue to 

publish Core Set data annually, as 

required under sections 1139A(c)(2) and 

1139B(d)(2) of the Act for the Child Core 

Set and the Adult Core Set, respectively. 

We have worked to find a balance in the 

reporting of State data that meets these 

statutory reporting requirements while 

taking into consideration data quality 

and the ability to conduct comparative 

analysis. We appreciate the submission 

of these comments and will take them 

into consideration as we review State 

data as well as for future policymaking. 

Comment: Several commenters 

recommended that CMS seek to align 

the Core Set measures with other 

national reporting systems such as the 

Core Quality Measures Collaborative 

(CQMC) or the Medicaid and CHIP 

Quality Rating System (MAC QRS) in 

order to minimize additional reporting 

burden on providers and to ensure 

parsimony, alignment, harmonization, 

and the avoidance of competing quality 

measures. Other commenters noted that 

CMS should align with measures 

appropriate for State health care goals as 

defined by the National Committee for 


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26https://www.cms.gov/files/document/2024- 

advance-notice-pdf.pdf. 

27CMS released both the 2023 and 2024 Child 

and Adult Core Sets in November 2022 (https://

www.medicaid.gov/federal-policy-guidance/ 

downloads/cib111522.pdf) and the 2023 and 2024 

Health Home Core Sets in December 2022 (https:// 

www.medicaid.gov/medicaid/quality-of-care/ 

downloads/2023-health-home-core-set.pdf). 

28Proposed 1945A Health Home Core Set https:// 

www.medicaid.gov/medicaid/quality-of-care/ 

downloads/2024-1945a-health-home-core-set.pdf. 

Quality Assurance (NCQA), National 

Quality Forum (NQF), and the 

Utilization Review Accreditation 

Commission (URAC). 

Response: We agree with the 

commenters on the importance of 

parsimony, alignment and 

harmonization in quality measurement 

and will consider these comments for 

subsequent rulemaking. Throughout the 

annual Core Set review process, we 

facilitate measure alignment through 

engagement with a variety of internal 

and external interested parties, Federal 

partners, other reporting systems related 

to Medicaid and CHIP, and Medicare 

and Marketplace quality programs, as 

well as through initiatives such as the 

Universal Foundation, a set of quality 

measures around which programs at 

CMS are aligned.26 In some cases, we 

may use different measures in order to 

capture quality at different levels of the 

health system, such as at the State level. 

Given that these processes are in place, 

we are not making changes to 

§ 437.10(a) in response to these 

comments. 

Comment: Several commenters stated 

that that the proposed language 

requiring consideration of regulatory 

burden would hinder CMS’ ability to 

add new measures to the Core Sets and 

to require States to report measures by 

specific populations or demographic 

characteristics. They recommended 

amending the proposed 

§ 437.10(a)(2)(iv) to delete the reference 

to burden to the States as follows (edits 

in bold): ‘‘(iv) Ensure that all measures 

included in the Core Sets reflect an 

evidence-based process including 

testing, validation, and consensus 

among interested parties; are 

meaningful for States; and are feasible 

for State-level and/or Health Home 

program level reporting as appropriate.’’ 

Response: We agree with this 

comment that this language is open to 

interpretation and therefore accept the 

suggestion to revise § 437.10(a)(2)(iv) to 

remove the language ‘‘and represent 

minimal additional burden to States.’’ 

The remaining language in the provision 

regarding feasibility will help to ensure 

that we will not overburden States when 

adding measures to the Core Sets, and 

we agree that the additional language 

about minimal additional burden may 

hinder our ability to require more 

complex measures and stratification 

over time. While section 1945A(g)(2)(A) 

of the Act, which applies to the section 

1945A Health Home Core Set, requires 

any State reporting under that provision 

to be ‘‘in such form and manner 

determined by the Secretary to be 

reasonable and minimally 

burdensome,’’ this requirement applies 

to CMS regardless of whether it is 

repeated in CMS’ regulations. We 

believe that we can and will meet this 

requirement by taking multiple steps 

and intend to keep doing so for all Core 

Sets. For example, as specified in 

§ 437.10(a) and (e) of the proposed rule, 

States and providers of health home 

services under sections 1945 and 1945A 

of the Act are among the interested 

parties that are consulted in 

development of the Core Sets, and this 

process is designed to consider burden 

of reporting in measure selection. We 

have already released the list of 

measures included in the 2024 Child, 

Adult, and section 1945 Health Home 

Core Sets.27 Additionally, we have 

released the list of measures under 

consideration for the 2024 section 

1945A Health Home Core Set to allow 

States and health home programs time 

to prepare.28 We also aim to align 

measures across programs as much as 

possible, and to identify measures for 

additional reporting that States already 

have the infrastructure to calculate. For 

example, the section 1945A Health 

Home Core Set under consideration 

currently contains 7 quality measures, 

all of which can be calculated using 

administrative claims data only. 

Comment: One commenter 

recommended that CMS harmonize the 

Core Sets so that reporting is not 

duplicated across different programs, 

such that State reporting of the Child 

Core Set would mean that reporting 

would not be required again for the 

subset of children included in the 

health home. This commenter 

recommended that, for those children, 

only the additional health home-specific 

measures should need to be reported. 

Response: While we aim to align 

measures across programs as much as 

possible, the Child, Adult, and Health 

Home Core Sets data are reported at 

different levels. Specifically, the Child 

and Adult Core Sets data is reported to 

us at the State level, and Health Home 

Core Sets data is reported to us at the 

program level. For this reason, the same 

calculation cannot be used in both the 

Child Core Set or Adult Core Set and 

either of the Health Home Core Sets, as 

States have not submitted the data in 

their Child and Adult Core Sets 

reporting that would be necessary for us 

to derive health home program rates 

from State-level reporting. Regarding 

duplication of reporting, section 

1945A(g)(1)(B) of the Act requires 

section 1945A health home providers to 

report to the State information on all 

applicable measures for determining the 

quality of health home services 

provided by that health home provider, 

including to the extent applicable, child 

health quality measures and measures 

for centers of excellence for children 

with complex needs developed under 

section 1139A of the Act. Per section 

1945A(g)(2)(A)(i) of the Act, the State 

then reports this information to us. 

Comment: One commenter 

recommended that CMS remove 

measures which do not have National 

Quality Forum (NQF) endorsement from 

the Core Sets. 

Response: We appreciate the 

submission of this comment, and it will 

be considered in the subregulatory 

measure identification process. 

However, we note that statute (sections 

1139A and 1139B of the Act) does not 

limit the Child and Adult Core Sets to 

measures with NQF endorsement and, 

as required under the statute (sections 

1139A and 1139B of the Act) for Child 

and Adult Core Sets, measures are 

selected through the Annual Core Set 

Workgroup process established by CMS. 

Health Home Core Sets are also selected 

through the Annual Core Set Workgroup 

process established by CMS, even 

though this process is not statutorily 

required for these core sets. 

Comment: Several commenters 

recommended that CMS review the list 

of individuals who participate in the 

Annual Core Set Workgroup to ensure 

meaningful representation from 

beneficiaries of all ages and their 

advocates, including people with 

disabilities and behavioral health 

disorders (including substance use 

disorders). Several commenters 

requested that the Workgroup have 

representation of specific types of 

organizations and individuals, 

including but not limited to: 

beneficiaries, MCOs, purchasers of 

health care, providers and consumers 

and/or national organizations that 

represent adults, FQHCs, pharmacies 

and pharmacists, providers and health 

care professionals, and beneficiaries 

served through a Health Home (this 

would apply only to the Health Home 

Core Sets). 

Response: We appreciate the 

submission of these comments and will 

take them into consideration as we 

organize future Workgroups. All 


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29Reporting guidance will be posted here: https:// 

www.medicaid.gov/medicaid/quality-of-care/ 

quality-of-care-performance-measurement/ 

index.html. 

Workgroup meetings are open to the 

public, and public comment is invited 

during each meeting. 

Comment: One commenter 

recommended that CMS monitor the 

Workgroup process to determine if 

interested parties’ feedback is being 

adequately addressed or if a formal 

rulemaking process is necessary. 

Response: We appreciate the 

submission of this comment and will 

take it into consideration as we organize 

future Workgroups and monitor the 

public comment process. 

Comment: One commenter 

recommended that CMS offer States and 

health care organizations financial 

assistance to develop and deploy health 

equity efforts, including funding 

support in addressing the capture of 

self-reported data. Another commenter 

recommended that CMS require States 

to submit plans for mitigating persistent 

disparities and regularly report on their 

progress to close access and quality 

gaps. 

Response: While we appreciate these 

comments, they are outside the scope of 

this rulemaking, which addresses only 

Core Sets data and measurement. 

However, we note that Medicaid and 

CHIP Federal matching funds are 

available for State expenditures on the 

design, development, and installation 

(including of enhancements), and for 

operation, of mechanized claims 

processing and information retrieval 

systems. This could include State 

expenditures related to operating such 

systems for Core Sets reporting. We also 

note that under section 1903(a)(7) of the 

Act, Federal matching funds are 

available for activities necessary for the 

proper and efficient administration of 

the Medicaid State plan. This may 

include improving data reporting, 

which could promote greater health 

equity. 

Comment: One commenter 

recommended that CMS examine and 

prioritize the selection of Child Core Set 

measures that can provide actionable 

data at the level of providers to continue 

to improve pediatric outcomes and 

focus on health disparities and 

measures that can provide the most 

value in terms of informing the quality 

of pediatric care. 

Response: While we appreciate this 

comment, provider-level data is outside 

the scope of the rulemaking, which 

addresses reporting at the State and 

health home program level. We note 

also that the statutory mission of the 

Child Core Set, as stated in section 

1139A(3)(D) of the Act, specifies ‘‘the 

types of measures that, taken together, 

can be used to estimate the overall 

national quality of health care for 

children, including children with 

special needs, and to perform 

comparative analyses of pediatric health 

care quality and racial, ethnic, and 

socioeconomic disparities in child 

health and health care for children.’’ 

Comment: One commenter 

recommended that CMS improve the 

measure sets’ relevance to children with 

special health care needs and children 

with medically complex conditions 

included in sections 1945 and 1945A 

health home programs. 

Response: We agree with the 

importance of reflecting all populations 

that are served in both section 1945 and 

1945A health home programs in the 

Health Home Core Sets. The specific 

measures to be included in the Health 

Home Core Sets, which are determined 

through the workgroup process finalized 

in § 437.10(a), will be released through 

annual subregulatory guidance. 

1. Annual Reporting Guidance 

As discussed in section II.C.1. of the 

proposed rule, we proposed in §§ 437.10 

and 437.15 to require that States use 

standardized formats and procedures 

established by the Secretary when 

reporting on the Child, Adult, and 

Health Home Core Sets. We also 

proposed in § 437.10(a)(3) and (b) that 

we would develop and annually update 

the reporting guidance needed by States 

to report on all applicable Core Sets and 

described the components of the annual 

reporting guidance. For a complete 

discussion of the components of the 

annual reporting guidance, please refer 

to the proposed rule section II.C.1. 

In general, commenters supported the 

proposed annual reporting process, but 

requested clarification on what would 

be included in the reporting guidance. 

We are finalizing these provisions with 

revisions to §§ 437.10(b) and 437.15(a), 

where we have provided additional 

detail on reporting requirements. We 

discuss these revisions in sections 

II.D.2. and II.D.3. of this final rule. 

Below is a summary of the public 

comments we received regarding this 

section and our responses. 

Comment: Commenters noted that 

there are many details related to the 

contents of reporting guidance that were 

not addressed by the regulatory text. In 

particular, they asked for additional 

guidance as to: (1) whether CMS would 

continue to arrange licensing 

agreements with measure stewards 

related to the use and reporting of Core 

Set measures; (2) how CMS would 

identify the mandatory measures, 

populations to be included in 

mandatory reporting, and the process 

for reporting; (3) the timeline for 

reporting new measures; and (4) 

attribution rules for beneficiaries 

enrolled in different coverage during the 

reporting period and how to 

operationalize them. 

Response: To address concerns raised 

by these commenters, through revisions 

to §§ 437.10 and 437.15, we have 

provided additional detail on reporting 

requirements and populations to be 

included in mandatory reporting, and 

we discuss these revisions in sections 

II.D.2. and II.D.3. of this final rule. We 

currently provide annual reporting 

guidance to States to support voluntary 

reporting, and as explained in this rule, 

this guidance will, in the future, include 

the requirements associated with 

mandatory reporting and will continue 

to be updated annually.29 As specified 

in § 437.10(b), we will continue to 

provide detailed reporting guidance 

annually to States, which will include 

all of the information and technical 

specifications required for reporting of 

each of the Core Set measures, including 

the mandatory measures, populations to 

be included in mandatory reporting, the 

process for reporting, the timeline for 

requiring reporting new measures, and 

attribution rules and how to 

operationalize them. We will continue 

to execute licensure agreements with 

measure stewards as needed for States 

to report Core Set measures to CMS. 

Comment: Multiple commenters 

recommended that, as future 

modifications or additions are made to 

the Core Set, CMS issue reporting 

guidance as soon as possible to give 

States, MCOs, and health care providers 

time to prepare for reporting. Some 

commenters recommended that CMS 

release reporting guidance in alignment 

with the NCQA reporting guidance 

release, while others recommended that 

CMS set a deadline for publishing 

reporting guidance by January 1st 

annually. 

Response: We will take this feedback 

into consideration when developing 

Core Set reporting guidance and 

materials for public reporting. Measure 

stewards release updated guidance 

throughout the calendar year. Due to the 

need to adapt the reporting guidance 

developed by individual measure 

stewards, such as NCQA, for State-level 

reporting, simultaneous release of these 

materials with the measure steward is 

not feasible. We recognize the time and 

effort it takes States to prepare for Core 

Set reporting and expect to make every 

effort to publish reporting guidance as 


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30To join the Core Set listserv email: 

MACQualityTA@cms.hhs.gov. 

31Executive Order 13985: https://

www.whitehouse.gov/briefing-room/presidentialactions/2021/01/20/executive-order-advancingracial-equity-and-support-for-underservedcommunities-through-the-federal-government/. 

soon as possible following the release of 

the updated Core Sets. 

Comment: Multiple commenters 

recommended that CMS consult MCOs 

and/or behavioral health organizations 

(BHOs) as CMS develops annual 

reporting guidance for States in order to 

promote awareness of these resources, 

as many States rely on MCOs to provide 

data for reporting on the Core Sets and 

will need to update their reporting 

systems to implement standardized 

reporting. Another commenter 

recommended that CMS clarify the role 

of MCOs in supporting providers and 

State agencies in their efforts to improve 

Medicaid and CHIP quality 

measurement. 

Response: As part of our annual 

process to update reporting guidance, 

we review all of the technical assistance 

requests received related to specific 

measures, which often include 

questions submitted by MCOs/BHOs 

that are working on behalf of States to 

calculate Core Sets measures. The 

publication of reporting guidance and 

any updates regarding the Core Sets, 

including the publication of Core Set 

data products, is disseminated through 

a public listserv.30 We defer to each 

individual State’s Medicaid and CHIP 

agencies to determine the role MCOs 

and BHOs will have in in their State’s 

Core Sets reporting and efforts to 

improve quality measurement within 

their State. 

Comment: One commenter agreed 

with reporting data for partial-year 

enrollees at the State level, but 

recommended against attributing these 

data to specific MCOs if CMS stratifies 

reporting by health plan, noting that 

MCOs would have limited opportunity 

to work with members to accomplish 

necessary screenings and visits. 

Response: Decisions regarding the 

continuous enrollment period and 

allowable gaps are established by the 

measure stewards for each measure. 

Core Set reporting applies to all 

beneficiaries who meet enrollment 

criteria in State Medicaid and/or CHIP 

programs. We will take this comment 

regarding health plan attribution into 

consideration as we develop reporting 

guidance regarding attribution and 

stratification categories. 

2. Advancing Health Equity Through 

Data Stratification 

Measuring and reporting on health 

disparities is a cornerstone of CMS’ 

approach to advancing health equity. As 

discussed in section II.C.2. of the 

proposed rule, we proposed in 

§ 437.10(d) requirements for 

stratification of Child, Adult, and Health 

Home Core Set data to enable us to 

monitor health outcomes for disparities 

between groups of individuals who may 

have different determinants of health. 

This approach to data reporting and 

stratification is aligned with Executive 

Order 13985, which calls for advancing 

equity for underserved populations.31

We proposed that the annual reporting 

guidance identify the specific measures 

in the Child Core Set, the behavioral 

health measures on the Adult Core Set, 

and the Health Home Core Sets that 

must be stratified by race, ethnicity, sex, 

age, rural/urban status, disability, 

language, or such other factors as may 

be specified by the Secretary. We note 

that in collecting and reporting data in 

accordance with the requirements of 

this rule, States and providers would be 

expected to comply with all applicable 

Federal non-discrimination laws. We 

also note that data stratification is 

intended to promote health equity for 

all patients and is not intended to 

promote discrimination or to create a 

conflict between a CMS requirement 

and a State’s civil rights laws. Please 

refer to the proposed rule, section 

II.C.2., for specific discussions of the 

method for identifying measures for 

stratification, stratification factors, data 

suppression policies, and proposed 

timeline for phased-in stratification. 

We believe that this stratification of 

data in the Child Core Set, Adult Core 

Set, and Health Home Core Sets 

measures is consistent with our 

statutory authorities. Regarding the 

Child Core Set, section 1139A(b)(2)(B) 

of the Act specifies that measures under 

the pediatric quality measures program 

shall be ‘‘designed to identify and 

eliminate racial and ethnic disparities in 

child health and the provision of health 

care.’’ In addition, section 

1139A(a)(3)(D) of the Act required that 

the initial Child Core Set contain the 

‘‘types of measures that, taken together, 

can be used to estimate the overall 

national quality of health care for 

children, including children with 

special needs, and to perform 

comparative analyses of pediatric health 

care quality and racial, ethnic, and 

socioeconomic disparities in child 

health and health care for children.’’ 

Regarding the Adult Core Set, section 

1139B(a) of the Act requires the 

Secretary to utilize similar parameters 

for establishing the Adult Core Set. 

Additionally, section 1902(a)(6) of the 

Act, which requires State Medicaid 

agencies to make such reports, in such 

form and containing such information, 

as the Secretary may from time to time 

require, authorizes us to require 

stratification of the data that States 

report to us. Regarding the Health Home 

Core Sets, in addition to the authority 

provided by section 1902(a)(6) of the 

Act, section 1945(g) of the Act requires 

section 1945 health home services 

providers to report to the State, in 

accordance with such requirements as 

the Secretary shall specify, on all 

applicable measures for determining the 

quality of such services. Section 

1945A(g)(2)(A)(i) of the Act requires 

States implementing the section 1945A 

health home benefit to submit to the 

Secretary, in such form and manner 

determined by the Secretary to be 

‘‘reasonable and minimally 

burdensome,’’ all section 1945A quality 

reporting data that was submitted to 

them under section 1945A(g)(1) of the 

Act. The information providers report to 

the State under section 1945A(g)(1)(B) 

of the Act includes, to the extent 

applicable, child health quality 

measures developed under section 

1139A of the Act. 

We received public comments on the 

proposed approach to stratification of 

Core Set data, and in general, 

commenters supported the proposed 

process. We are finalizing these 

provisions generally as proposed in 

§ 437.10(b)(7) and (d), with minor 

wording changes. Below is a summary 

of the public comments we received 

regarding this section and our 

responses. 

Comment: Several commenters 

supported the proposed requirement to 

phase in stratified reporting over a 

period of 5 years and recommended that 

the Secretary specify which measures 

must be stratified in order to promote 

consistency and comparability across 

States rather than allowing States to 

decide the measures and factors for 

which they will submit stratified data 

each year. A few commenters 

recommended instead that States be 

able to choose based on data availability 

or State health care priorities. Multiple 

commenters also supported the 

proposed requirements that States 

stratify certain measures by 

demographics, health care delivery 

systems, and other characteristics to 

enable better care comparisons and 

identification of health disparities. 

Some commenters recommended that 

CMS ensure that stratified data be 

reported for both managed care and FFS 

delivery systems. Several commenters 

supported the improved and expanded 


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32Technical Assistance Fact Sheet: https://

www.medicaid.gov/medicaid/quality-of-care/ 

downloads/tafactsheet.pdf. 

33The categories for HHS data standards for race 

and ethnicity are based on the disaggregation of the 

OMB standard: https://minorityhealth.hhs.gov/ 

omh/browse.aspx?lvl=3&lvlid=53. 

collection of data, and analysis of 

quality measures by population (such as 

dually eligible individuals), 

stratification categories (such as race 

and ethnicity or disability status), and 

delivery systems and provider types. 

They noted that these activities would 

allow for the deployment of strategies 

that better account for the needs of 

beneficiaries and further understanding 

of barriers to care and health disparities. 

One commenter also recommended that 

CMS make available reporting guidance, 

information on potential or expected 

data sources, and share examples of 

State data collection, organization, and 

lessons learned. 

Response: We worked to find a 

balance in the reporting of State data 

that meets the statutory reporting 

requirements under sections 

1139A(c)(2) and 1139B(d)(2) of the Act 

while taking into consideration data 

quality and the ability to conduct 

comparative analysis, and we 

determined that allowing States to 

choose which measures to stratify based 

on data availability or State health care 

priorities would limit our ability to 

publish standardized core measure data 

that could be compared across States 

and over time. Therefore, in the 

methodology we are finalizing in 

§ 437.10(b)(7) and (d), stratified 

reporting will be phased in over a 

period of 5 years, and the Secretary will 

specify which measures should be 

stratified and by which factors data will 

be stratified. We will provide technical 

assistance to support mandatory 

reporting of stratified data and will 

ensure that States have access to 

reporting guidance and other tools in 

order to assist with annual reporting.32

Comment: One commenter stated that 

the Core Sets were initially developed 

as a within-State quality improvement 

tool. Because State Medicaid programs 

vary greatly in eligibility and offerings, 

it is important that proposed 

stratifications do not lead to State-toState comparison without consideration 

for the populations served. The 

commenter also stated that 

stratifications would add to State 

reporting burden while not adding 

additional value or information for 

improvement, and recommended 

stratification be piloted first to 

determine if it is needed. 

Response: The Child Core Set was 

intended not only to provide States with 

a tool to drive improvement for their 

enrollees but also to provide an estimate 

of the overall national quality of health 

care for children (section 1139A(a)(5) of 

the Act). As discussed previously in this 

final rule, we believe that stratification 

of data in the Child Core Set, Adult Core 

Set, and Health Home Core Sets 

measures is consistent with our 

statutory authorities. Stratified Core Set 

quality measure data will enable CMS 

and States to identify the health 

outcomes of underserved populations as 

well as potential differences in health 

outcomes between populations. 

Stratified data can also inform adoption 

of broadly applicable quality 

improvement initiatives that address the 

drivers of health disparities experienced 

by underserved populations. Due to the 

variability across States in the 

populations served by Medicaid and 

CHIP, and the different populations and 

health care services included in each 

core measure, a pilot project using a 

subset of States and/or measures would 

not provide sufficient data or results 

that could be generalized to provide an 

understanding of differences in health 

outcomes overall. 

Comment: Several commenters 

submitted recommendations and 

requests related to the details of 

stratified reporting, such as definitions 

of specific categories, data suppression 

policies and how to handle missing 

data, and different measures of delivery 

systems. 

Response: We will take these 

comments into consideration when 

developing annual reporting guidance. 

We are finalizing the list of stratification 

factors in § 437.10(b)(7) with minor 

edits, to include race, ethnicity, sex, age, 

rural/urban status, disability, and 

language, as well as additional factors as 

may be specified by the Secretary and 

informed by annual consultation with 

States and interested parties. 

Comment: Several commenters 

recommended that consistent data 

standards for stratification of race, 

ethnicity, and language, across programs 

and agencies would clarify and facilitate 

data collection. However, one 

commenter noted that new standards 

should not inhibit the ability of States 

to tailor their data fields to reflect their 

populations as long as they are able to 

be aggregated to Federal categories and 

that any guidance provided by CMS in 

this area should also recognize the 

experiences of people with multiple 

racial and/or ethnic identities. 

Additionally, several commenters 

suggested that CMS include a ‘‘Middle 

Eastern or North African’’ response 

among the race and ethnicity measures, 

allowing for stratified health outcomes 

for a population that experiences 

disparities. 

Response: The specific response 

categories included in stratified 

reporting will be addressed as part of 

the reporting guidance process that is 

discussed in the rule. We will take these 

recommendations into consideration 

when developing annual reporting 

guidance, considering data availability, 

data quality, and burden to States. We 

expect to align with Department of 

Health and Human Services (HHS) data 

standards for stratification, based on the 

disaggregation of the 1997 Office of 

Management and Budget (OMB) 

Statistical Policy Directive No 15.33 We 

expect to update Core Set reporting 

stratification categories if there are any 

changes to OMB or HHS Data Standards. 

Comment: One commenter 

recommended that unknown, missing, 

or nonresponses on demographic 

variables be its own stratification 

category with its own associated 

measure rate. Another commenter 

recommended that CMS provide 

technical assistance to States on how to 

collect and report race and ethnicity 

information, including how States 

should handle large percentages of data 

records with ‘‘unknown’’ race and 

ethnicity. Several commenters 

recommended that an optional category 

for ‘‘declined to answer’’ or similar 

category be included in State reporting. 

A few commenters recommended a 

methodology for identifying 

beneficiaries with a disability based on 

disability questions from the American 

Community Survey. Another 

commenter noted that there is not a 

Federal standard defining ‘‘disability’’ 

and requested that CMS establish one 

for consistency in reporting in this and 

other programs. 

Response: We will take this feedback 

into consideration when developing 

Core Set reporting guidance on 

stratification requirements. This area of 

data collection and reporting is evolving 

rapidly, and we expect to provide 

additional technical assistance and 

support in this space in the future. 

Comment: Several commenters 

supported all the proposed 

requirements for stratification but 

recommended either faster or slower 

implementation. Some commenters 

suggested that States be required to 

report stratified data by the 2024 

reporting period rather than phase in 

this requirement. Another commenter 

noted that a shorter phase-in period 

would not be overly burdensome to 

States given the enhanced Federal 


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Federal Register / Vol. 88, No. 168 / Thursday, August 31, 2023 / Rules and Regulations 60289 

34Technical Assistance Fact Sheet: https://

www.medicaid.gov/medicaid/quality-of-care/ 

downloads/tafactsheet.pdf. 

35Technical Assistance Fact Sheet: https://

www.medicaid.gov/medicaid/quality-of-care/ 

downloads/tafactsheet.pdf. 

Medicaid match for upgrading computer 

systems for this kind of reporting. 

Multiple commenters provided alternate 

phase-in schedules for stratification of 

Core Set measures. 

Response: We agree on the 

importance of reporting stratified data to 

help identify and eliminate health 

disparities across populations. 

Reporting of stratified data is a 

cornerstone of our approach to 

advancing health equity, as outlined in 

the proposed rule. We determined that 

a shorter phase-in period, such as 

between 1 and 4 years, would not likely 

be operationally feasible because of the 

potential systems and contracting 

changes (to existing contracts or the 

establishment of new contracts) that 

States may be required to make in order 

to collect these data. For example, 

additional reporting requirements may 

need to be added to State contracts, 

changes may be needed to data sharing 

agreements with MCOs, and 

modifications of databases or systems 

might be required to record new 

variables. Based on discussions with 

States regarding the feasibility of 

reporting stratified data, and the 

comments received supporting the 

proposed timeframe, we have addressed 

the comments recommending a longer 

duration of phase-in by revising 

§ 437.10(b)(5) to include flexibility in 

the reporting of some populations in the 

initial years of reporting the Child and 

Adult Core Sets. Of note, the section 

1945A health home benefit requires 

providers of that benefit to report to 

States on quality measures as a 

condition of payment. The populations 

which will be optional for States to 

include in reporting of the Child and 

Adult Core Sets will be specified in 

annual subregulatory guidance. In 

addition, we anticipate that States will 

not need more than 5 years to 

implement systems and contracting 

changes, or any additional support 

needed to report stratified data. We plan 

to work collaboratively with States to 

provide the technical assistance and 

reporting guidance necessary to support 

reporting of stratified data.34 While 

States may be eligible for an increased 

Federal match for systems changes, 

States still bear a share of the cost, and 

making the needed systems changes is 

time-intensive, likely requiring several 

years or more to implement. We have 

therefore determined that the proposed 

5-year phased-in approach to data 

stratification is reasonable and would 

also be consistent with section 

1945A(g)(2)(A) of the Act for 1945A 

health home programs. With this 

approach, we are balancing our strong 

interest in identifying differences in 

health outcomes between populations 

(as supported by our statutory 

authorities, as discussed previously in 

this final rule) with the operational 

challenges that States may face in 

implementing these requirements. We 

are finalizing the proposed phase-in 

time frames under § 437.10(b)(7) and (d) 

as proposed. States will thus be required 

to submit stratified data for 25 percent 

of the measures on each of the Core Sets 

(the Child Core Set, behavioral health 

measures within the Adult Core Set, and 

Health Home Core Sets) for which the 

Secretary has specified that reporting 

should be stratified by the second year 

of annual reporting after the effective 

date of the final rule; 50 percent of such 

measures for the third and fourth years 

of annual reporting after the effective 

date of the final rule; and 100 percent 

of measures beginning in the fifth year 

of annual reporting after the effective 

date of the final rule, on all factors as 

specified by the Secretary pursuant to 

§ 437.10(b)(7), such as race and 

ethnicity, sex, age, rural/urban, 

disability and language. 

Comment: One commenter 

recommended that CMS modify the 

stratification schedule to consider a 

phased-in approach based on the 

stratification factor, for example, race, 

instead of the number of measures. 

Response: We appreciate this 

feedback and will consider it when 

developing annual reporting guidance. 

Specific factors by which data will by 

stratified will be delineated in annual 

reporting guidance, and we will select 

these factors based on relevance and 

feasibility with the plan to add over 

time as the quality and completeness of 

data improve. We are finalizing 

§ 437.10(d) generally as proposed. 

Comment: Multiple commenters 

recommended strategies for determining 

which measures should be stratified 

first and by which stratification factor(s) 

(that is, separate factors or multiple 

factors simultaneously). These strategies 

included working collaboratively with 

States and State-contracted entities, 

aligning with the measures and timeline 

for stratification as determined by 

NCQA Healthcare Effectiveness Data 

and Information Set (HEDIS) for their 

measures, beginning the phase-in with 

measures that are currently stratified for 

NCQA HEDIS reporting, and giving 

States the flexibility to decide the 

measures and factors for which they 

will submit stratified data each year. 

Several commenters recommended that 

CMS prioritize how measure 

stratification is phased in based on the 

topics of most urgent need, such as 

maternal and behavioral health, or 

measures addressing disease prevention. 

Some commenters encouraged 

stratification of the Core Set measures 

based on data obtained from the 

Consumer Assessment of Healthcare 

Providers and Systems (CAHPS) survey, 

while others encouraged CMS not to 

require stratified CAHPS data. Some 

commenters encouraged CMS to ensure 

buy-in from interested parties such as 

States, beneficiary groups, and 

providers on measures selected for 

stratification so that States have 

adequate time to ensure that they are 

reporting high quality data. 

Response: We will take these ideas 

into consideration when developing 

annual reporting guidance, and plan to 

work collaboratively with States to 

provide the technical assistance and 

reporting guidance necessary to support 

reporting of stratified data.35 We are 

finalizing as proposed the phase-in 

process for reporting stratified Core Set 

measures in § 437.10(b)(7) and (d) of 

this final rule. 

Comment: We received many 

comments making recommendations on 

stratification factors for State reporting 

of Core Sets in § 437.10(b)(7) and (d) 

such as: 

• Addition of sexual orientation and 

gender identity; socio-demographic 

data; pregnancy status; and 

socioeconomic status; 

• Addition of the State’s Medicaid 

expansion status with respect to 

coverage of adults under age 65 who are 

described in 42 CFR 435.119, as well as 

extended coverage during the 12-month 

postpartum period under section 

1902(e)(16) and 2107(e)(1)(J) of the Act; 

and 

• Recommendations both for and 

against addition of health care delivery 

system as a stratification factor. Many 

commenters noted that stratification by 

health plan could identify trends in 

quality, advance State alternative 

payment methodologies, and support 

oversight. One commenter noted that 

stratification by health plan would be 

especially helpful in comparing plans 

that are engaged in quality improvement 

projects to those that are not. Other 

commenters suggested that it may be 

helpful for certain measures to be 

stratified on a multi-level basis, for 

example, health plan data disaggregated 

by race, ethnicity, and other factors. 

Another commenter suggested that 

stratification by delivery system be used 


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36https://www.medicaid.gov/medicaid/data-andsystems/macbis/tmsis/tmsis-blog/109701. 

37Elliott, Marc N., et al. ‘‘Using the Census 

Bureau’s surname list to improve estimates of race/ 

ethnicity and associated disparities.’’ Health 

Services and Outcomes Research Methodology 9.2 

(2009): 69–83. 

38The categories for HHS data standards for race 

and ethnicity are based on the disaggregation of the 

OMB standard: https://minorityhealth.hhs.gov/ 

omh/browse.aspx?lvl=3&lvlid=53. 

39Health Insurance Marketplace Application 

Instructions: https://www.healthcare.gov/ 

downloads/marketplace-application-for-familyinstructions.pdf. 

40States could adopt this or similar language in 

their application, regardless of the modality (paper, 

online, phone). 

41CMS Cell Suppression Policy: https://

www.hhs.gov/guidance/document/cms-cellsuppression-policy. 

for quality improvement efforts only, 

and public reporting occur at the State 

level. A few commenters recommended 

that CMS not require stratification by 

health plan given the regional and 

population differences served by 

Medicaid managed care in States unless 

CMS can account for variation in 

geography, population, and benefits. 

Response: We will take these 

comments into consideration when 

developing annual reporting guidance, 

which will include stratification factors. 

We are finalizing § 437.10(b)(7) and (d) 

generally as proposed to allow for the 

additional stratification by other factors 

as may be specified by the Secretary and 

informed by annual consultation with 

States and interested parties per 

§ 437.10(a)(3), which could include 

stratification by health plan or other 

factors described previously in this final 

rule. This approach provides us with 

flexibility to adjust stratification 

requirements by factors that are both 

feasible and relevant in a rapidly 

evolving field. 

Comment: Many commenters 

discussed both the positives and 

negatives of CMS potentially using 

geolocation or other types of data to 

impute identification of race and 

ethnicity. Several commenters 

recommended that CMS not use 

imputed data to calculate race and 

ethnicity data, and instead focus efforts 

on improving the collection and 

completeness of self-reported race and 

ethnicity data, and minimizing the 

burden of data collection and reporting, 

particularly on consumers. Multiple 

commenters recommended that CMS 

use imputed data sparingly, with some 

suggesting that CMS share any imputed 

data with States for review prior to 

publication, or not publicly report the 

results of stratification based on 

imputed data given the lack of validity 

of such data. Commenters noted it is 

critical that CMS provide details on 

what specific imputation methods 

would be used to stratify the Medicaid 

data, as many methods have been 

developed based on Medicare data and 

may not yield as accurate results in the 

Medicaid population. Additionally, one 

commenter recommended use of 

standardized imputation methods across 

the industry. 

Response: We agree that self-reported 

beneficiary data should be used 

whenever possible, and that it is 

important to undertake efforts to 

improve data quality. To that end, in 

our efforts to improve the quality of race 

and ethnicity data, we have: issued 

guidance on reporting race and ethnicity 

in Transformed Medicaid Statistical 

Information System (T–MSIS); 36

provided State technical assistance on 

identifying and investigating data 

quality issues based on unspecified, 

unknown, missing or invalid race and 

ethnicity data and worked with States to 

improve data quality and completeness; 

and published data quality assessments 

in the Medicaid Data Quality (DQ) 

Atlas. Complete demographic 

information from beneficiaries is the 

optimal source of data for stratification, 

and our development of imputation 

models is intended to complement this 

source with a reliable method to 

identify disparities in the face of 

missing or inaccurate data.37 We will 

release detailed documentation about 

the methodology used to develop 

imputations prior to the release of these 

data. We will take these suggestions into 

consideration and will consult with 

States on the use of imputed race and 

ethnicity when developing annual 

reporting guidance, technical assistance, 

and other resources for States. 

Comment: We received several 

comments about other sources of 

demographic data. Several commenters 

recommended that CMS use 

demographic data collected on the 

Medicaid and CHIP eligibility 

application and provide guidance that 

covers the entire process of data 

collection, reporting, and sharing. In 

reference to self-reported data, one 

commenter suggested CMS ensure that 

consumers are aware of the reasons why 

the data are being collected, that the 

process is voluntary, that no adverse 

action will result for failing to provide 

the data (that is, no loss of health 

benefits or access to services), and of 

how the data may be used, shared, and 

disclosed. Multiple commenters 

recommended that the CMS Single, 

Streamlined Online Application be 

revised to allow beneficiaries to select a 

‘‘decline to answer’’ option in response 

to demographic questions. Other 

commenters suggested using State 

administrative data to supplement 

missing demographic information, and 

the use of electronic data in general, and 

recommended that CMS provide 

technical assistance on how to report 

measures for individuals with 

‘‘unknown’’ race/ethnicity. One 

commenter suggested providing detailed 

measure information, such as indicating 

the data source or imputation 

methodology for demographic and 

performance data. 

Response: Modifications to the Single 

Streamlined Application and State 

eligibility forms are outside the scope of 

this rulemaking; however, we will take 

the suggestions into consideration when 

making updates to the Single 

Streamlined Application. The Single 

Streamlined Application follows the 

OMB data standards for collection of 

race and ethnicity data, and use of this 

application is optional for States.38

When developing their own 

applications, States are encouraged to 

use the same standards and must ensure 

that questions asking about race and 

ethnicity are optional. The Single 

Streamlined Application eligibility 

application available through 

HealthCare.gov includes the following 

language alongside questions about race 

and ethnicity: ‘‘Selecting this person’s 

race and ethnicity helps the U.S. 

Department of Health and Human 

Services improve service to all people 

using the Marketplace. We use this 

information to make sure everyone gets 

fair access to coverage. Providing this 

information won’t impact eligibility, 

plan options, or costs.’’ 39 State 

Medicaid and CHIP agencies have the 

flexibility to choose to include similar 

language in their eligibility applications 

and are better positioned than CMS to 

collect this data directly.40

Comment: Several commenters 

recommended that CMS acknowledge 

that States with smaller and/or more 

homogeneous populations may not be 

able to report data for a sufficient 

number of individuals for some 

stratification categories, such that CMS 

will need to suppress data to ensure 

privacy protections. 

Response: We agree with the need to 

protect beneficiary privacy. We noted in 

the proposed rule that we will follow 

data suppression policies for measure 

stewards in addition to the CMS Cell 

Size Suppression Policy such that if 

sample sizes are too small, data will not 

be publicly reported to avoid a potential 

violation of privacy. We are finalizing 

§ 437.10(d) generally as proposed.41 We 

plan to provide technical assistance to 


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States as needed and will publish data 

suppression guidance in annual 

reporting guidance. 

Comment: One commenter 

recommended establishing minimum 

denominators to identify statistically 

significant changes in disparities. 

Response: We will take this comment 

into consideration for future guidance 

regarding health disparity analysis. 

Comment: Some commenters 

suggested methods for CMS to align 

with other measure sets and 

organizations. Several commenters 

requested that CMS align with NCQA 

HEDIS as much as possible, including 

stratification categories and age ranges, 

and that other stratification factors be 

phased in after race and ethnicity. One 

commenter recommended that CMS 

explore using data submitted to NCQA 

for accreditation to ease burden on 

providers, plans, and States. Another 

commenter recommended that CMS 

encourage States to use the NCQA 

Electronic Clinical Data System (ECDS) 

reporting method for applicable 

measures. One commenter suggested the 

Federal government streamline efforts 

and standardize measures sets across all 

payers, and that CMS, Health Resources 

and Services Administration (HRSA), 

and HHS provide available data when 

possible to reduce burden to States and 

providers. Another commenter 

suggested CMS explore opportunities to 

get a broader view of child health by 

connecting different Federal databases, 

including those that collect data for 

Title V, public health, child welfare and 

children’s mental health programs, and 

encourage these same connections at the 

State level. 

Response: We will take these ideas 

into consideration when developing 

annual reporting guidance. We agree 

with the commenters on the importance 

of parsimony, alignment, and 

harmonization in quality measurement 

to the extent possible. Throughout the 

annual Core Set review process, we 

actively engage with a variety of internal 

and external interested parties, Federal 

partners, other reporting agencies 

related to Medicaid and CHIP, and 

Medicare and Marketplace. This process 

facilitates measure alignment as 

appropriate, noting areas of needed 

divergence due to differences in 

reporting levels. 

Comment: Several commenters 

recommended that CMS work with 

other Federal agencies on Fast 

Healthcare Interoperability Resources 

(FHIR) application programming 

interfaces (API) standards, stating that 

aligning with FHIR standards would 

resolve many of the challenges in 

accessing both administrative and 

clinical data required to report Core Set 

measures, including demographic data 

required for stratification. These 

commenters encouraged CMS to explore 

ways to leverage the current 

interoperability and information sharing 

regulations to promote data sharing 

across systems and minimize the 

reporting burden on consumers. One 

commenter recommended that CMS 

undertake an assessment of the barriers 

and opportunities to enable data 

exchange and information systems 

interoperability in order to help report 

outcomes-based measures. Another 

commenter noted that simply relying on 

Electronic Health Record (EHR) vendors 

to implement FHIR and United States 

Core Data for Interoperability (USCDI) 

standards will not be enough to ensure 

complete and accurate data. One 

commenter noted challenges with 

sharing data across systems with 

different EHRs. Several commenters 

expressed concern about data entry 

errors creating an increased State 

burden and recommended that CMS 

consider technical interventions such as 

open-source tools or use of structured 

electronic data files, standardized 

spreadsheets, API or other upload 

options to reduce burden and errors 

created through manual data entry. 

Response: We will take these 

comments into consideration when 

developing annual reporting guidance, 

technical assistance, and other resources 

for States. 

D. Annual Reporting on the Child, 

Adult, and Health Home Core Sets 

As discussed in section II.D. of the 

proposed rule, we proposed in §§ 437.10 

and 437.15 the key requirements and 

procedures for States in reporting both 

mandatory and voluntary measures, 

including the procedures to identify 

measures that States would report, 

measures that we would report on 

behalf of States, and measures for which 

States may elect to have us report on 

their behalf. We also solicited comments 

on what technical assistance we should 

provide to support these activities. 

We received public comments on the 

process proposed in §§ 437.10 and 

437.15, and in general, commenters 

supported the proposed process. We are 

finalizing these provisions with 

revisions to §§ 437.10 and 437.15. We 

describe in section II.D.2. of this final 

rule our revisions to §§ 437.10 and 

437.15 regarding reporting of mandatory 

measures, in addition to a revision 

regarding survey-based measures in 

§ 437.10(b)(1)(v). We describe in section 

II.D.3. of this final rule our revisions to 

§§ 437.10 and 437.15 regarding 

populations required for mandatory 

reporting. Below is a summary of the 

public comments we received regarding 

this section and our responses. 

Comment: Several commenters 

recommended that CMS allow States the 

option to self-report; or allow other 

alternate data sources such as 

Transformed Medicaid Statistical 

Information System (T–MSIS) Analytic 

Files (TAF) to be used to calculate 

measures on States’ behalf. However, 

these and other commenters requested 

additional information on the use of T– 

MSIS/TAF and noted that alternate data 

sources should be used only under 

certain conditions, namely: that States 

are allowed to opt-out; that States are 

provided the opportunity to review and 

confirm results; and that the calculation 

methodology adheres to the measure 

specifications including use of denied 

claims, among other stipulations. One 

commenter also requested that CMS 

provide States with assistance in 

investigating data discrepancies or 

measurements that seem to be in error. 

Response: We will continue to assess 

whether T–MSIS/TAF or other alternate 

data sources can be used to calculate 

Core Set measures on behalf of States. 

As stated in § 437.10(b)(1)(iv), we will 

continue to calculate selected measures 

on States’ behalf using alternative data 

sources and, in these cases, we 

anticipate providing States with an 

opportunity to preview data. For other 

selected measures, as stated in 

§ 437.10(b)(1)(iv), we will allow States 

the option to either self-report (if they 

adhere to CMS-issued reporting 

guidance as per § 437.15(a)(3)), or allow 

the measures to be calculated on States’ 

behalf using alternate data sources. We 

currently provide States an opportunity 

to preview data for any measure 

calculated utilizing alternate data 

sources such as ‘‘Live Births Weighing 

Less Than 2,500 Grams’’ on the Child 

Core Set and ‘‘National Core Indicators 

Survey’’ on the Adult Core Set and 

intend to continue doing so. We are 

finalizing §§ 437.10(b)(1)(iv) as 

proposed and § 437.15(a)(3) with a 

minor wording change. 

Comment: Several commenters raised 

concerns with the use of T–MSIS/TAF 

data to calculate Core Set data or for 

stratification, as there may be issues 

with the data validity for many States, 

and recommended that CMS not use T– 

MSIS for reporting on behalf of States. 

For example, some measures may 

require more years of data than are 

available through T–MSIS, or data 

reported through T–MSIS may be 

incomplete. 

Response: We assess each Core Set 

measure individually to determine if it 

is able to be calculated using T–MSIS/ 


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42Health Home FAQs (January 21, 2016), https:// 

www.medicaid.gov/sites/default/files/2020-02/ 

health-homes-section-2703-faq.pdf. 

43Technical Assistance Fact Sheet: https://

www.medicaid.gov/medicaid/quality-of-care/ 

downloads/tafactsheet.pdf. 

44About the Medicaid and CHIP Core Set 

Technical Assistance and Analytic Support 

Program: https://www.medicaid.gov/medicaid/ 

quality-of-care/downloads/tafactsheet.pdf. 

TAF data, based on the technical 

specifications, considering the years of 

data available in T–MSIS and also the 

types of data required to accurately 

calculate that measure. As stated 

previously in this final rule preamble, 

we also intend to allow States to 

preview all Core Set data generated by 

T–MSIS. 

Comment: One commenter 

recommended that CMS develop a 

third-party validation process that 

certifies State measure logic and audits 

Information Technology (IT)/ 

measurement systems in a standardized 

way. This commenter also suggested 

validating supplemental data from the 

source, providing the example of 

NCQA’s Data Aggregatory Validation 

program. Another commenter 

recommended that CMS test and 

validate stratified results to ensure they 

are accurate. 

Response: We agree with the 

commenter on the importance of data 

quality in Core Set reporting. We have 

built a pre-publication quality assurance 

process into the review of all Core Sets 

data. Through this process, we work 

with States to resolve data quality issues 

and confirm any deviations from the 

reporting guidance. Sections 1139A and 

1139B of the Act require the Secretary 

to collect, analyze, and make publicly 

available the information reported by 

States; however, these sections do not 

require the levels of data validation 

recommended by these commenters. 

While sections 1945(g) and 1945A(g) of 

the Act give the Secretary the authority 

to establish requirements related to the 

form and manner of health home quality 

reporting, they do not specify that the 

Secretary must require data validation 

of submissions. We will continue to 

evaluate data validation needs in 

developing resources for Core Set 

reporting. 

Comment: One commenter 

recommended that CMS maximize the 

use of performance data that can be 

collected and transmitted electronically, 

and to minimize manual data collection. 

We understand the commenter to be 

recommending that the measures on the 

Core Sets primarily be those that can be 

calculated using only administrative or 

EHR data versus those that require 

manual chart reviews or in-person 

surveys. 

Response: We appreciate the 

submission of these comments and will 

take this feedback into consideration in 

the subregulatory measure review 

process. 

Comment: One commenter noted that 

if Health Homes are required to report 

to the State, each Health Home will 

require extensive technical assistance, 

funding for technical assistance and 

result validation, expertise in quality 

measure specifications, and staff. Some 

commenters noted that Health Home 

programs and their providers of Care 

Management do not have reliable, 

current, and consistent access to claims, 

encounter, and clinical data to 

effectively report on these measures. 

They further stated that Health Home 

care management is not itself a clinical 

protocol model of care management, but 

rather a set of care management 

practices that facilitate clinical care, 

address social care needs, provide 

education, increase member health 

literacy, and address health equity and 

disparities to improve health outcomes, 

all of which makes it challenging to 

report on the Health Home Core Sets. 

Response: This final rule implements 

statutory reporting requirements for 

providers of section 1945 and section 

1945A health home services at sections 

1945(g) and 1945A(g)(1)(B) of the Act. 

Providers of section 1945 health home 

services are required to meet the 

reporting requirements specified at 

section 1945(g) of the Act, and providers 

of section 1945A health home services 

are required to meet reporting 

requirements specified at section 

1945A(g)(1)(B) of the Act. If a Health 

Home provider is submitting data into a 

State-based system that the State is then 

using to calculate and report the Health 

Home Core Sets measures to us, those 

data submissions from the provider to 

the State would satisfy the statutory 

requirements under sections 1945(g) 

and 1945A(g)(1)(B) of the Act. 

Comprehensive care management 

services are not a set protocol but rather 

one of the six services included in both 

the section 1945 and section 1945A 

Health Home benefits, as specified at 

sections 1945(h)(4)(B)(i) and 

1945A(i)(4)(B)(i) of the Act. We have 

provided additional information about 

how we interpret this component of the 

section 1945 benefit in frequently asked 

questions (FAQs).42 Health Home 

quality measure reporting has always 

been mandatory for participating 

providers under both sections 1945 and 

1945A of the Act (even if using CMS’ 

recommended measures has not been 

mandatory), and health home providers 

will need to coordinate with the State 

Medicaid Agency to seek assistance 

with Core Set reporting. We understood 

the comment to express the belief that 

the Health Home Core Set measures will 

be challenging to report, because the 

health home model does not provide 

direct, clinical care services to patients. 

This health home benefit is designed to 

be a care coordination model, and we 

recognize that implementing a service 

model that is separate from the 

provision of direct, clinical care services 

to patients may be a shift for some 

providers and States from models that 

provide direct, clinical care services, 

and that data sources may be different 

between the two types of models. We 

are available to provide technical 

assistance to States to navigate any 

challenges they may have when 

reporting Health Home Core Sets, and as 

such, we do not believe the reporting 

burden on States and providers is 

unreasonable.43

Comment: One commenter 

recommended allowing a minimum of 

18 months to develop, test, and deploy 

new reporting requirements from a 

health IT standpoint once a State 

provides technical specifications to 

developers. Another commenter 

proposed that CMS consider that 

whenever multiple mandatory hybrid 

and survey measures are introduced in 

1 year, staffing constraints, contractual 

agreements, procurement cycles, and 

similar issues may have an impact on 

States’ abilities to gather data and 

calculate rates. 

Response: We will take these 

comments into consideration when 

determining additions to the Core Sets 

for mandatory reporting. 

Comment: One commenter requested 

that we explain whether the reporting 

requirements would increase the 

reporting burden on States and would 

not increase the burden on Indian 

Health Service (IHS) or Tribal facilities. 

They further recommended that if there 

was a reporting burden on IHS or Tribes 

and Tribal Organizations that CMS 

provide the same technical assistance to 

Tribes as it provides to States. 

Response: We will provide States 

with technical assistance 44 related to 

Core Set reporting and will encourage 

States to work with Tribes and Tribal 

Organizations to improve data sharing. 

We recognize that States and Tribes 

establish individual contractual 

agreements that might affect the 

availability of Tribal data for Core Sets 

reporting. Given the different 

responsibilities for reporting that States 

and health care providers (such as those 

operated by IHS, Tribes, and Tribal 

Organizations) will have and the 


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differences in resources available to 

them, it is hard to gauge for whom the 

burden of reporting will be greater or 

lesser. States should undertake Tribal 

Consultation related to reporting of Core 

Set measures, and are encouraged to 

coordinate with IHS, Tribes, and Tribal 

Organizations, to support data sharing. 

Comment: One commenter noted a 

need for technical assistance 

incorporating States’ Immunization 

Registry into their data warehouse, with 

tasks such as mapping individuals from 

the registry against Medicaid members 

and identifying the percent match rate. 

This commenter also stated that their 

State may need assistance with 

including CHIP enrollees’ birth and 

mortality records from the State’s Vital 

Statistics Office into their Medicaid and 

CHIP data warehouse. 

Response: We will take this feedback 

into consideration when developing 

technical assistance resources and 

reporting guidance for Core Set 

reporting. 

Comment: Multiple commenters 

recommended that CMS continue to 

offer technical assistance using a variety 

of formats including written guidance, 

standard templates, FAQs, measure 

specification and coding assistance, 

sharing of best practices, one-on-one 

State-specific technical assistance, 

learning collaboratives, direct 

communication with the technical 

assistance contractor, and instructional 

webinars that allow for questions. 

Commenters noted these have been 

effective mechanisms and will be 

needed in the future to meet mandatory 

reporting requirements. One commenter 

recommended templates and examples 

as part of technical assistance, while 

another recommended further 

clarification, structuring, and additional 

details in the reporting guidance to help 

streamline reporting and reduce error, 

but also to help States conduct quality 

assurance for their results. Additionally, 

several commenters requested technical 

assistance on data sharing with Federal 

and commercial partners, data 

stratification requirements, and how to 

address data limitations such as small 

sample sizes. 

Response: We thank the commenters 

for their feedback on technical 

assistance methods and needs. We will 

provide technical assistance and will 

consider the suggestions when 

developing future technical assistance 

resources. 

1. Adherence to Reporting Guidance 

As discussed in section II.D.1. of the 

proposed rule, we proposed in 

§ 437.15(a)(3) to require States to report 

on the Core Sets in a manner that 

adheres to CMS-issued reporting 

guidance described in § 437.10(b), 

which we proposed would include 

procedures and standardized formats for 

reporting measure data. 

In general, commenters supported 

these proposals, and we are not making 

any changes to them in response to 

these comments. Below is a summary of 

the public comments we received 

regarding specific components of these 

proposals and our responses. 

Comment: Multiple commenters 

concurred with CMS requiring States to 

adhere to the annual reporting 

guidelines to enable comparisons across 

States on quality performance and to 

calculate national performance rates for 

quality of care. Other commenters noted 

that standardized reporting should be 

the minimum requirement, and 

expectations for reporting should 

increase over time. 

Response: We agree that requiring 

States to adhere to the reporting 

guidance, which we are finalizing in 

§ 437.15(a)(3), is essential to provide 

effective comparisons across States on 

quality measure performance and to 

derive national performance rates for 

the care provided to Medicaid and CHIP 

beneficiaries. We also recognize that 

adherence to CMS-issued reporting 

guidance as described would be a 

substantial change from current 

reporting for some States. Recognizing 

the challenges that States may face in 

reporting stratified measure data and 

data for certain populations, we are 

finalizing in this rulemaking a phase-in 

approach for both the required 

stratification in § 437.10(d) and the 

reporting for certain populations in 

§ 437.10(c), with stratified reporting of 

all mandatory measures required in the 

fifth year of annual reporting after the 

effective date of part 437 of this final 

rule. 

Comment: Multiple commenters 

expressed concerns regarding strict 

adherence to reporting guidance as 

some deviations are the result of 

underlying differences in how State 

Medicaid programs or their data systems 

are structured. For example, some States 

limit the number of diagnosis codes that 

MCOs can submit, which may result in 

an eligible beneficiary being excluded 

from, for example, a diabetes measure if 

diabetes was not one of the highest 

diagnosis codes submitted for a visit in 

which multiple conditions were 

addressed. Another commenter 

requested that allowances be made for 

States to use the most reliable data 

source available, stating for example, 

the use of birth/vital records data vs. 

claims data for pregnancy/birth-related 

measures provides more specific 

information than can be found in claims 

data alone. One commenter proposed 

that if adherence is required, States 

should be permitted to explain any 

underlying systems differences that 

result in un-representative rates, and 

CMS should include this information 

with public reporting. 

Response: Adherence to the reporting 

guidance is essential to provide effective 

comparisons across States on 

standardized quality measure 

performance and to derive national 

performance rates for the care provided 

to Medicaid and CHIP beneficiaries. As 

such, we are finalizing § 437.15(a)(3) to 

require that States adhere to reporting 

guidance issued by CMS. We will 

provide technical assistance to States to 

support their ability to do so. 

Comment: Several commenters 

requested that reporting guidance 

address the level of data completeness 

required to ensure that the stratified rate 

would be considered valid. Another 

commenter recommended that technical 

assistance be focused first on improving 

data quality. 

Response: We will take these ideas 

into consideration when developing 

technical assistance resources and 

reporting guidance for Core Set 

reporting. 

Comment: Several commenters 

requested that CMS reporting guidance 

for the Core Sets be identical to the 

measure developers’ specifications to 

allow organizations to report measures 

used in multiple programs consistently. 

Several commenters made this 

recommendation specifically due to the 

burden associated with reporting 

measures that deviate from NCQA 

HEDIS specifications, while others also 

recommended this approach specifically 

if deviation from CMS guidance is no 

longer permitted. One commenter also 

recommended that CMS continue 

allowing States to report using audited 

MCO NCQA HEDIS rates. 

Response: We will consider these 

comments when developing reporting 

guidance. Core Set reporting is Statelevel or health home program-level 

reporting, while NCQA HEDIS is planlevel reporting, and therefore, measure 

adaptations are necessary for us to 

provide guidance to States for State- or 

Health Home program-level reporting. 

In making measure adaptations, we 

work closely with measure stewards, 

including NCQA, to develop reporting 

guidance and to make as few 

adaptations to the technical 

specifications as possible. Such 

adjustments generally are limited to 

adjusting the age ranges of a measure to 

align with either the Child or Adult 

Core Sets. 


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45CMS released both the 2023 and 2024 Child 

and Adult Core Sets in November 2022 and the 

2023 and 2024 section 1945 Health Home Core Set 

in December 2022. 

Comment: One commenter 

encouraged CMS to be mindful of 

implementation timelines, which may 

overlap with States’ work related to the 

restoration of eligibility and enrollment 

operations, including terminations of 

enrollment, following the end of the 

continuous enrollment condition under 

section 6008(b)(3) of the Families First 

Coronavirus Response Act, as amended 

by the CAA, 2023, a process referred to 

as ‘‘unwinding.’’ 

Response: The timeline for mandatory 

reporting was statutorily established in 

2018 to implement mandatory annual 

reporting of the Child Core Set and the 

behavioral health measures on the Adult 

Core Set, and these statutes do not 

include any provisions allowing us to 

modify the implementation timeline. 

We interpret the language in the 

Bipartisan Budget Act of 2018 and the 

SUPPORT Act to mandate annual 

reporting of these Core Sets beginning 

with the annual State report on FFY 

2024 and align with State reporting of 

the 2024 Core Sets, currently projected 

to occur in Fall 2024. However, 

consistent with § 437.10(c) and (d), to 

minimize State burden, we plan to 

phase in requirements for measure 

stratification and Child and Adult Core 

Sets reporting for populations for which 

States do not have data access. 

2. Reporting of Mandatory Measures 

As discussed in section II.D.2. of the 

proposed rule, we proposed a 

methodology to phase in reporting of 

certain measures, including those that 

may be complex or difficult to report, 

those that are newly added to the Core 

Sets, or those that had significant 

updates to technical specifications from 

the prior year. We also asked for 

comment on how best to phase in 

reporting, the optimal frequency for 

reporting of outcome and survey-based 

measures, technical assistance States 

may need, and promising practices and 

approaches for data collection and data 

linkages. 

We received comments stating that 

the Secretary does not have the statutory 

authority to delay the reporting of 

selected measures for any of the Core 

Sets, in addition to many comments 

supporting the proposed phased-in 

reporting process for mandatory 

measures. Upon additional review, we 

have determined that all of the measures 

currently on the Child Core Set and all 

of the behavioral health measures on the 

Adult Core Set should be subject to 

mandatory reporting in 2024. The 

majority of the measures proposed for 

the initial mandatory measure set for 

these Core Sets can be calculated using 

administrative data and have been on 

these Core Sets for many years, 

specifically, a median of 7 years for the 

Child Core Set and 10 years for the 

behavioral health measures on the Adult 

Core Set. Based on this analysis, and the 

fact that we have already released the 

list of measures included in the 2024 

Child and Adult Core Sets,45 allowing 

States significant time to prepare to 

report on these measures, we believe 

that all measures on the 2024 Child Core 

Set and all behavioral health measures 

on the 2024 Adult Core Set can be 

reported by States and, in this final 

rulemaking, are requiring that States 

report on all of them. 

We have similarly determined that 

States and health home providers must 

report on all measures in the section 

1945 and/or 1945A Health Home Core 

Sets, to better inform CMS evaluations 

of these health home programs and help 

us to analyze health home measures. 

Section 1945(g) of the Act specifies that, 

as a condition for receiving payment for 

section 1945 health home services, a 

health home provider shall report to the 

State, in accordance with such 

requirements as the Secretary shall 

specify, on all applicable measures for 

determining the quality of such services. 

Section 1945A(g)(1)(B) of the Act states 

that to receive payments for section 

1945A health home services from the 

State a health home provider shall 

report to the State information on all 

applicable measures for determining the 

quality of health home services 

provided by such provider, including, to 

the extent applicable, child health 

quality measures and measures for 

centers of excellence for children with 

complex needs developed under title 

XIX, title XXI, and section 1139A of the 

Act. Additionally, section 

1945A(g)(1)(C) of the Act requires 

section 1945A health home providers to 

report to the State such other 

information as the Secretary shall 

specify in guidance. In sum, both health 

home program statutes require health 

home providers to report to States on all 

applicable health home quality 

measures and give the Secretary 

discretion to identify the measures 

required for reporting each year. Since 

the inception of the section 1945 health 

home benefit, we have strongly 

encouraged States implementing that 

benefit to report on all applicable Health 

Home Core Set measures specified by 

the Secretary, and most have done so. 

Although prior to this rule, Health 

Home Core Set reporting has not been 

mandatory, we have no indication that 

States currently reporting the section 

1945 Health Home Core Set measures 

have faced major burdens in doing so, 

and 100 percent of the current section 

1945 Health Home Core Set measures 

can be reported using administrative 

claims only. When selecting measures to 

add to the Health Home Core Sets, we 

have been careful to ensure States and 

providers are able to report on all 

selected measures, and to ensure that 

the data provided when reporting on the 

measure would be useful for monitoring 

program performance and the quality of 

services provided to beneficiaries 

enrolled in the health home program. 

Based on the high rate of voluntary 

health home measure submission thus 

far, and the careful consideration we 

have given to measure selection, it is 

reasonable for CMS to expect States to 

comply with mandatory reporting for all 

measures on both of the Health Home 

Core Sets in the future. Additionally, 

since both sections 1945 and 1945A 

state that health home providers are 

statutorily required to report to the State 

as a condition of payment, States should 

have these data readily available for 

reporting to us. Finally, reporting of all 

measures on the Health Home Core Sets 

would inform CMS evaluation of both 

health home programs, assist us to 

identify racial, socioeconomic and 

geographical disparities in health 

outcomes, and inform future qualityrelated decisions about national policy 

for Medicaid health home programs by 

providing more uniform national data. 

Therefore, via this rule, we are 

mandating that both States and health 

home providers report on all Health 

Home Core sets measures, consistent 

with the Secretary’s authority under 

sections 1945, 1945A, and 1902(a)(6) of 

the Act. 

We therefore are revising the final 

rule as it pertains to the Child, Adult, 

and Health Home Core Sets as follows. 

We are removing proposed 

§ 437.10(b)(1)(v), which provided States 

with additional time to report selected 

measures. We are replacing that 

proposed paragraph, in response to 

public comment, with language 

specifying that the frequency of 

reporting survey-based measures will be 

no more than annual. Additionally, we 

are revising § 437.10(c) to remove 

reference to phasing in measures and 

adding § 437.15(a)(1)(i) to require 

reporting on all measures in the 2024 

Child Core Set and the behavioral health 

measures in the Adult Core Set. 

Mandatory reporting of the Health 

Home Core Sets is required only for an 

approved health home SPA that has an 


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46Technical Assistance Fact Sheet: https://

www.medicaid.gov/medicaid/quality-of-care/ 

downloads/tafactsheet.pdf. 

effective date and has been 

implemented more than 6 months prior 

to the December 31st reporting deadline. 

This means that, for the States with 

approved health home program 1945 

SPAs that were effective and 

implemented prior to June 30, 2023, the 

section 1945 Health Home Core Set 

would become mandatory in 2024. For 

both 1945 and 1945A SPAs that were 

effective and implemented starting July 

1, 2023 through June 30, 2024, reporting 

the section 1945 and 1945A Core Set(s) 

would become mandatory in 2025. 

Future new mandatory measures will 

be added to the Core Sets through the 

subregulatory process described in this 

rule. Below is a summary of the public 

comments we received regarding this 

section and our responses. 

Comment: Several commenters 

recommended that all States be required 

to report all Child and Adult Core Sets 

quality measures, as specified in statute 

at sections 1139A(a)(4)(B) and 

1139B(b)(3)(B) of the Act, in the 2024 

reporting year. Many commenters stated 

that they did not agree that the Secretary 

has the statutory authority to delay the 

reporting of selected measures for any of 

the Core Sets. One commenter 

recommended that mandatory State 

reporting should be required for all 

Child and Adult Core Sets required in 

statute, but that CMS could create an 

exceptions process for States that 

demonstrated that the requirement 

would generate unreliable data. This 

commenter requested that CMS ensure 

that States operating under such an 

exception report at least a standardized 

minimum set of measures to ensure 

valid comparisons across all States. 

Response: Upon additional review, 

we agree that all of the measures on the 

Child Core Set and the behavioral health 

measures on the Adult Core Set should 

be subject to mandatory reporting in 

2024, consistent with sections 

1139A(a)(4)(B) and 1139B(b)(3)(B) of the 

Act. 

Comment: Some commenters 

supported a phased-in approach to the 

inclusion of measures in mandatory 

reporting. One commenter 

recommended that CMS collect 

feedback from impacted interested 

parties on the most feasible reporting 

timeframe for specific measures while 

another recommended that States be 

allowed at least 2 years to begin 

reporting on new measures. One 

commenter recommended that the 

‘‘Screening for Depression and Followup Plan’’ measure that is on both the 

Child and Adult Core Sets be required 

no earlier than the 2026 Core Sets. 

Another commenter recommended that 

CMS begin mandatory reporting of 

outcome measures using measures that 

only require administrative data and do 

not require supplementary data from 

other sources. Other commenters 

suggested several years of optional 

reporting for outcome and survey 

measures, and for measures that require 

EHR data. 

Response: Upon additional review, 

we have determined that the statute 

requires that all of the measures on the 

Child Core Set and the behavioral health 

measures on the Adult Core Set should 

be subject to mandatory reporting in 

2024. We recognize that some types of 

data collection are more burdensome 

than others, and States often struggle 

with collecting data for measures that 

depend on non-claims sources, hybrid 

specifications, or EHRs. We will provide 

technical assistance including one-onone support to assist States with 

mandatory measures.46 The outcomes of 

this process would be published in 

annual subregulatory guidance, as 

finalized in § 437.10(b) and (c) of this 

final rule. 

Comment: One commenter 

recommended allowing States flexibility 

to determine the approach for hybridand survey-based measures based on 

their delivery system and not limiting 

reporting to one survey type, noting that 

a survey from an MCO that only serves 

beneficiaries with serious mental illness 

would not be comparable to other 

survey populations. 

Response: We appreciate that there is 

considerable variability between States 

in how populations are served within 

their delivery systems and programs and 

how these populations are represented 

in State-level and health home programlevel reporting. Despite these 

differences we believe the use of 

standardized quality measures, 

reporting guidance, and reporting is 

needed to accurately assess and 

compare data across populations and 

time and to allow for identification of 

more specific quality improvement 

opportunities. Use of alternative 

measures or survey types would 

undermine this goal. Therefore, we are 

not making any changes to § 437.10(b) 

in response to this comment. 

Comment: Several commenters made 

recommendations regarding the surveybased measures in the Child and Adult 

Core Sets, such as those based on the 

CAHPS survey. A few commenters 

recommended that CMS require States 

to report data biennially (that is, once 

every 2 years) for all health outcome 

and survey-based measures. However, 

one commenter stated that they 

preferred annual reporting due to the 

loss of measure consistency, need to 

monitor quality improvement projects, 

and staffing and training issues. One 

commenter recommended that CMS 

consider the impact of declining 

response rates to surveys on Core Set 

reporting, and avoid duplicating efforts, 

noting that MCOs are also required to 

conduct CAHPS surveys. Some 

commenters encouraged CMS to explore 

alternative patient experience measures 

before phasing-in mandatory reporting 

of CAHPS-based measures. 

Response: We intend to require 

annual reporting of health outcome and 

survey-based measures, which aligns 

with CHIP reporting requirements in 

section 2108(e) of the Act, as 

implemented through section 402 of 

CHIPRA. Specifically, Title XXI 

programs are required to annually 

submit to CMS data regarding access to 

primary and specialty services, access to 

networks of care, and care coordination 

provided under the State child health 

plan, using quality of care and 

consumer satisfaction measures 

included in the CAHPS survey. 

However, we appreciate the concerns 

raised regarding barriers to annual 

reporting of these measures and believe 

it is important for us to have the 

flexibility to reconsider frequency as 

needed based on State feedback. 

Therefore, we have revised § 437.10 to 

replace paragraph (b)(1)(v), which now 

specifies that survey-based measures 

will be required no more frequently 

than annually, allowing flexibility to 

respond to State needs in the future. 

3. Populations Required for Mandatory 

Reporting 

In section II.D.3. of the proposed rule, 

we explained that we interpret sections 

1139A and 1139B of the Act to require 

that reporting for the Child Core Set 

include all beneficiaries covered by 

Medicaid and CHIP and to require that 

reporting for the behavioral health 

measures in the Adult Core Sets include 

all beneficiaries covered by Medicaid. 

We further explained that this would 

include beneficiaries enrolled in all 

Medicaid and CHIP delivery systems as 

well as services received in all 

applicable health care settings, such as 

hospitals, outpatient settings, Federally 

Qualified Health Centers (FQHCs), rural 

health clinics (RHCs), and facilities 

operated by IHS, by Tribes and Tribal 

Organizations under the Indian SelfDetermination and Education 

Assistance Act, and by Urban Indian 

Organizations under Title V of the 

Indian Health Care Improvement Act. 


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We also explained in section II.D.3. of 

the proposed rule that sections 1945(g), 

1945(c)(4)(B), 1945A(g)(1)(B), and 

1945(g)(2)(A)(i) of the Act, together with 

section 1902(a)(6) of the Act, support 

CMS guidance requiring State reporting 

on the Health Home Core Sets to 

include all beneficiaries enrolled in the 

applicable health home program. We 

further explained that this would 

include health home program 

beneficiaries receiving services through 

all Medicaid delivery systems, as well 

as health home program beneficiaries 

who received Medicaid-covered services 

in all applicable health care settings, 

such as hospitals, outpatient settings, 

FQHCs, RHCs, and facilities operated by 

IHS, Tribes and Tribal Organizations, 

and Urban Indian Organizations, during 

the measurement period. Further, we 

explained that we anticipated that 

health home programs would have to 

report on beneficiaries who have 

received Medicaid-covered health home 

services in FQHCs, RHCs, and facilities 

operated by IHS, Tribes and Tribal 

Organizations, and Urban Indian 

Organizations only if a beneficiary who 

is enrolled in the applicable health 

home program received Medicaidcovered health home services in one of 

these settings during the measurement 

period. 

As explained in the proposed rule, we 

ultimately expected to require States to 

report on the populations discussed 

previously in this final rule for each 

Core Set through the annual reporting 

guidance; however, we did not propose 

to require this to begin with 2024 Core 

Set reporting in light of concerns about 

whether it would be feasible for States 

to begin reporting on all populations as 

soon as the rule would apply. Therefore, 

we proposed that the Secretary could, 

through the annual reporting guidance, 

phase in reporting on certain 

populations. Specifically, we proposed 

at § 437.10(b)(5) that annual reporting 

guidance would identify those 

populations for which States would be 

required to report measure data for a 

given year, and also proposed at 

§ 437.10(c) that this annual guidance 

might provide that mandatory State 

reporting for certain populations of 

beneficiaries would be phased in over a 

specified period of time. These 

proposals applied to all Core Set 

reporting: Child, Adult, and Health 

Home. We solicited comment on how 

best to provide technical assistance to 

support States in reporting on all 

populations as well as on how long 

States may need to be able to report on 

all Medicaid, CHIP, and Health Home 

program beneficiary populations. 

Comment: We received several 

comments supporting full mandatory 

reporting for all populations. However, 

many comments about these proposals 

noted concerns and challenges with 

reporting for specific populations of 

beneficiaries, such as those who are 

dually eligible for Medicare and 

Medicaid; those whose Medicaid or 

CHIP coverage is limited to payment of 

premiums and/or cost sharing, which 

may include those with private 

insurance; and those who receive 

services through Tribes and Tribal 

Organizations. We also received 

comments encouraging CMS to consider 

allowing States the ability to identify 

specific populations where reporting is 

difficult due to unique State 

circumstances. 

Response: Although the majority of 

comments addressed concerns with 

including specific discrete populations 

in reporting of the Child and Adult Core 

Sets, we continue to believe that the 

intention of the statute is to provide the 

most comprehensive quality 

information on as much of the 

population as possible. Our view is that 

Congress’ requirement for a mandatory 

reporting regime emphasizes their intent 

to ensure that all Medicaid and CHIP 

populations are aware of the quality of 

care in their state. Therefore, we have 

revised § 437.15(a)(4) of this final rule to 

require State reporting of mandatory 

Child and Adult Core Set measures for 

all Medicaid and CHIP beneficiaries, 

including those enrolled in fee-forservice and managed care, unless the 

Secretary specifies in annual guidance 

that the population is not required to be 

reported in accordance with 

§ 437.10(b)(5) or CMS grants a State 

exemption for the population for one or 

more Child or Adult Core Set measures 

in accordance with § 437.15(a) of this 

rule. This differs somewhat in approach 

from the proposed rule, in which 

subregulatory guidance would identify 

populations for which States would be 

required to report; however, the final 

rule provisions are generally consistent 

with those commenters who supported 

comprehensive reporting of quality 

information for all Medicaid and CHIP 

populations, and with the proposed rule 

preamble’s discussion of the proposed 

policy for the Child and Adult Core 

Sets. Rather than using subregulatory 

guidance to identify the populations for 

which States must report the Child and 

Adult Core Sets, as we proposed, we 

will instead use the guidance to identify 

specific difficult-to-report populations 

which will be, for a given reporting 

year, optional for states to include in 

reporting of the Child and Adult Core 

Sets. 

With respect to the Health Home Core 

Sets, for the following reasons, we have 

determined that States with section 

1945 or 1945A health home programs 

must report on all beneficiaries enrolled 

in the applicable health home program 

or programs, with no exceptions. 

Reporting on all populations served in 

health home programs will provide us 

with more accurate and comprehensive 

data that will help inform us of the 

effect of the health home benefits on 

coordination of care and aid us in 

identifying ethnic, racial and 

socioeconomic disparities. Also, 

reporting on all beneficiaries allows 

improved analysis of the quality of 

services rendered to persons enrolled in 

health home programs; such reporting 

can be utilized as a tool for the Annual 

Core Set Measures Workgroup when 

evaluating how a measure is 

contributing to the overall CMS mission 

of quality improvement for all 

populations served. Additionally, States 

will have Health Home Core Set 

measure data on all populations 

enrolled in the applicable health home 

from their health home providers, 

which are required to provide it to the 

State as a condition of payment under 

sections 1945(g) and 1945A(g) of the 

Act. Since the requirement for providers 

to report the data collected at the 

program level to States has been in 

effect from the beginning of both 

benefits, most states that have 

implemented the 1945 health home 

benefit have been voluntarily reporting 

on the health home core set for all 

populations. The 1945A health home 

benefit has not been in effect long 

enough to have data on a reporting 

cycle. Additionally, the population 

enrolled in health home programs is 

usually small and easily identifiable 

through existing data collected at the 

program level. Therefore, we have 

added § 437.15(a)(5) to the final rule, to 

require State reporting of sections 1945 

and 1945A Health Home Core Sets 

measures for all beneficiaries enrolled 

in an approved health home program. 

This includes those beneficiaries that 

received Medicaid-covered health home 

services in FQHCs, RHCs, and facilities 

operated by IHS, Tribes and Tribal 

Organizations, and Urban Indian 

Organizations, if the beneficiary who is 

enrolled in the applicable health home 

program received Medicaid-covered 

health home services in one of these 

settings during the measurement period. 

Because reporting on the Health Home 

Core Sets is required for all beneficiaries 

enrolled in an approved health home 


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program, we also have revised 

§ 437.10(b)(5) and (c) of this final rule to 

specifically reference only the Child and 

Adult Core Sets. The revisions to 

§ 437.10(b)(5) required us to remove the 

wording, ‘‘as described in paragraph 

(b)(5) of this section’’ from § 437.10(b)(6) 

as annual reporting guidance on 

attribution rules applies to the Child, 

Adult, and Health Home Core Sets. 

We address concerns about the 

feasibility of Child and Adult Core Sets 

reporting for specific populations in the 

final rule in two ways. First, because we 

recognize that there are certain 

populations for which all States 

potentially face difficulties in obtaining 

data, we are revising § 437.10(b)(5) and 

(c) of this final rule to provide that we 

will use the annual subregulatory 

guidance to identify specific 

populations which will be optional (that 

is, not mandatory) for States to include 

in reporting of the Child and Adult Core 

Sets for a given reporting year. For 

example, all States that commented on 

the proposed rule (including those 

States that currently participate in the 

Medicare-Medicaid Data Sharing 

program) requested more time to obtain, 

link, and analyze Medicare FFS claims 

and Part D events data. Further, States 

do not have access to the Medicare Part 

C data required to report on dually 

eligible beneficiaries who have enrolled 

in Medicare Advantage. Given these 

concerns with data access and 

experience, this could be an example of 

a population that the Secretary may 

exempt in subregulatory guidance 

issued prior to mandatory reporting. We 

note that these data access concerns do 

not impact the States’ ability to report 

on Health Home Core Set measures 

since these measures do not require 

Medicare data. As stated previously, 

States will have Health Home Core Sets 

measure data on all populations 

enrolled in the applicable health home 

from their health home providers, 

which are required to provide it to the 

State as a condition of payment under 

sections 1945(g) and 1945A(g) of the 

Act. In addition, all the measures in the 

2023 and 2024 section 1945 Health 

Home Core Set as well as all of the 

measures under consideration for the 

section 1945A Health Home Core Set 

can be reported using administrative 

claims data. Therefore, reporting on all 

populations for the Health Home Core 

Sets should not pose an excessive 

burden on States in the absence of any 

exceptions. 

Second, as set forth in 

§§ 437.10(b)(5)(i) and 437.15(a)(4) and 

(6) of this final rule, we allow States to 

request a 1-year exemption from 

reporting for specific populations for 

one or more Child and/or Adult Core 

Set measures where those populations 

have not already been exempted by the 

Secretary for that year in the annual 

subregulatory guidance. The State 

would be eligible for such a 1-year 

exemption if it demonstrates to CMS 

that, despite reasonable efforts, it is not 

able to obtain access to data required to 

report for the population; for example, 

that it is unable to obtain needed third 

party data or to finalize a necessary 

data-sharing agreement between parties 

before the reporting deadline. The State 

must request the exemption from us by 

September 1st of the applicable 

reporting year, the exemption would be 

only for that year’s reporting, and it 

would apply only to the specific 

population for which the State receives 

an exemption. We do not expect that 

this population-based exemption 

process will create an avenue for states 

to request an exemption from reporting 

one or more measure(s) in their entirety 

as most states are already reporting the 

majority of Core Sets measures for most 

of the beneficiaries in Medicaid and 

CHIP. The State will be required to 

explain why this exemption is necessary 

and provide a reasonable timeline of the 

actions underway to resolve the data 

access issue. In addition, as previously 

stated in this final rule, the State must 

demonstrate to us that it has made a 

reasonable effort to obtain the required 

data by the reporting deadline. We plan 

to respond to the State’s request before 

the close of the mandatory reporting 

period to ensure that the State has time 

to complete reporting by December 31st. 

If we deny a State’s request for 

exemption, the State will be expected to 

include the relevant population in that 

year’s annual Child and Adult Core Sets 

reporting. Additionally, a State may reapply in subsequent years to extend an 

exemption that has been granted. As 

stated in § 437.10(b)(5)(i), annual 

subregulatory guidance will provide 

information about how States can 

request an exemption. 

Below is a summary of the public 

comments we received regarding this 

section and our responses. 

Comment: Several commenters 

supported the requirement that States 

include populations that are harder to 

report in Core Set reporting, as outlined 

in the proposed rule, including those 

who are dually eligible for Medicare and 

Medicaid, those who use long-term 

services and supports, people with 

substance use disorders, and people in 

FFS Medicaid, including in States that 

enroll most people in managed care. 

Response: We thank these 

commenters for their support of 

required reporting for these populations. 

Comment: Multiple commenters 

requested additional clarification from 

CMS on how States should allocate 

beneficiaries who experience gaps in 

coverage or who are enrolled in 

multiple plans during the reporting 

period. Specifically, in some States, 

commenters noted that FFS enrollment 

is temporary until a beneficiary selects 

a managed care plan. In other States, 

FFS populations may comprise a very 

small percentage of total Medicaid 

enrollment. The commenters 

recommended that CMS consider 

whether the inclusion of the 

beneficiaries temporarily enrolled in 

FFS in Core Set reporting is an 

appropriate use of significant State 

resources. 

Response: As discussed in section 

II.D.3. of this final rule, we interpret 

sections 1139A and 1139B of the Act to 

require reporting of all beneficiaries 

covered by Medicaid and CHIP for the 

Child Core Set, and to require reporting 

for the behavioral health measures in 

the Adult Core Set of all beneficiaries 

covered by Medicaid. Additionally, as 

discussed previously in this section of 

this final rule, we are requiring in this 

final rule that reporting for the Health 

Home Core Sets include all beneficiaries 

enrolled in the applicable health home 

program. Attribution of performance 

and quality data poses challenges for the 

health care field, and Medicaid and 

CHIP in particular, as it requires striking 

a balance between the person-centered 

goal of measuring quality of care for a 

beneficiary regardless of delivery system 

and feasibility for providers, plans, 

health systems, and States. Our intent in 

implementing mandatory reporting 

requirements is for the data collected to 

be as inclusive of all beneficiaries as 

possible. However, when developing 

annual guidance, we will consider what 

distinctions between delivery systems 

are meaningful, being mindful of shortterm transitions. 

Comment: Multiple commenters 

supported a phased-in approach to the 

inclusion of populations in mandatory 

reporting but provided different 

recommendations about the approach 

CMS should take. One commenter 

recommended that CMS collect 

feedback from affected and interested 

parties on the most feasible reporting 

timeframe for specific populations. 

Another commenter requested that 

States have the flexibility to make the 

decisions about phasing in reporting of 

populations that are challenging to 

report on a timeframe that is feasible for 

each State. One commenter 

recommended that phasing in reporting 

for any given population should be 

limited to no more than 3 years, while 


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others noted that 2 to 5 years is the 

minimum amount of time needed. One 

commenter recommended that CMS 

extend the phase-in period beyond 5 

years, proposing up to 7 years to phase 

in fully reporting all measures for all 

populations. Several commenters 

recommended allowing more time 

before CMS phases in mandatory 

reporting for other populations, such as 

dually eligible beneficiaries; 

recommendations varied from as soon 

as 3 years to 10 years. 

Response: Commenters had varying 

preferences regarding the amount of 

time that we should provide for phasing 

in mandatory reporting on specific 

populations; some commenters 

recommended that we give States the 

flexibility to decide what populations 

they are able to report on, based on their 

unique circumstances. While reporting 

on standardized populations will help 

us achieve data consistency across 

States and provide actionable data to 

identify disparities and support efforts 

to improve the quality of health care, we 

recognize, based on the range of years 

supported in public comments, that the 

ability of States to report on the Child 

and Adult Core Sets for certain 

populations may vary, and there are 

unique circumstances which may result 

in States’ inability to report on certain 

populations in a given year. As 

discussed previously in this final rule, 

we have revised § 437.10(b)(5) and (c) to 

specify that the Secretary will identify 

in annual guidance the populations for 

which States may voluntarily, but are 

not required to, report the Child and 

Adult Core Set measures for a specific 

year. As further discussed previously in 

this final rule, this same flexibility is 

not needed for the Health Home Core 

Sets due to the ready availability of 

provider data, small population size, 

and ease of measure calculation. In 

§§ 437.10(b)(5)(i), 437.15(a)(4), and (6) 

we also added an opportunity for States 

to request a 1-year exemption from 

reporting mandatory populations for the 

Child and Adult Core Sets for one or 

more Child or Adult Core Set measures 

if the State demonstrates an inability to 

obtain access to data required to report 

on the measure(s) for the population— 

for example, if a State is unable to 

obtain a necessary data-sharing 

agreement between parties before the 

reporting deadline. We will consider 

renewing exemptions for specific 

populations on an annual basis. 

Additionally, we revised § 437.15(a)(4) 

to specify that mandatory reporting 

would include both fee-for-service and 

managed care delivery systems unless 

the population is otherwise specified by 

the Secretary pursuant to § 437.10(b)(5) 

or the State has received an exemption. 

We will work collaboratively with 

States to provide the technical 

assistance and reporting guidance 

necessary to support improvements in 

reporting for certain populations. 

We have also revised §§ 437.10(b)(5), 

(c), and 437.15(a)(4) of this final rule to 

specifically reference only the Child and 

Adult Core Sets. This is because, as 

discussed previously, under this final 

rule, Health Home Core Set reporting 

must include reporting on all 

beneficiaries enrolled in an approved 

health home program. 

Comment: Multiple commenters 

noted concerns with accessing claims 

data for beneficiaries who may be 

enrolled in Medicaid only for premium 

assistance programs. Multiple 

commenters requested that CMS 

provide clarification that the rule would 

not apply to individuals who have both 

Medicaid coverage and private 

insurance coverage, as the Medicaid 

agency would not have access to claims 

information from the member’s private 

plan. 

Response: We agree with the 

commenters that reporting Child and 

Adult Core Set measures for 

beneficiaries whose Medicaid or CHIP 

coverage is limited to payment of 

private insurance premiums and/or cost 

sharing may be challenging, as States 

currently do not have consistent access 

to data needed from the liable thirdparty payer, and as discussed previously 

in this final rule, we are revising 

§ 437.10(b)(5) such that the Secretary 

will identify in annual guidance 

populations for which States may, but 

are not required to, report the Child and 

Adult Core Set measures. We will work 

with States to determine reporting 

feasibility and the technical assistance 

needed for mandatory Child and Adult 

Core Sets reporting on such 

beneficiaries, and will update reporting 

guidance and mandatory reporting 

requirements based on these 

assessments. Reporting for populations 

who are dually eligible for Medicare and 

Medicaid is discussed below. We 

further note that the process for 

delaying reporting under § 437.10(b)(5) 

does not apply to the Health Home Core 

Sets as discussed previously in this final 

rule. As discussed previously, States are 

expected to have the data they need to 

report on the Health Home Core Sets 

from health home providers, and 

therefore, are not expected to experience 

the challenges in reporting for 

beneficiaries whose Medicaid or CHIP 

coverage is limited to payment of 

private insurance premiums and/or cost 

sharing discussed above. 

Comment: Several commenters 

opposed mandatory State reporting for 

the dually eligible population and 

suggested that CMS should be the 

responsible party for reporting on the 

dually eligible population as Medicare 

is the primary payer for most benefits 

and services for these beneficiaries. A 

few commenters recommended that 

CMS should limit mandatory State 

reporting for dually eligible 

beneficiaries to delivery systems or 

measures where the State is directly 

accountable. One commenter 

recommended limiting reporting to 

States that operate Statewide, fullyintegrated models for dually eligible 

beneficiaries (for example, fully 

integrated dual eligible special needs 

plans), and one commenter 

recommended limiting reporting on 

Core Set measures for dually eligible 

beneficiaries to measures for which the 

State is directly accountable so that the 

quality reporting on dually eligible 

beneficiaries is reflective of the payer of 

services. 

Response: We recognize the concerns 

about States’ ability to report on the 

dually eligible population when States 

are not the primary payer for most 

health care services for this population. 

We disagree that States should not 

report on all dually eligible individuals 

in the States’ reporting of Core Sets 

measures. Dually eligible individuals 

experience the health care system and 

incur health outcomes as individuals, 

regardless of whether Medicare or 

Medicaid pays for the service. The 

purpose of the Child and Adult Core 

Sets is to measure the overall national 

quality of care for beneficiaries, which 

is not limited to services reimbursed by 

Medicaid or CHIP. The main goal of the 

health home programs is to improve 

health outcomes for beneficiaries 

through care coordination that is 

intended to better link primary, 

behavioral health, and long-term 

services and supports for beneficiaries 

served by the health home program. The 

Health Home Core Sets will be used for 

ongoing monitoring and evaluation 

purposes across all State health home 

programs to measure this goal. As 

discussed previously, States are 

expected to have the data they need to 

report on the Health Home Core Sets 

from health home providers and 

therefore are not expected to experience 

challenges in reporting for dually 

eligible individuals. We recognize that 

States must obtain, link, and analyze 

Medicare data in order to report the 

Child and Adult Core Sets of measures 

for fee-for-service beneficiaries, and that 

States do not have access to encounter 


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data for Medicare Part C (Medicare 

Advantage), and we expect to phase in 

required reporting of Child and Adult 

Core Set measures for dually eligible 

beneficiaries. We will include 

information, including available 

technical assistance, on mandatory 

Child and Adult Core Sets reporting for 

this population in annual reporting 

guidance. Since all States that 

commented on the proposed rule, 

including those States that currently 

participate in the Medicare-Medicaid 

Data Sharing Program, requested more 

time to obtain, link, and analyze 

Medicare data, we will work with States 

and interested parties to identify the 

timeframe for which mandatory Child 

and Adult Core Sets reporting for dually 

eligible beneficiaries will be required. 

Additionally, we will continue to assess 

whether we can use T–MSIS or other 

alternative data sources to calculate 

Child, Adult, and Health Home Core 

Sets measures on behalf of States. 

Comment: Several commenters 

expressed concern about access to and 

the availability of assistance with using 

the Medicare FFS claims and Part D 

events data that are needed to report on 

dually eligible beneficiaries and were 

concerned that States would require 

extensive resources to utilize the data. 

They further commented that CMS is 

disadvantaging States, as this data is 

very difficult to obtain and out of their 

control. A few commenters encouraged 

CMS to facilitate State participation in 

the Medicare-Medicaid Data Sharing 

Program. A commenter recommended 

CMS establish a standardized data 

license/sharing agreement to facilitate 

Medicare data requests for the dually 

eligible population. 

Response: Since 2011, we have 

provided States access to Medicare FFS 

claims and Part D events data for dually 

eligible beneficiaries, including dually 

eligible beneficiaries whose Medicaid or 

CHIP coverage is limited to payment of 

premiums and/or cost sharing (also 

known as partial-benefit dually eligible 

beneficiaries), free-of-charge via the 

Medicare-Medicaid Data Sharing 

Program. Information on the MedicareMedicaid Data Sharing Program, 

including how to request data and the 

standard data sharing agreements, is 

available through the State Data 

Resource Center. We acknowledge that 

not all States currently request Medicare 

claims and events data, and that those 

States that do not currently request 

Medicare claims and events data may 

need additional time to request and 

effectively utilize these data. We also 

acknowledge that the MedicareMedicaid Data Sharing Program does 

not currently make available Medicare 

Part C encounter data, as discussed in 

the response below. Since all States that 

commented on the proposed rule, 

including those States that currently 

participate in the Medicare-Medicaid 

Data Sharing Program, requested more 

time to obtain, link, and analyze 

Medicare FFS data, and in light of the 

systematic Medicare Part C data access 

challenges, we anticipate that the 

Secretary’s subregulatory guidance 

issued under § 437.10(b) may specify 

that mandatory Child and Adult Core 

Sets reporting will not be required 

initially for dually eligible beneficiaries. 

This approach will address concerns for 

States that are not currently requesting 

Medicare claims and events data, 

providing them additional time to gain 

familiarity with the available claims and 

events data. Subregulatory reporting 

guidance will also consider care 

delivery systems and data availability. 

Specific to Health Home Core Sets, 

States collect data from the provider at 

the program level for this population to 

inform the health home measures, and 

therefore the health home measures do 

not rely on Medicare claims data. Health 

home programs are an optional State 

benefit, and there is the possibility that 

a dually eligible beneficiary could be 

enrolled in both Medicare and a State 

health home program if the dually 

eligible beneficiary has full Medicaid 

coverage (that is, a ‘‘full-benefit dually 

eligible beneficiary’’). If a full-benefit 

dually eligible beneficiary is enrolled in 

both a State health home program and 

Medicare, the provider would submit 

data for health home measures to the 

State, and the State would include this 

population in Health Home Core Sets 

reporting. We will consider implications 

of data access when reviewing measures 

for possible addition to the Health 

Home Core Sets in future years. 

Information on the MedicareMedicaid Data Sharing Program, 

including on how to request data and 

the standard data sharing agreements, is 

available at https://www.cms.gov/ 

Medicare-Medicaid-Coordination/ 

Medicare-and-Medicaid-Coordination/ 

Medicare-Medicaid-CoordinationOffice/StateAccesstoMedicareData or by 

contacting the State Data Resource 

Center at https://

www.statedataresourcecenter.com/ 

home/contact-us. We will take under 

advisement the commenters’ 

recommendations on additional 

technical assistance and resources for 

using Medicare FFS data, and we will 

consider Medicare data availability and 

ease of use when determining the Child 

and Adult Core Sets reporting schedule 

for the dually eligible population in 

general. 

Comment: Multiple commenters 

supported provision of technical 

assistance to States on inclusion of 

those dually eligible for Medicare and 

Medicaid and recommended that CMS 

provide open-source tools, 

opportunities for shared learning, 

assistance in developing data 

infrastructure, guidance on how to link 

Medicaid and Medicare data, data 

infrastructure, model analysis with T– 

MSIS data, and standardized Medicare 

data packages tailored to Core Set 

analysis. A commenter recommended 

considering the work of the NQF 

Measure Application Partnership (MAP) 

Dual Eligible Beneficiaries Workgroup 

when considering measures for the Core 

Sets and data availability. 

Response: We plan to provide 

technical assistance on Child, Adult, 

and Health Home Core Sets reporting for 

dually eligible beneficiaries and will 

take these ideas into consideration 

when developing technical assistance 

resources and learning opportunities. 

Comment: Several commenters were 

concerned about the lack of available 

Medicare Part C encounter data. These 

commenters explained that States 

cannot report on dually eligible 

beneficiaries enrolled in Medicare Part 

C without these data. 

Response: We recognize that we do 

not currently make available Medicare 

Advantage data to States free-of-charge 

via the Medicare-Medicaid Data Sharing 

Program. We are looking into how to 

address this issue. We do not intend to 

require that States report Child and 

Adult Core Set measures on dually 

eligible beneficiaries enrolled in 

Medicare Part C (that is, in Medicare 

Advantage) until such data are 

available. Specific to Health Home Core 

Sets, States collect data from the 

provider at the program level for this 

population to inform the health home 

measures, and therefore the health home 

measures do not rely on Medicare 

claims data. We will consider 

implications of data access when 

reviewing measures for possible 

addition to the Health Home Core Sets 

in future years. 

Comment: One commenter expressed 

concern with reporting of Medicaid FFS 

beneficiaries in their State, as they may 

not meet continuous enrollment 

requirements for quality measurement. 

Another commenter noted that there is 

a significant burden for including 

Medicaid FFS beneficiaries in Statewide reporting of hybrid measures. 

Response: The purpose of the Child 

and Adult Core Sets, as suggested by 

sections 1139A and 1139B of the Act, is 


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47https://www.medicaid.gov/resources-for-states/ 

medicaid-state-technical-assistance/health-homeinformation-resource-center/index.html. 

48https://www.medicaid.gov/resources-for-states/ 

medicaid-state-technical-assistance/health-homeinformation-resource-center/1945a-health-homeresources/index.html. 

49https://aspe.hhs.gov/reports/gaps-strategiesimproving-american-indianalaska-nativenativeamerican-data#TOC. 

50https://www.gao.gov/products/gao-22-104698. 

to measure the overall national quality 

of care for beneficiaries, monitor 

performance at the State level, and 

improve the quality of health care. The 

main goal of the health home programs 

is to improve health outcomes for 

beneficiaries through care coordination 

that is intended to better link primary, 

behavioral health, and long-term 

services and supports for beneficiaries 

served by the health home program.47 48

The Health Home Core Sets will be used 

for ongoing monitoring and evaluation 

purposes across all State health home 

programs to measure progress towards 

this goal. While we recognize the 

additional burden to States that may not 

currently include Medicaid FFS 

beneficiaries in their reporting, in order 

to improve the quality of care delivered 

to all beneficiaries, States must include 

in reporting the entire population 

covered by Medicaid and CHIP (or 

served by the applicable health home 

program), including Medicaid FFS 

beneficiaries, except to the extent the 

Secretary exempts a population from 

reporting for Child and/or Adult Core 

Sets measures in annual guidance or 

grants a state exemption for a specific 

population for a specific reporting year, 

as discussed in detail previously in this 

section. We have revised § 437.15(a) 

accordingly. The vast majority of 

measures on the Core Sets (84 percent 

of the 2023 and 2024 Child Core Set and 

behavioral health measures on the Adult 

Core Set can be calculated using 

administrative claims or survey data. 

One hundred percent of the 2023 and 

2024 section 1945 Health Home Core 

Set as well as 100 percent of the 

measures under consideration for the 

section 1945A Health Home Core Set) 

can be calculated using administrative 

claims data. We are assessing the 

resources and technical assistance to 

support States in using other data 

sources more widely. In order to be 

included in Core Set reporting, 

beneficiaries must still meet enrollment 

requirements for quality measurement, 

which are established by the measure 

stewards for each measure and based on 

a beneficiary’s continuous enrollment in 

Medicaid and CHIP. Additionally, for 

Health Home Core Sets a beneficiary 

must also be enrolled in an approved 

health home program. FFS or other 

beneficiaries who do not meet the 

enrollment requirements for a given 

measure would not be included in a 

State’s report. 

Comment: One commenter suggested 

CMS test the validity of mandatory 

measures that have been expanded to 

include additional populations, 

specifically populations that may be 

more difficult to include, prior to public 

reporting, and that CMS ensure that risk 

adjustment models of mandatory 

measures are robust enough to provide 

fair comparisons when including 

expanded populations. This commenter 

further recommended that CMS work 

with measure developers to evaluate the 

fit of the risk adjustment models for 

mandatory measures prior to reporting 

results publicly to ensure they generate 

meaningful information and allow for 

fair comparisons. 

Response: We anticipate that our Core 

Set reporting guidance will align with 

measure steward technical 

specifications with regard to defining 

the populations included in the measure 

and to risk adjustment. If the measure 

steward includes risk adjustment for a 

measure on the Core Sets, we will 

include risk adjustment for that 

measure. We work with measure 

stewards to adapt measures for State 

level reporting and provide appropriate 

reporting guidance. The issue of validity 

testing of mandatory measures is 

outside the scope of this rulemaking. 

Comment: Several commenters noted 

that decisions about whether to submit 

health care data necessary to calculate 

Core Set measures for beneficiaries 

receiving care from Indian Health Care 

Providers (IHCPs) rest with the Tribes 

and Tribal Organizations, and any CMS 

rules about data completeness must 

respect Tribal sovereignty and Tribes’ 

decisions about whether to submit 

health care data. One commenter noted 

that the addition of health care facility 

data from IHS, Tribes, and Tribal 

Organizations would require significant 

technical assistance and funding from 

CMS to facilitate the development of 

needed infrastructure to support these 

providers’ readiness to capture required 

data elements, and to assist with data 

transmission. 

Response: We understand that Tribes 

and Tribal providers take seriously their 

role in protecting the confidentiality of 

American Indian/Alaska Native (AI/AN) 

data and note that State Core Set data is 

de-identified before it is submitted to us 

for Core Set reporting. We also 

recognize that States enter into 

individual contractual and data use 

agreements with Tribes and Tribal 

providers that may affect the availability 

of Tribal data for Core Sets reporting. 

States might choose to require their 

Medicaid providers to report certain 

data to the State as a condition of 

receiving Medicaid payment, if doing so 

would help the State comply with the 

Core Sets reporting requirements. We 

strongly encourage States to consult 

with Tribes and to coordinate with IHS, 

and Tribes and Tribal Organizations, to 

discuss reporting of Child and Adult 

Core Set measures regarding the services 

provided by IHS and Tribal health care 

providers in their State. Collaborative 

relationships between government 

entities and Tribes are essential to 

responsible and effective data use and to 

understanding and addressing the gaps 

in these data,49 which limit analyses 

that support public health decisionmaking in AI/AN communities.50 Any 

delay of reporting data for AI/AN 

beneficiaries will impede efforts to 

improve health outcomes for these 

populations, and we encourage Tribes to 

report Core Set data to their respective 

States to help improve the quality of 

their State’s Medicaid program, and 

ultimately the quality of health care 

provided to AI/AN individuals. 

As discussed previously in this final 

rule, States are required to report Child 

and Adult Core Sets quality measure 

data for all populations, unless a 

population is identified as optional in 

annual subregulatory guidance to be 

issued by CMS, and States may request 

a 1-year exemption from reporting 

mandatory populations for one or more 

measures on the Child and Adult Core 

Sets if the State demonstrates an 

inability to obtain access to data, which 

may include for example, an inability to 

obtain needed third-party data or to 

finalize a necessary data-sharing 

agreement between parties before the 

reporting deadline. Moreover, this final 

rule requires States and health home 

providers to report data on all 

populations enrolled in the applicable 

health home. If Tribes or Tribal 

Organizations are providing section 

1945 or section 1945A health home 

services, sections 1945 and 1945A of the 

Act require them to report data to the 

State as a condition of payment for these 

health home services, as discussed in 

more detail previously in this final rule. 

E. Application of the Child and Adult 

Core Sets to CHIP 

As discussed in section II.E. of the 

proposed rule, in §§ 437.15(b), 457.700 

and 457.770 we proposed the following 

requirements for CHIP programs: to 

require that separate CHIPs report on all 

measures in the Child Core Set in 


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51CMS Cell Suppression Policy: https://

www.hhs.gov/guidance/document/cms-cellsuppression-policy. 

accordance with the requirements 

outlined in the proposed rule and 

include all CHIP beneficiaries in State 

reporting, including pregnant 

individuals receiving child health 

assistance coverage for the duration of 

pregnancy in States that elect to provide 

coverage through the group known as 

the ‘unborn option’. Separate CHIP 

programs are encouraged, but not 

required, to report on the measures in 

the Adult Core Set. 

We received public comments on the 

application of mandatory reporting to 

CHIP, and in general, commenters 

supported the proposed process. We are 

finalizing these provisions with 

revisions to §§ 437.15(b)(1) and 

457.770(c) as discussed in section II.E.1. 

of this final rule. Below is a summary 

of the public comments we received 

regarding this section and our 

responses. 

Comment: Several commenters 

supported CMS’ proposal, in section 

II.E. of the proposed rule, to include 

pregnant individuals receiving coverage 

under CHIP, including those provided 

CHIP child health assistance for the 

duration of pregnancy (also referred to 

as the ‘‘unborn option’’), in the 

mandatory reporting requirements for 

the Child Core Set, if the pregnant 

individual meets the age parameters for 

the measures. One commenter requested 

guidance on whether States would be 

required to report quality measures for 

pregnant individuals receiving coverage 

through the option to extend special 

CHIP child health assistance for the 

duration of pregnancy and whether 

States would be required to include this 

population in Adult Core Set reporting. 

Response: We appreciate the support 

from these commenters. We are 

finalizing the mandatory reporting 

requirements as proposed in 

§ 457.770(a) to require States to include 

this population of CHIP beneficiaries 

when reporting on quality measures in 

the Child Core Set. States that provide 

coverage for the duration of pregnancy 

under CHIP would be required to 

include this population in reporting of 

the Child Core Set if the participants 

meet the age parameters for the 

measures referenced in § 457.770(a) of 

this final rule. Reporting on the Adult 

Core Set is encouraged, but voluntary, 

for beneficiaries enrolled in CHIP in 

§ 457.770(b) of this final rule. 

Comment: One commenter 

recommended that individuals receiving 

coverage under CHIP should also be 

included in reporting for any measures 

from the Adult Core Set that the State 

reports on for their CHIP population. 

Response: Section 1139B(b)(3)(B) of 

the Act makes reporting by States on the 

Adult Core Set measures mandatory 

only with respect to the quality of 

behavioral health care provided to 

Medicaid-eligible adults. As a result, 

States are encouraged, but not required, 

to report on the measures in the Adult 

Core Set for beneficiaries in separate 

CHIP programs as per § 457.770(b) of 

this final rule. 

Comment: One commenter requested 

guidance on whether CMS would give 

States the option to report by combining 

the Child Core Set State-level data and 

section 1945 health home program data. 

Response: We will provide technical 

assistance and further details on how 

small population sizes should be 

handled through our reporting 

guidance. Under this final rule, data 

would be reported separately at the 

health home program level for the 

Health Home Core Sets and the State 

level for the Child and Adult Core Sets. 

Given these different denominators for 

these obligations, we do not plan to 

combine these reporting requirements. 

Comment: One commenter noted that 

their State enrollment under the special 

CHIP child assistance option for 

pregnant individuals is very low and 

reporting on it will have little impact on 

the overall rate. Another commenter 

noted that many individuals who 

receive special CHIP child assistance for 

pregnant individuals would not meet 

the eligibility requirements for 

reporting, such as receiving CHIP for the 

duration of the pregnancy or age 

requirements, and as such, collection of 

the data may not be a good use of data 

resources. 

Response: While the special CHIP 

child assistance for pregnant 

individuals is reflective of a very 

specific and relatively small population, 

we believe it is important to gather data 

for as many populations as possible. In 

some cases of small population sizes, 

core set measure data would not be 

reported separately, but would be 

included in reports of larger 

populations. We will provide technical 

assistance and further details on how 

small population sizes should be 

handled through our reporting 

guidance. We will follow data 

suppression policies for measure 

stewards in addition to our Cell Size 

Suppression Policy such that if sample 

sizes are too small, data will not be 

publicly reported to avoid a potential 

violation of privacy.51

Comment: One commenter 

encouraged CMS to adhere to measure 

steward specifications and urged that if 

CMS expands the denominator beyond 

those specifications, such as including 

individuals without 12 months of data, 

CMS should assess the validity and 

actionability of the measures. 

Response: We will take this feedback 

into consideration when developing 

Core Set reporting guidance. We will 

provide technical assistance and further 

details on enrollment requirements for 

inclusion of beneficiaries in Core Set 

reporting through our reporting 

guidance. In order to be included in 

Core Set reporting, beneficiaries must 

still meet enrollment requirements for 

quality measurement, which are 

established by the measure stewards for 

each measure and based on a 

beneficiary’s continuous enrollment in 

Medicaid and CHIP. This would ensure 

that the State has enough time to render 

services during the measurement period 

and would be based on a beneficiary’s 

enrollment date in Medicaid and CHIP 

(not inclusive of retroactive eligibility). 

In making measure adaptations, we 

work closely with measure stewards to 

develop reporting guidance and to make 

as few adaptations to the technical 

specifications as possible. 

1. Separate Reporting of the Child Core 

Set for Medicaid and CHIP Beneficiaries 

As discussed in section II.D.4. of the 

proposed rule, in §§ 437.15(b) and 

457.770(c), we proposed that States with 

a separate CHIP report on Child Core Set 

measures in three categories: Medicaid 

and CHIP combined; Medicaid inclusive 

of CHIP-funded Medicaid expansion 

(Titles XIX and XXI); and separate CHIP 

(Title XXI). We also proposed that 

reporting guidance would include 

attribution rules, to specify in which 

program (Medicaid or CHIP) a State 

would count a child who transitioned 

between programs within a reporting 

period. 

In response to comments received, we 

have revised §§ 437.15(b)(1)(i) and (ii), 

and 457.770(c), to specify that States 

with separate CHIP programs report on 

the Child Core Set measures in two 

categories instead of three as originally 

proposed: (1) separate CHIP (Title XXI) 

and (2) Medicaid inclusive of CHIPfunded Medicaid expansion (Titles XIX 

and XXI). Below is a summary of the 

public comments we received regarding 

this section and our responses. 

Comment: Several commenters 

supported the proposed rule proposal to 

require adherence to the same reporting 

guidance for Medicaid (funded through 

Title XIX and Title XXI) and separate 

CHIP programs, and recommended that 

the proposed language at § 437.15(b) be 

revised to clearly articulate that States 

with a separate CHIP program report on 


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52Fact Sheet 2012: https://www.medicaid.gov/ 

medicaid/quality-of-care/downloads/ 

cahpsfactsheet.pdf. 

53Technical Assistance Fact Sheet: https://

www.medicaid.gov/medicaid/quality-of-care/ 

downloads/tafactsheet.pdf. 

Child Core Set measures in three 

categories: Medicaid and CHIP 

combined; Medicaid inclusive of CHIPfunded Medicaid expansion (Titles XIX 

and XXI); and separate CHIP (Title XXI). 

Several other commenters 

recommended that CMS simplify the 

reporting categories to instead only 

require reporting on two categories for 

Medicaid inclusive of CHIP-funded 

Medicaid expansion (Titles XIX and 

XXI) and separate CHIP (Title XXI). 

Response: In response to public 

comment, we have revised 

§§ 437.15(b)(1)(i) and (ii), and 

457.770(c), to specify that States with 

separate CHIP programs will be required 

to report on the Child Core Set measures 

in two categories, instead of three as 

originally proposed. The category of 

Medicaid inclusive of CHIP-funded 

Medicaid expansion includes all 

Medicaid enrollees, regardless of 

whether they are funded by Title XIX or 

XXI. We will aggregate the separate 

CHIP and Medicaid inclusive of CHIPfunded Medicaid expansion data to 

create the Medicaid and CHIP combined 

category, alleviating the burden on 

States to create and report that data. We 

believe the change from the three 

originally proposed reporting categories 

to the two reporting categories described 

previously in this final rule maintains 

the intent of the proposed rule. 

Comment: Several commenters did 

not support separate reporting of 

children in Medicaid and CHIP. They 

thought that it added little value and 

would result in an additional reporting 

burden, as combined reporting more 

closely aligns with how services are 

provided. Instead, one commenter 

recommended combining reporting for 

Medicaid and CHIP, and using 

attribution to determine to which 

program beneficiaries should be 

assigned. One commenter recommended 

CMS allow aggregate reporting to align 

with current State practices, while 

another commenter asked if separate or 

combined reporting of CHIP could be 

determined at the State level. 

Response: Separate CHIP programs 

have different service requirements than 

Medicaid. Therefore, we expect that 

results for certain measures could vary 

within States for separate CHIP and 

Medicaid. We believe these differences 

are important to document, and 

therefore are maintaining the 

requirement at §§ 437.15(b) and 

457.770(c) that States with a separate 

CHIP report separate CHIP data 

separately from Medicaid data. 

Meanwhile, we have updated the 

reporting categories to incorporate both 

Title XIX and Title XXI-funded 

Medicaid under one category to reduce 

State burden and to reflect the fact that 

the source of funds (Title XIX or Title 

XXI) providing the Federal match for a 

child enrolled in Medicaid does not 

impact which or how services are 

provided. We will also aggregate the 

separate CHIP and Medicaid data to 

obtain the combined Medicaid and 

CHIP results, rather than requiring 

States to report the combined results, to 

reduce State burden. 

Comment: One commenter suggested 

that any separate CHIP reporting should 

be limited to administrative measures 

that are in the control of MCOs. 

Response: The Core Sets are Statelevel and health home program-level 

reporting programs, not managed care or 

health plan-level reporting programs. 

One of the goals of mandatory reporting 

is to provide inclusive data on quality 

and performance for all beneficiaries, 

regardless of delivery system. We will 

provide technical assistance to address 

the needs of States and State partners to 

report the Core Sets. 

Comment: Several commenters noted 

that if States were required to report 

results for Medicaid and CHIP 

separately, a separate CAHPS survey for 

CHIP would be required. Multiple 

surveys would result in significant cost 

increases, require additional time to 

implement, and increase the potential 

for insufficient sample sizes. 

Response: We will take this feedback 

into consideration as part of the 

guidance process that is discussed in 

the rule. Section 2108(e)(4) of the Act 

requires states to collect and report 

CAHPS survey results for Title XXI 

CHIP programs (see CHIPRA section 

402(a)(2)) as part of their annual reports 

to the Secretary. Reporting CAHPS 

survey results separately currently is 

encouraged for voluntary Core Set 

reporting, and several States 

successfully do so. We note that 

previous CMS guidance outlines how 

States can sample and report CHIP and 

Medicaid results separately for 

CAHPS.52

Comment: One commenter supported 

the proposal that CMS include 

attribution rules in reporting guidance 

for counting children who move 

between Medicaid and separate CHIP. 

One commenter recommended that 

States be required to include children 

that meet continuous enrollment criteria 

in reporting for CHIP, as is required for 

Medicaid reporting and enrollment 

criteria, in order to allow for better 

comparisons. This commenter requested 

a separate population category for 

enrollees transitioning from Medicaid to 

CHIP if CMS were to require reporting 

on this group, noting that combining 

these data for children who transition 

between programs would be 

burdensome. Multiple commenters 

acknowledged the need to include 

children in Child Core Set reporting 

who transition between Medicaid and 

CHIP in order to promote consistency 

and prevent duplicative reporting. Some 

commenters raised concerns that 

inconsistencies in Medicaid and CHIP 

requirements could make it difficult to 

combine these two groups for reporting. 

Response: We plan to provide 

detailed guidance about attribution 

rules in the annual reporting guidance 

required under § 437.10(b), as finalized 

in § 437.10(b)(6) of this rulemaking with 

minor changes. We note the importance 

of capturing data for the population of 

children who transition between 

Medicaid and CHIP, given the 

implications of insurance churn on 

health care quality. 

Comment: One commenter noted that 

some States with small separate CHIP 

programs may have difficulty reporting 

on their CHIP population and requested 

technical assistance and support from 

CMS to address data collection and 

calculation challenges. 

Response: We appreciate these 

comments and concerns and will 

provide technical assistance to meet the 

needs of States and State partners.53

F. Ensuring Compliance With the 

Mandatory Reporting Requirements 

As discussed in section II.F. of the 

proposed rule, in § 437.20, we proposed 

to require that States submit a Medicaid 

SPA attesting that the State agency 

would report on the Child, Adult, and 

Health Home Core Sets in accordance 

with the requirements in the final rule. 

Health Home SPAs would also include 

an attestation that the State will require 

its providers of health home services to 

report to the State on the measures that 

the State has to report. With these 

attestations in the State plan, we would 

have authority under section 1904 of the 

Act to withhold Federal Medicaid 

payments, in whole or in part, if an 

agency fails to comply with the 

Medicaid reporting requirements. 

We also proposed changes to 

§ 433.112 which would apply existing 

Health Insurance Portability and 

Accountability Act of 1996 (HIPAA) 

Privacy, Security, Breach Notification, 

and Enforcement Rules under 45 CFR 

parts 160 and 164, the HIPAA electronic 


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54See section 1903(a)(3)(A)(i) and (B) of the Act, 

42 CFR 433.15(b)(3) and (4), subpart C of 42 CFR 

part 433, and State Medicaid Director Letter (SMDL) 

#22–001. 

55Medicaid Enterprise Systems Compliance and 

Reapproval Process for State Systems with 

Operational Costs Claimed at the 75 Percent Federal 

Match Rate CIB at https://www.medicaid.gov/ 

federal-policy-guidance/downloads/cib052423.pdf. 

56Medicaid Enterprise Systems Compliance and 

Reapproval Process for State Systems with 

Operational Costs Claimed at the 75 Percent Federal 

Match Rate CIB at https://www.medicaid.gov/ 

federal-policy-guidance/downloads/cib052423.pdf. 

transactions standards under 45 CFR 

part 162, and the health information 

technology standards under 45 CFR part 

170 subpart B to the Core Sets. 

We received public comments on 

compliance requirements, and in 

general, commenters supported the 

proposed process. We are finalizing 

these provisions with a minor wording 

change to § 437.20(a) to clarify that 

reporting on Health Home Core Sets 

measures applies to all populations 

served by the health home and other 

minor wording changes to clarify crossreferences within the same subpart. 

Below is a summary of the public 

comments we received regarding this 

section and our responses. 

Comment: Several commenters 

supported the proposed standards that 

States must meet to qualify for 

enhanced Federal matching funds for 

Medicaid systems and encouraged the 

Secretary to use this authority to enforce 

compliance with mandatory reporting of 

the Core Set measures. One commenter 

asked for more information on Federal 

matching funds for systems. 

Response: We thank the commenters 

for their support for our proposal to use 

these Federal authorities to enforce 

compliance with Core Set requirements. 

CMS regulations at 42 CFR part 433, 

subpart C specify conditions that State 

Medicaid systems must meet in order 

for the State’s expenditures on 

mechanized claims processing and 

information retrieval systems to be 

matched at the 90 and 75 percent rates 

described in section 1903(a)(3)(A)(i) and 

(B) of the Act. These conditions include 

industry standards described in 

§ 433.112(b)(12), which with the 

publication of this final rule now 

include standards and protocols for 

reporting on the Child and Adult Core 

Sets and the Health Home Core Sets, as 

relevant to the specific State Medicaid 

system or module. Under these 

regulations, which implement section 

1903(a)(3)(A)(i) and (B) of the Act, 

enhanced FFP is available at 90 percent 

for State expenditures for the design, 

development, and installation 

(including of enhancements) of 

qualifying State Medicaid systems, and 

at 75 percent for State expenditures for 

operations of such systems, once 

approved by CMS, in accordance with 

applicable Federal requirements.54

Furthermore, in accordance with 

regulations at §§ 433.117 and 433.119, 

we may not approve replacement State 

systems or may not reapprove existing 

State systems if the State does not meet 

Core Set reporting requirements that are 

now described in § 433.112(b)(12) and 

cross-referenced in § 433.116(c), which 

means that we would not approve or 

reapprove a Federal matching 

percentage of 75 percent under section 

1903(a)(3)(B) of the Act for such 

systems.55

Additional information about FFP 

rates for State Medicaid system design, 

development, and installation 

(including of enhancements) and 

operation available under section 

1903(a)(3)(A)(i) and (B) of the Act can be 

found in the Mechanized Claims 

Processing and Information Retrieval 

Systems regulations at 42 CFR part 433, 

subpart C. Separately, under section 

1903(a)(3)(A)(iii) of the Act, State 

expenditures for Medicaid system 

development and modifications 

necessary for collecting and reporting 

on child health quality measures are 

matched at the State’s FMAP rate as 

defined in section 1905(b) of the Act. 

Comment: Some commenters 

suggested CMS should develop more 

explicit guidance outlining specific, 

graduated enforcement mechanisms for 

States that remain out of compliance 

with quality reporting requirements, in 

order to ensure clear enforcement action 

is taken against States and other entities 

that fail to comply and encourage State 

corrective action. 

Response: As noted previously in this 

final rule, States will be required to 

submit a Medicaid SPA attesting that 

the State agency will report on the 

Child, Adult, and Health Home Core 

Sets in accordance with the 

requirements in 42 CFR part 437, as 

finalized in § 437.20. Since States have 

to attest that they will meet the 

mandatory reporting requirements, we 

will be able to withhold Federal 

Medicaid payments, in whole or in part, 

from a State that is non-compliant with 

these reporting requirements in 

accordance with section 1904 of the Act 

and implementing regulations at 42 CFR 

430.35. We will be able to withhold 

Federal funds under Title XXI for 

noncompliance with the reporting 

requirements for CHIP in accordance 

with § 457.204 once § 457.770 is 

codified. The requirement at § 437.20 to 

submit a SPA does not apply to the 

CHIP agency. The CHIP State plan 

already includes an attestation in 

section 9.4 that ‘‘the State assures it will 

collect all data, maintain records and 

furnish reports to the Secretary at the 

times and in the standardized format 

that the Secretary requires.’’ All States 

have made this attestation in the current 

version of their State plan. Graduated 

enforcement mechanisms for 

compliance with Core Sets reporting 

requirements due to issues with State 

data systems will align with existing 

CMS policy regarding State corrective 

action plans.56

Comment: Several commenters 

supported the proposed requirement 

that States amend their State Plans to 

indicate that they would report on the 

Core Sets in order to give CMS clear 

authority to enforce the Core Set 

reporting requirements by withholding 

Federal Medicaid payments under 

section 1904 of the Act in the event of 

noncompliance by a State. One 

commenter requested clarification on 

the deadline for submission of the SPA. 

Response: We appreciate the support 

for this proposed Medicaid requirement 

at § 437.20, which we are finalizing as 

proposed in this rulemaking. We plan to 

discuss details of changes to the SPA, 

including the deadline for submission, 

in annual reporting guidance. 

Comment: Several commenters 

suggested that requiring Health Home 

programs to submit Core Set measures 

to the State as a condition of receiving 

payment, in addition to the State 

reporting to CMS, is duplicative and 

redundant. 

Response: While we appreciate the 

submission of these comments, the 

proposed rule implements statutory 

reporting requirements that health home 

providers must meet, as a condition of 

payment, under sections 1945(g) and 

1945A(g)(1) of the Act. If a Health Home 

provider is submitting all required data 

into a State-based system that the State 

is then using to calculate and report the 

Health Home Core Sets measures to 

CMS, that would satisfy the statutory 

requirement for providers under 

sections 1945(g) and 1945A(g)(1) of the 

Act. 

Comment: A few commenters 

recommended that CMS change 42 CFR 

431.16, which implements section 

1902(a)(6) of the Act, to specify that the 

State plan requirements include the 

reporting of the Core Sets and 

underscore the importance of State 

compliance with Core Sets reporting. 

Response: Section 431.16 requires 

that States comply with all reporting 

requirements established by the 

Secretary and that their State plans 

reflect that the State will do so. Section 


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57The costs associated with our August 22, 2022, 

proposed rule differ from the costs in this final rule 

since the proposed rule used BLS’ May 2020 mean 

hourly wages whereas this final rule uses BLS’ 2022 

wage estimates. 

58See section 1905(ff) of the Act. 

59https://aspe.hhs.gov/sites/default/files/ 

migrated_legacy_files//176806/VOT.pdf. 

431.16 does not list any specific reports 

that States are required to submit, and 

we do not believe it would be 

appropriate to single out Core Sets 

reporting alone. Further, it is not 

necessary to do so, as the current 

language of § 431.16 is broad enough to 

encompass these newly finalized Core 

Sets reporting requirements (as they 

pertain to Medicaid), and because 

§ 437.20 of this final rule sets forth the 

requirement for States to submit a State 

plan amendment attesting to 

compliance with the Core Sets reporting 

requirements. 

III. Collection of Information 

Requirements 

Under the Paperwork Reduction Act 

of 1995 (PRA) (44 U.S.C. 3501 et seq.), 

we are required to provide 60-day notice 

in the Federal Register and solicit 

public comment before a ‘‘collection of 

information’’ requirement is submitted 

to the Office of Management and Budget 

(OMB) for review and approval. For the 

purpose of the PRA and this section of 

the preamble, collection of information 

is defined under 5 CFR 1320.3(c) of the 

PRA’s implementing regulations. 

To fairly evaluate whether an 

information collection must be 

approved by OMB, section 3506(c)(2)(A) 

of the PRA requires that we solicit 

comment on the following issues: 

• The need for the information 

collection and its usefulness in carrying 

out the proper functions of our agency. 

• The accuracy of our estimate of the 

information collection burden. 

• The quality, utility, and clarity of 

the information to be collected. 

• Recommendations to minimize the 

information collection burden on the 

affected public, including automated 

collection techniques. 

In our August 22, 2022 (87 FR 51303) 

proposed rule, we solicited public 

comment on each of these issues for the 

following provisions that contain 

information collection requirements. As 

stated in section II. of this final rule, we 

received 93 public comments on the 

proposed rule, but only one of those 

comments was related to the rule’s 

collection of information requirements. 

The comment and our response can be 

found in section III.C. of this preamble. 

A. Wage Estimates 

Private Sector, States, and Territories: 

To derive average costs, we used data 

from the U.S. Bureau of Labor Statistics’ 

May 2022 57 National Occupational 

Employment and Wage Estimates 

(http://www.bls.gov/oes/current/oes_

nat.htm). Table 1 presents BLS’ mean 

hourly wage along with our estimated 

cost of fringe benefits and other indirect 

costs (calculated at 100 percent of 

salary) and our adjusted hourly wage. 

TABLE 1—NATIONAL OCCUPATIONAL EMPLOYMENT AND WAGE ESTIMATES

Occupation title Occupation 

code 

Mean hourly 

wage 

($/hr) 

Fringe benefits 

and other 

indirect costs 

($/hr) 

Adjusted 

hourly wage 

($/hr) 

Business Operations Specialists ..................................................................... 13–1000 40.04 40.04 80.08 

Chief Executives .............................................................................................. 11–1011 118.48 118.48 236.96 

Computer Programmers .................................................................................. 15–1251 49.42 49.42 98.84

Data Entry/Information Processing Workers ................................................... 43–9020 18.97 18.97 37.94 

General Operations Manager .......................................................................... 11–1021 59.07 59.07 118.14 

Statistician ........................................................................................................ 15–2041 50.73 50.73 101.46 

As indicated, we are adjusting our 

employee hourly wage estimates by a 

factor of 100 percent. This is necessarily 

a rough adjustment, both because fringe 

benefits and overhead costs vary 

significantly from employer to 

employer, and because methods of 

estimating these costs vary widely from 

study to study. Nonetheless, we believe 

that doubling the hourly wage to 

estimate total cost is a reasonably 

accurate estimation method. 

To estimate the burden on States, it 

was important to consider the Federal 

government’s contribution to the cost of 

administering the Medicaid and CHIP 

programs. The Federal government 

provides Federal Medicaid funds for 

medical assistance based on an FMAP 

that is established for each State, based 

on the per capita income in the State as 

compared to the national average. 

FMAPs range from a minimum of 50 

percent in States with higher per capita 

incomes to a maximum of 83 percent in 

States with lower per capita incomes. 

States receive an ‘‘enhanced’’ FMAP for 

administering their CHIP programs, 

ranging from 65 to 85 percent. Medicaid 

funding for U.S. territories works a bit 

differently than funding for the 50 

States and District of Columbia. Section 

5101 of subtitle A of title V of division 

FF of the CAA, 2023 permanently set 

the FMAP for the four smaller territories 

(the Virgin Islands, Guam, the Northern 

Mariana Islands, and American Samoa) 

under Medicaid at 83 percent. Puerto 

Rico’s FMAP under Medicaid is 

statutorily set at 55 percent but has been 

temporarily increased to 76 percent 

until September 30, 2027.58 For each 

territory, the annual amount of available 

Federal matching funds is capped. For 

Medicaid, all States (including the 

territories) receive a 50 percent Federal 

matching rate for activities found 

necessary by the Secretary for the 

proper and efficient administration of 

the Medicaid program. As noted 

previously in this final rule, States may 

receive higher Federal matching rates 

for expenditures on certain services and 

for certain systems improvements, 

redesign, or operations, up to 90 

percent. As such, in considering the 

Federal contribution to the costs of 

administering the Medicaid and CHIP 

programs for purposes of estimating 

State burden with respect to collection 

of information, we elected to use the 

higher end estimate that the States 

would contribute 50 percent of the 

costs, even though the burden would 

likely be much smaller. 

Beneficiaries: We believe that the cost 

for beneficiaries undertaking 

administrative and other tasks on their 

own time is a post-tax wage of $21.98/ 

hr. The Valuing Time in U.S. 

Department of Health and Human 

Services Regulatory Impact Analyses: 

Conceptual Framework and Best 

Practices 59 identifies the approach for 

valuing time when individuals 

undertake activities on their own time. 

To derive the costs for beneficiaries, a 

measurement of the usual weekly 


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60https://fred.stlouisfed.org/series/ 

LEU0252881500A. 

61Core Set Measure lists: https://

www.medicaid.gov/medicaid/quality-of-care/ 

index.html. 

62https://www.cms.gov/Medicare/QualityInitiatives-Patient-Assessment-Instruments/MMS/ 

MMS-Blueprint. 

earnings of wage and salary workers of 

$1,059 60 for 2022, divided by 40 hours 

to calculate an hourly pre-tax wage rate 

of $26.48/hr. This rate is adjusted 

downwards by an estimate of the 

effective tax rate for median income 

households of about 17 percent or 

$4.50/hr ($26.48/hr × 0.17), resulting in 

the post-tax hourly wage rate of $21.98/ 

hr. 

Unlike our State and private sector 

wage adjustments, we are not adjusting 

beneficiary wages for fringe benefits and 

other indirect costs since the 

individuals’ activities, if any, would 

occur outside the scope of their 

employment. 

B. Information Collection Requirements 

(ICRs) 

The following collection of 

information requirements and burden 

estimates were posted for public review 

and submitted to OMB for review under 

control number 0938–1188 (CMS–10434 

#26 for the Child Core Set and the Adult 

Core Set and CMS–10434 #47 for the 

Health Home Core Sets) in association 

with the August 22, 2022 proposed rule. 

Under sections 1139A, 1139B, and 

1902(a)(6) of the Act, we have the 

authority to collect quality metrics on 

State-specific Medicaid and CHIP 

programs for the purpose of: measuring 

the overall national quality of care for 

Medicaid and CHIP beneficiaries, 

monitoring performance at the Statelevel, and improving the quality of 

health care. Under sections 1902(a)(6), 

1945(c)(4)(B), 1945(g), and 1945A(g) of 

the Act, in this final rule, we are 

requiring States that are implementing 

the section 1945 and/or section 1945A 

health home benefits to report on 

certain quality measures to the Secretary 

and to require their health home 

providers to report on these same 

measures to the State. The reported data 

is intended to provide a comprehensive 

landscape of the quality of care 

provided by Medicaid and CHIP, 

because the measures focus on a range 

of topics including access to primary 

and preventive care, maternal and 

perinatal health care, care of acute and 

chronic conditions, behavioral health 

care, dental and oral health care, long 

term services and supports, and overall 

experience of care. 

Currently, Child, Adult, and section 

1945 Health Home Core Sets reporting 

is voluntary for States but highly 

encouraged. Under this final rule, our 

voluntary annual reporting 

requirements will become mandatory 

for States for the: Child Core Set (CMS– 

10434 #26), behavioral health measures 

in the Adult Core Set (also CMS–10434 

#26), and the section 1945 and 

forthcoming section 1945A Health 

Home Core Sets (CMS–10434 #47).61

This final rule does not add, remove, or 

revise any of the existing measures in 

any of the aforementioned Core Sets. 

Annual updates to the Core Sets will 

continue to be made as required by 

sections 1139A and 1139B of the Act for 

the Child and Adult Core Sets and this 

annual update process will also be 

applied to both Health Home Core Sets 

as described in section I.C. of this 

preamble and §§ 437.10(a)(2) and (e). 

Mandatory reporting of the Child Core 

Set and behavioral health measures on 

the Adult Core Set will impact all 50 

States, DC, Puerto Rico, Guam, and the 

Virgin Islands as described in section 

II.A. of this final rule and in § 437.1. 

The Health Home Core Sets 

requirements will apply if a State (as 

defined under section 1101 of the Act 

for purposes of Title XIX) has an 

approved Health Home SPA under 

section 1945 or 1945A of the Act (see 

§ 437.1(d)(2)), and the burden associated 

with the mandatory reporting 

requirement is not expected to influence 

the number of health home SPAs. 

Currently, 19 States and DC have a total 

of 34 section 1945 Health Home SPAs. 

Under this final rule, we anticipate 

that the mandatory reporting burden for 

States would increase in comparison to 

the current voluntary Core Set reporting 

burden, including anticipated burden to 

States for system changes as a result of 

this final rule. This is due to the 

mandatory nature of the data collection 

which may increase: the number of 

measures reported by States, adherence 

to the reporting guidance provided by 

CMS, and stratification of data by 

delivery system and demographic 

characteristics. However, many of the 

mandatory measures can be calculated 

from alternate data sources. For 

example, we have been working to use 

T–MSIS (CMS–R–284, OMB 0938–0345) 

reporting to generate measure reporting 

on behalf of States. Among the three 

Core Sets, approximately 50 measures 

will become mandatory (the Child Core 

Set measures, behavioral health 

measures on the Adult Core Set, and the 

1945 and 1945A Health Home Core Sets 

of measures for States with a health 

home program), two of which we 

currently report for States and Puerto 

Rico using alternate data sources. The 

remaining non-behavioral health Adult 

Core Set measures will remain 

voluntary for States to report. The 

burden to report voluntary measures is 

not included in this final rule but is 

submitted annually to OMB for their 

approval under control number 0938– 

1188 (CMS–10434 #26). We are 

currently assessing whether T–MSIS 

could be used to report any of the 

remaining measures. If so, this will 

reduce the number of measures that 

States will be required to calculate. 

The data fields included in Core Set 

reporting templates are determined by 

the measure stewards who own the 

measures. We are not the measure 

steward for most measures, and 

therefore, do not control the actual data 

fields for most of the measures in the 

Core Sets. As a result, the templates 

used for Core Sets reporting will not be 

published for public comment. Instead, 

measure stewards implement a separate 

process for public comment during 

measure development and measurement 

updates. We also have 

recommendations in the CMS Measures 

Management System Blueprint for a 

similar process for public comment 

during measure development.62

We are adding SPA preprints to the 

final rule package under control number 

0938–1188 (CMS–10434 #26) for the 

Child Core Set and the Adult Core Set 

and CMS–10434 #22, entitled: ‘‘Health 

Home State Plan Amendment (SPA)’’) 

for the Health Home Core Sets. These 

preprints were excluded from the 

proposed rule package, but the contents 

of the preprints were described under 

the collection of information 

requirements, and the burden estimates 

were included under ICR #1 in the 

proposed rule. The final rule’s preprint 

does not deviate from those 

descriptions: ‘‘that the agency would 

report on the Child and Adult Core Sets 

in accordance with the requirements in 

§ 437.20(a)’’ and that States would need 

‘‘to submit a SPA attesting that the 

agency would report on the Health 

Home Core Sets in accordance with the 

requirements in § 437.20(a).’’ 

Additionally, we are changing the 

package under which the Health Home 

Core Sets SPA preprint is associated 

from control number 0938–1188 (CMS– 

10434 #47) to 0938–1188 (CMS–10434 

#22, entitled: ‘‘Health Home State Plan 

Amendment (SPA)’’), as this package 

(CMS–10434 #22) is associated with the 

health home program State plan 

requirements. The requirements for the 

SPA are the same, and the burden set 

out in the proposed rule is the same as 

in the final rule (at 54 responses × 1 


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hour/response = 54 hours total time); 

only the location is being changed. 

Subsequent to the proposed rule we 

have revised §§ 437.10(b)(5)(i) and 

437.15(a)(4) and (6) in this final rule to 

allow States to request a 1-year 

exemption from Child and Adult Core 

Sets reporting for specific populations 

that have not already been exempted by 

the Secretary for the year in question in 

the annual subregulatory guidance. Our 

assessment of the burden of the 

exemption request process has been 

added under ICR #5 (54 responses × 4 

hour/response = 216 hours total time). 

This option is available to all States, and 

the burden includes all States and 

Territories subject to mandatory 

reporting requirements for the Child and 

Adult Core Sets who may submit an 

exemption request. As required by the 

PRA, we will solicit public comment via 

60-day and 30-day notices that we will 

issue in the Federal Register separate 

from this rulemaking document as this 

voluntary requirement takes effect 

September 1, 2024. 

As noted previously in this rule, we 

received one public comment related to 

the collection of information 

requirements calculation of the burden 

estimate, which applied to the estimates 

provided for reporting the Child, Adult, 

and Health Home Core Sets. The 

comment, and our response can be 

found in section III.C. of this final rule. 

The burden for reporting voluntary 

Adult Core Set measures (the measures 

outside of behavioral health measures) 

for States to report is not included in 

this rule’s ICR discussions as the 

mandatory reporting requirements being 

implemented with this final rule do not 

apply to the voluntary measures; 

however, these costs will be included 

under control number 0938–1188 

(CMS–10434 #26). The burden to health 

home providers for reporting section 

1945 and section 1945A Health Home 

Core Sets data to States is not included 

in this rule’s ICR discussions or under 

control number 0938–1188 (CMS–10434 

#47) as this final rule outlines State 

requirements to comply with reporting 

the Health Home Core Sets. The burden 

to health home providers for reporting 

the section 1945 and section 1945A 

Health Home Core Sets along with the 

development of a Health Home SPA is 

approved by OMB under control 

number 0938–1188 (CMS–10434 #22, 

entitled: ‘‘Health Home State Plan 

Amendment (SPA)’’). 

1. ICRs Regarding Attestation of 

Mandatory Reporting (§ 437.20(a)) 

The following changes will be 

submitted to OMB for their approval 

under control number 0938–1188 

(CMS–10434 #26 and CMS–10434 #22). 

As noted previously in this final rule, 

we are changing the package under 

which the Health Home Core Sets SPA 

preprint is associated from control 

number 0938–1188 (CMS–10434 #47) to 

0938–1188 (CMS–10434 #22, entitled: 

‘‘Health Home State Plan Amendment 

(SPA)’’) as this package (CMS–10434 

#22) is associated with the health home 

program State plan requirements. 

With the changes outlined in this 

final rule, the 50 States, DC, Puerto 

Rico, Guam, and the Virgin Islands that 

will be subject to the Child and Adult 

Core Sets reporting requirements will 

need to submit a single SPA attesting 

that the agency will report on the Child 

and Adult Core Sets in accordance with 

the requirements in § 437.20(a). The 

approximately 20 States (with 

approximately 40 health home 

programs) with section 1945 Health 

Home SPAs and the approximately 10 

States estimated to apply for section 

1945A Health Home SPAs would need 

to submit a SPA attesting that the 

agency would report on the Health 

Home Core Sets in accordance with the 

requirements in § 437.20(a). Health 

Home SPAs will also include an 

attestation that the State will require its 

providers of health home services to 

report to the State on the measures that 

the State has to report in accordance 

with the requirements in § 437.20(a). 

We estimate it would take a business 

operations specialist 2 hours at $80.08/ 

hr and a general operations manager 1 

hour at $118.14/hr to update and submit 

the State or territory SPA to us for 

review. We estimate a one-time burden 

of 162 hours (54 States and territories × 

3 hr/response) at a cost of $15,028 (54 

States and territories × ([2 hr/response × 

$80.08/hr] + [1 hr/response × $118.14/ 

hr])). Taking into account the Federal 

contribution to Medicaid and CHIP 

program administration, the estimated 

State share of this cost is approximately 

$7,514 ($15,028 × 0.50). CMS is 

attributing 2⁄3 of this burden ($5,009 

State share and 108 hr) to Child and 

Adult Core Sets reporting and 1⁄3 to 

Health Home Core Sets reporting 

($2,505 State share and 54 hr). CMS is 

attributing additional burden to Child 

and Adult Core Sets reporting (versus 

Health Home Core Sets reporting) due to 

additional effort to coordinate 

attestation of State Core Sets reporting 

across State Medicaid and CHIP 

programs. 

TABLE 2—ATTESTATION REQUIREMENTS AND BURDEN UNDER OMB CONTROL NUMBER 0938–1188 

[CMS–10434 #26, Child Core Set and the Adult Core Set] 

Regulatory section(s) under Title 42 of the CFR Number 

respondents 

Total 

number of 

responses 

Time per 

response 

(hr) 

Total time 

(hr) 

Labor cost 

($/hr) 

Total cost 

($) 

Adjusted cost 

($) 

(50% FMAP 

or FFP) 

§ 437.20—One-time SPA Submission * ............... 54 54 2 108 (162 hr × 2⁄3) .... Varies ........... 10,019 5,009 

* States will be required to submit a SPA that attests that the State will be in compliance with Child, Adult, and Health Home Core Sets reporting. Every State would 

complete the SPA and States with a Health Home would only have to identify as applicable. 

TABLE 3—ATTESTATION REQUIREMENTS AND BURDEN UNDER OMB CONTROL NUMBER 0938–1188 

[CMS–10434 #22, Health Home SPA] 

Regulatory section(s) under Title 42 of the CFR Number 

respondents 

Total 

number of 

responses 

Time per 

response 

(hr) 

Total time 

(hr) 

Labor cost 

($/hr) 

Total cost 

($) 

Adjusted cost 

($) 

(50% FMAP 

or FFP) 

§ 437.20—One-time SPA Submission * ............... 54 54 1 54 (162 hr × 1⁄3) ...... Varies ........... 5,009 2,505 

* States will be required to submit a SPA that attests that the State will be in compliance with Child, Adult, and Health Home Core Sets reporting. Every State would 

complete the SPA and States with a Health Home would only have to identify as applicable. 


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63https://www.medicaid.gov/chip/downloads/ 

chip-map.pdf. 

64The Agency for Healthcare Research and 

Quality is the measure steward for the CAHPS 

survey (CAHPS health plan database OMB Control 

No.: 0935–0165). 

65Child Core Set: https://www.medicaid.gov/ 

medicaid/quality-of-care/performancemeasurement/adult-and-child-health-care-qualitymeasures/childrens-health-care-quality-measures/ 

index.html. 

66Per CAHPS Health Plan Survey 5.1H 

Guidelines: The sample needs to be large enough 

to achieve a goal of 411 completed surveys per 

reporting unit (for example, health plan or State). 

2. ICRs Regarding Core Set of Children’s 

Health Care Quality Measures for 

Medicaid and CHIP (Child Core Set) 

(Part 437, Subpart A) 

The following will be submitted to 

OMB for their approval under control 

number 0938–1188 (CMS–10434 #26). 

As required by section 50102(b) of the 

Bipartisan Budget Act of 2018, a new 

subparagraph (B) was added to section 

1139A(a)(4) of the Act to mandate 

annual reporting of the Child Core Set 

beginning with the annual State report 

on FFY 2024. As referenced in section 

II.A. of this final rule, mandatory 

reporting of the Child Core Set will be 

required for all 50 States, DC, Puerto 

Rico, Guam, and the Virgin Islands. The 

data collection, as explained in section 

II.C. of this final rule, will be required 

to include: reporting on all mandatory 

measures following the reporting 

guidance provided by CMS; 

populations, identified by CMS, for 

which States must report on each 

measure such as specified delivery 

systems, health care settings, and 

beneficiaries dually eligible for 

Medicare and Medicaid; and the 

stratification of certain measures by 

factors such as race, ethnicity, sex, age, 

rural/urban status, disability and 

language. 

The burden for each respondent is 

dependent on the State reporting 

structure and the status of the State’s 

Medicaid and CHIP programs. 

Currently, there are 14 States and 

territories with Medicaid expansion 

CHIP only, 2 States with separate CHIPs, 

and 38 States with both Medicaid 

expansion and separate CHIPs.63 We 

expect the burden for States with 

separate CHIPs or both types of CHIPs 

to be higher than for States with 

Medicaid expansion CHIP only. This is 

because States with separate CHIPs or 

both types of CHIPs would have to 

report data for children enrolled across 

both Medicaid and CHIP. This would 

result in more complex data sets and 

would require the State to conduct the 

Consumer Assessment of Healthcare 

Providers and Systems (CAHPS) survey 

twice, once for Medicaid and once for 

CHIP.64 To account for the added 

reporting and survey effort for States 

with separate CHIP or with both 

Medicaid expansion and separate 

CHIPs, we have applied a multiplier of 

1.5 to the burden hours for Child Core 

Set measure reporting and a multiplier 

of 2 to the burden estimate for 

conducting and reporting CAHPS 

survey data. 

For the 14 States with Medicaid 

expansion CHIP only, we expect that the 

reporting of approximately 25 Child 

Core Set measures would take: 154 

hours at $98.84/hr for a computer 

programmer to re-program and 

synthesize the data; 20 hours at 

$101.46/hr for a statistician to conduct 

data sampling; 115 hours at $118.14/hr 

for a general operations manager to 

analyze the data; 216.5 hours at $37.94/ 

hr for a data entry worker to input the 

data; and 11.75 hours at $236.96/hr for 

a chief executive to verify, certify, and 

approve a State data submission to 

CMS.65 We estimate an annual burden 

of 7,242 hours (517.25 hr × 14 

responses) at a cost of $585,689 (14 

responses × ([154 hr × $98.84/hr] + [20 

hr × $101.46/hr] + [115 hr × $118.14/hr] 

+ [216.5 hr × $37.94/hr] + [11.75 hr × 

$236.96/hr])). 

Additionally, we expect the new 

reporting mandate to require vendor 

contract modifications in all 14 States. 

We expect the contract modifications 

would take 6 hours at $118.14/hr for a 

general operations manager to draft a 

vendor contract and 2 hours at $236.96/ 

hr for a chief executive to review and 

approve a modified vendor contract. We 

estimate an annual burden of 112 hours 

(8 hr/response × 14 responses) at a cost 

of $16,559 (14 responses × ([6 hr × 

$118.14/hr] + [2 hr × $236.96/hr])). 

In aggregate, for States with Medicaid 

expansion CHIP only, we estimate an 

annual State burden of 7,354 hours 

(7,242 hr + 112 hr) at a cost of $602,248 

($585,689 + $16,559). Taking into 

account the Federal contribution to 

Medicaid and CHIP program 

administration, the estimated State 

share of this cost is approximately 

$301,124 ($602,248 × 0.50). 

For the 40 States (with separate CHIPs 

(2) and States with both Medicaid 

Expansion and separate CHIPs (38)) we 

expect a higher burden, because States 

with separate CHIP programs or 

combination CHIP programs would have 

to report data for children enrolled 

across both Medicaid and CHIP 

programs. We expect the Child Core Set 

of approximately 25 measures would 

take: 264.5 hours at $98.84/hr for a 

computer programmer to collect and 

synthesize the data; 40 hours at 

$101.46/hr for a statistician to conduct 

data sampling; 186.5 hours at $118.14/ 

hr for a general operations manager to 

analyze the data; 427.75 hours at 

$37.94/hr for a data entry worker to 

input the data; and 18 hours at $236.96/ 

hr for a chief executive to verify, certify, 

and approve a State data submission to 

CMS. We estimate an annual burden of 

37,480 hours (937 hr × 40 responses) at 

a cost of $2,909,152 (40 responses × 

([264.5 hr × $98.84/hr] + [40 hr × 

$101.46/hr] + [186.5 hr × $118.14/hr] + 

[427.75 hr × $37.94/hr] + [18 × $236.96/ 

hr])). 

Additionally, we expect the new 

reporting mandate would require 

vendor contract modifications. We 

expect the contract modifications to take 

6 hours at $118.14/hr for a general 

operations manager to draft a vendor 

contract and 2 hours at $236.96/hr for 

a chief executive to review and approve 

a modified vendor contract. We estimate 

an annual burden of 320 hours (8 hr × 

40 responses) at a cost of $47,310 (40 

responses × ([6 hr × $118.14/hr] + [2 hr 

× $236.96/hr])). 

In aggregate, for States with separate 

CHIPs and States with both Medicaid 

Expansion and separate CHIPs, we 

estimate an annual State burden of 

37,800 hours (37,480 hr + 320 hr) at a 

cost of $2,956,462 ($2,909,152 + 

$47,310). Taking into account the 

Federal contribution to Medicaid and 

CHIP program administration, the 

estimated State share of this cost is 

approximately $1,478,231 ($2,956,462 × 

0.50). 

The CAHPS measure is the only 

mandatory measure on the Child Core 

Set which would include a burden on 

beneficiaries. We estimate it would take 

20 minutes (0.33 hr) at $21.98/hr for a 

Medicaid or CHIP beneficiary to 

complete the CAHPS Health Plan 

Survey (Child Core Set includes: Child 

version including Medicaid and 

Children with Chronic Conditions 

Supplemental Items). The collected 

survey data are incorporated into a 

Child Core Set measure. 

For the 14 States with Medicaid 

expansion CHIP programs only, the 

survey will be conducted once each 

year. We estimate an annual per State 

beneficiary burden of 136 hours (0.33 hr 

per response × 411 beneficiary 

responses/State × 1 survey/yr) at a cost 

of $2,989 (136 hr × $21.98/hr).66 In 

aggregate, for States with Medicaid 

expansion CHIP only, we estimate an 

annual beneficiary burden of 1,904 

hours (136 hr × 14 States) at a cost of 

$41,846 ($2,989 × 14 States). We 

estimate a total of 5,754 beneficiary 


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67Per CAHPS Health Plan Survey 5.1H 

Guidelines: The sample needs to be large enough 

to achieve a goal of 411 completed surveys per 

reporting unit (for example, health plan or State). 

68https://www.medicaid.gov/medicaid/quality-ofcare/performance-measurement/adult-and-childhealth-care-quality-measures/adult-health-carequality-measures/index.html. 

69The Agency for Healthcare Research and 

Quality is the measure steward for the CAHPS 

survey (CAHPS health plan database OMB Control 

No.: 0935–0165). 

70Per CAHPS Health Plan Survey 5.1H 

Guidelines: The sample needs to be large enough 

to achieve a goal of 411 completed surveys per 

reporting unit (for example, health plan or State). 

responses (14 States × 411 beneficiary 

responses). 

States with combination CHIP 

programs or separate CHIP program only 

would conduct the survey twice each 

year to account for the separate 

Medicaid and CHIP populations. There 

are 40 States and territories with this 

program structure. We estimate an 

annual per State beneficiary burden of 

271 hours (0.33 hr per response × 411 

beneficiary responses/State × 2 surveys/ 

yr) at a cost of $5,957 (271 hr × $21.98/ 

hr).67 In aggregate, for States with 

combination CHIP programs or separate 

CHIP program only, we estimate an 

annual beneficiary burden of 10,840 

hours (271 hr × 40 States) at a cost of 

$238,280 ($5,957 × 40 States). We 

estimate a total of 32,880 beneficiary 

responses (40 States × 411 beneficiary 

responses × 2 surveys/year). 

For States to administer the survey, 

we estimate an ongoing aggregate 

beneficiary burden of 12,744 hours 

(1,904 + 10,840 hr) at a cost of $280,126 

($41,846 + $238,280). 

TABLE 4—CHILD CORE SET REQUIREMENTS AND BURDEN UNDER OMB CONTROL NUMBER 0938–1188 

(CMS–10434 #26, Child Core Set and the Adult Core Set) 

Regulatory section(s) under Title 42 of the CFR Number 

respondents 

Total 

number of 

responses 

Time per 

response 

(hr) 

Total time 

(hr) 

Labor cost 

($/hr) 

Total cost 

($) 

Adjusted cost 

($) 

(50% FMAP 

or FFP) 

§ 437.15—Medicaid Expansion CHIP Programs ............ 14 14 525.25 ........... 7,354 Varies ........... 602,248 301,124 

§ 437.15—States with combination CHIP programs or 

separate CHIP programs only.

40 40 945 ................ 37,800 Varies ........... 2,956,462 1,478,231 

Subtotal: States ................................................ 54 54 Varies ........... 45,154 Varies ........... 3,558,710 1,779,355 

§ 437.15—CAHPS survey: Medicaid Expansion CHIP 

Programs.

5,754 5,754 0.33 ............... 1,904 21.98 ............. 41,846 NA 

§ 437.15—CAHPS survey: States with combination 

CHIP programs or separate CHIP programs only.

32,880 32,880 0.33 ............... 10,840 21.98 ............. 238,280 NA 

Subtotal: CAHPS Survey beneficiary ............... 38,634 38,634 Varies ........... 12,744 21.98 ............. 280,126 NA 

Total ................................................... 38,688 38,688 Varies ........... 57,898 Varies ........... 3,838,836 1,779,355 

3. ICRs Regarding Core Set of Adult 

Health Care Quality Measures for 

Medicaid (Adult Core Set) (Part 437, 

Subpart A) 

The following changes will be 

submitted to OMB for their approval 

under control number 0938–1188 

(CMS–10434 #26). 

As required by the SUPPORT Act, a 

new subparagraph (b)(3)(B) was added 

to section 1139B of the Act, to make 

mandatory the annual reporting of 

behavioral health measures in the Adult 

Core Set beginning with the annual 

State report on FFY 2024. As referenced 

in section II.A. of this final rule, 

mandatory reporting of the Adult Core 

Set will be required for all 50 States, DC, 

Puerto Rico, Guam, and the Virgin 

Islands. The data collection, as 

explained in section II.C. of this final 

rule, is required to include: reporting on 

all mandatory measures following the 

reporting guidance provided by CMS; 

populations, identified by CMS, for 

which States must report on each 

measure such as specified delivery 

systems, health care settings, and 

beneficiaries dually eligible for 

Medicare and Medicaid; and the 

stratification of certain measures by 

factors such as race, ethnicity, sex, age, 

rural/urban status, disability and 

language. 

For the behavioral health measures on 

the Adult Core Set, consisting of 

approximately 13 measures, we estimate 

it would take: 115 hours at $98.84/hr for 

a computer programmer to re-program 

and synthesize the data; 20 hours at 

$101.46/hr for a statistician to conduct 

data sampling; 76 hours at $118.14/hr 

for a general operations manager to 

analyze the data; 212 hours at $37.94/ 

hr for a data entry worker to input the 

data; and 6.5 hours at $236.96/hr for a 

chief executive to verify, certify, and 

approve a State data submission to 

CMS.68 We estimate an annual burden 

of 23,193 hours (429.5 hr/response × 54 

responses) at a cost of $1,725,730 (54 

responses × ([115 hr × $98.84/hr] + [20 

hr × $101.46/hr] + [76 hr × $118.14/hr] 

+ [212 hr × $37.94/hr] + [6.5 × $236.96/ 

hr])). 

Additionally, we expect the new 

reporting mandate would require 

vendor contract modifications. We 

expect the contract modifications to take 

6 hours at $118.14/hr for a general 

operations manager to draft a vendor 

contract and 2 hours at $236.96/hr for 

a chief executive to review and approve 

a modified vendor contract. We estimate 

a one-time burden of 432 hours (8 hr × 

54 responses) at a cost of $63,869 (54 

responses × ([6 hr × $118.14/hr) + [2 hr 

× $236.96/hr])). 

In aggregate, we estimate an annual 

State burden of 23,625 hours (23,193 hr 

+ 432 hr) at a cost of $1,789,599 

($1,725,730 + $63,869). Taking into 

account the Federal contribution to 

Medicaid and CHIP program 

administration, the estimated State 

share of this cost is approximately 

$894,800 ($1,789,599 × 0.50). 

The CAHPS measure is the only 

mandatory measure on the Adult Core 

Set which would include a burden on 

beneficiaries.69 We estimate it would 

take 20 minutes (0.33 hr) at $21.98/hr 

for a Medicaid beneficiary to complete 

a CAHPS Health Plan survey. The 

collected survey data is incorporated 

into one of the behavioral health 

measures on the Adult Core Set. For 

each State Medicaid program, we 

estimate an annual per State beneficiary 

burden of 136 hours (0.33 hr/response × 

411 beneficiary responses/State) at a 

cost of $2,989 (136 hr × $21.98/hr).70

For States to administer the survey, in 

aggregate, we estimate an annual 

beneficiary burden of 7,344 hours (136 

hr/State × 54 States) at a cost of 

$161,406 ($2,989 per State × 54 States). 

We estimate a total of 22,194 beneficiary 


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responses (54 States × 411 beneficiary 

responses). 

TABLE 5—ADULT CORE SET REQUIREMENTS AND BURDEN UNDER OMB CONTROL NUMBER 0938–1188 

[CMS–10434 #26, Child Core Set and the Adult Core Set] 

Regulatory section(s) under Title 42 of the CFR Number 

respondents 

Total 

number of 

responses 

Time per 

response 

(hr) 

Total time 

(hr) 

Labor cost 

($/hr) 

Total cost 

($) 

Adjusted 

cost 

($) 

(50% FMAP 

or FFP) 

§ 437.15—(Adult Core Set) States .................... 54 States ........... 54 437.5 ................. 23,625 Varies ................ 1,789,599 894,800 

§ 437.15—CAHPS Survey (Beneficiaries) ......... 22,194 ............... 22,194 0.33 ................... 7,344 21.98 ................. 161,406 NA 

Total ............................................................ 22,248 ............... 22,248 Varies ................ 30,969 Varies ................ 1,951,005 894,800 

4. ICRs Regarding Core Sets of Health 

Home Quality Measures for Medicaid 

(Health Home Core Sets) (Part 437, 

Subpart A) 

The following changes will be 

submitted to OMB for their approval 

under control number 0938–1188 

(CMS–10434 #47). The burden 

associated with health home providers 

submitting data to the States is not 

included in this ICR as the burden 

estimate for the 1945 and 1945A health 

home programs is already included in 

control number 0938–1188 (CMS–10434 

# 22). Including the provider burden in 

this estimate would be duplicative. 

Sections 1945(g) and 1945A(g)(1)(B) 

of the Act require health home 

providers to report to States on 

measures for determining the quality of 

health home services provided, as a 

condition for payment of such services. 

Sections 1945(c)(4)(B) and 1945A(g)(2) 

of the Act require States to report on 

certain health home information to the 

Secretary, and we rely on these 

authorities, as well as on section 

1902(a)(6) of the Act, in proposing to 

require all States implementing the 

section 1945 or section 1945A health 

home benefits to report on mandatory 

measures in the Health Home Core Sets. 

Additionally, to enable this State 

reporting, States will be required to 

require their health home providers to 

report on these measures too, consistent 

with sections 1945(g) and 

1945A(g)(1)(B) of the Act. As discussed 

in section II.A. of this final rule, State 

reporting of the Health Home Core Sets 

would be required only if the State (as 

defined in section 1101 for purposes of 

Title XIX) has an approved health home 

SPA under sections 1945 or 1945A of 

the Act. The data collection, as 

explained in section II.C. of this final 

rule, will be required to include: 

reporting on all mandatory measures 

following the reporting guidance 

provided by CMS; all beneficiaries 

served in each State’s relevant health 

home program; and the stratification of 

data under certain measures by factors 

such as race, ethnicity, sex, age, rural/ 

urban status, disability and language. 

The burden for each respondent is 

dependent on the State’s adoption of 

Health Home programs. We expect 

approximately 20 States to operate 

approximately 40 Health Home 

programs under section 1945 authority 

and approximately 10 States to operate 

Health Home programs under section 

1945A authority. 

Section 1945 Authority: The section 

1945 Health Home Core Set for section 

1945 programs consists of 

approximately 13 measures. For each 

respondent with this program, we 

estimate it would take: 52 hours at 

$98.84/hr for a computer programmer to 

collect and synthesize the data; 52 hours 

at $118.14/hr for a general operations 

manager to analyze the data; 6.5 hours 

at $37.94/hr for a data entry worker to 

input the data; and 6.5 hours at $236.96/ 

hr for a chief executive to verify, certify, 

and approve a State data submission to 

CMS. We estimate an annual burden of 

4,680 hours (117 hr × 40 responses) at 

a cost of $522,792 (40 responses × ([52 

hr × $98.84/hr] + [52 hr × $118.14/hr] 

+ [6.5 hr × $37.94/hr] + [6.5 × $236.96/ 

hr])). 

Additionally, we expect the new 

reporting mandate would require 

vendor contract modifications. We 

expect the contract modifications to take 

6 hours at $118.14/hr for a general 

operations manager to draft a vendor 

contract and 2 hours at $236.96/hr for 

a chief executive to review and approve 

a modified vendor contract. We estimate 

a one-time burden of 320 hours (8 hr × 

40 responses) at a cost of $47,310 (40 

responses × ([6 hr × $118.14/hr) + [2 hr 

× $236.96/hr])). 

In aggregate, for States with a 1945 

health home program, we estimate an 

annual burden of 5,000 hours (4,680 hr 

+ 320 hr) at a cost of $570,103 ($522,792 

+ $47,310). Taking into account the 

Federal contribution to Medicaid 

program administration, the estimated 

State share of this cost is approximately 

$285,052 ($570,103 × 0.50). 

Note that the section 1945 Health 

Home Core Set does not include a 

survey-based measure; thus, there are no 

burden and cost estimates associated 

with a survey, such as the costs of a 

statistician to conduct sampling and 

weighting for the survey. 

TABLE 6—1945 ADULT CORE SET REQUIREMENTS AND BURDEN UNDER OMB CONTROL NUMBER 0938–1188 

[CMS–10434 #47, Health Home Core Sets] 

Regulatory section(s) under Title 42 of the CFR Number 

respondents 

Total 

number of 

responses 

Time per 

response 

(hr) 

Total time 

(hr) 

Labor cost 

($/hr) 

Total cost 

($) 

Adjusted 

cost 

($) 

(50% FMAP 

or FFP) 

§ 437.15—(1945 Health Home Core Set) ......................... 40 40 125 5,000 Varies ................ 570,103 285,052 

Section 1945A Authority: We 

anticipate that the section 1945A Health 

Home Core Set for section 1945A 

programs would consist of 

approximately 7 measures. For each 

respondent with this program, we 

estimate it would take: 28 hours at 

$98.84/hr for a computer programmer to 

collect and synthesize the data; 28 hours 

at $118.14/hr for a general operations 

manager to analyze the data; 3 hours at 

$37.94/hr for a data entry worker to 


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input the data; and 3 hours at $236.96/ 

hr for a chief executive to verify, certify, 

and approve a State data submission to 

us. We estimate an annual State burden 

of 620 hours (62 hr/response × 10 

responses) at a cost of $69,001 (10 

responses × ([28 hr × $98.84/hr] + [28 hr 

× $118.14/hr] + [3 hr × $37.94/hr] + [3 

× $236.96/hr])). 

Additionally, we expect the new 

reporting mandate would require 

vendor contract modifications. We 

expect the contract modifications to take 

6 hours at $118.14/hr for a general 

operations manager to draft a vendor 

contract and 2 hours at $236.96/hr for 

a chief executive to review and approve 

a modified vendor contract. We estimate 

a one-time burden of 80 hours (8 hr × 

10 responses) at a cost of $11,828 (10 

responses × ([6 hr × $118.14/hr) + [2 hr 

× $236.96/hr])). 

In aggregate, for States with a 1945A 

health home program, we estimate an 

annual State burden of 700 hours (620 

hr + 80 hr) at a cost of $80,829 ($69,001 

+ $11,828). Taking into account the 

Federal contribution to Medicaid 

program administration, the estimated 

State share of this cost is approximately 

$40,415 ($80,829 × 0.50). 

Note that we anticipate that the 

section 1945A Health Home Core Set 

would not include a survey-based 

measure; thus, there are no burden and 

cost estimates associated with a survey, 

such as the costs of a statistician to 

conduct sampling and weighting for the 

survey. 

TABLE 7—1945A ADULT CORE SET REQUIREMENTS AND BURDEN UNDER OMB CONTROL NUMBER 0938–1188 

[CMS–10434 #47, Health Home Core Sets] 

Regulatory section(s) under Title 42 of the CFR Number 

respondents 

Total 

number of 

responses 

Time per 

response 

(hr) 

Total time 

(hr) 

Labor cost 

($/hr) 

Total cost 

($) 

Adjusted 

cost 

($) 

(50% FMAP 

or FFP) 

§ 437.15—(1945A Health Home Core Set) ....................... 10 10 70 700 Varies ................ 80,829 40,415 

5. ICRs Regarding Optional Request for 

Exemption From Mandatory Child and 

Adult Core Sets Reporting for Specific 

Populations (Child and Adult Core Sets 

(Part 437, Subpart A)) 

With the changes outlined in this 

final rule, the 50 States, DC, Puerto 

Rico, Guam, and the Virgin Islands that 

will be subject to the Child and Adult 

Core Sets reporting requirements will 

have an opportunity each year to 

request a 1-year exemption from 

reporting data for one or more 

mandatory populations for the Child 

and Adult Core Sets if the State 

demonstrates an inability to obtain 

access to data required to report on the 

Child and Adult Core Sets in 

accordance with the requirements in 

§§ 437.10(b)(5), 437.15(a)(4)(ii), and (6). 

We have added this option to address 

concerns about the feasibility of Child 

and Adult Core Sets reporting for 

specific populations. A State that needs 

an exemption must request the 

exemption from CMS by September 1st 

of the applicable reporting year, the 

exemption would be only for that year’s 

reporting, and it would apply only to 

the specific population for which the 

State receives an exemption for 

reporting that population in one or more 

measures. The State would be required 

to define the specific population for 

which exemption from reporting is 

sought and to which measure(s) the 

request applies. The State will be 

required to explain why this exemption 

is necessary (that is, why the State 

agency was not able to obtain access to 

the data required to report on the 

relevant population) and what actions 

are underway to resolve the data access 

problems. In addition, the State must 

demonstrate to us that it has made a 

reasonable effort to obtain the required 

data by the reporting deadline. As 

discussed previously in this final rule, 

we will solicit public comment via 60- 

day and 30-day Paperwork Reduction 

Act notices that we will issue in the 

Federal Register separate from this 

rulemaking document before this 

voluntary requirement takes effect 

September 1, 2024. 

The process to request an exemption 

from reporting one or more mandatory 

populations for the Child and Adult 

Core Sets will require the state to submit 

an exemption request to us. We estimate 

it would take a business operations 

specialist 1 hour at $80.08/hr to 

determine which populations the state 

is unable to report, a general operation 

manager 2 hours at $118.14/hr to draft 

an exemption request and 1 hour at 

$236.96/hr for a chief executive to 

review, approve, and submit the 

exemption request. We estimate an 

annual burden of 216 hours (54 States 

and territories × 4 hr/response) at a cost 

of $29,879 (54 States and territories × ([1 

hr/response × $80.08/hr] + [2 hr/ 

response × $118.14/hr]) + [1 hr/response 

× $236.96/hr])). Taking into account the 

Federal contribution to Medicaid and 

CHIP program administration, the 

estimated State share of this cost is 

approximately $14,940 ($29,879 × 0.50). 

TABLE 8—REQUEST FOR EXEMPTION FROM REPORTING SPECIFIC POPULATIONS

[Child/Adult Core Sets only] 

Regulatory section(s) under Title 42 of the CFR Number 

respondents 

Total 

number of 

responses 

Time per 

response 

(hr) 

Total time 

(hr) 

Labor cost 

($/hr) 

Total cost 

($) 

Adjusted cost 

($) 

(50% FMAP 

or FFP) 

§ 437.15(a)(6)—Annual Exemption Request * ................ 54 54 4 216 hrs ......... Varies ........... 29,879 14,940 

* States will have the option to submit a request for exemption from reporting one or more mandatory populations. Exemption requests only apply to Child and Adult 

Core Sets reporting. 

C. Summary of Annual Requirements 

and Annual Burden Estimates 

As stated in section II. of this final 

rule, we received 93 public comments 

on the proposed rule, but only one of 

those comments was related to the rule’s 

collection of information requirements. 

Comment: One commenter noted that 

in their experience with the Child and 

Adult Core Sets, the time to convert the 

reporting guidance into analytic code is 

underestimated in the COI (by 3–4 

times) and the time to input the data is 

an overestimate. 


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Response: As the COI estimate reflects 

the average costs for all States that are 

required to comply with mandatory 

Core Set reporting requirements, it is 

expected that there will be variation in 

time estimates experienced by 

individual States. Upon additional 

review, we have revised the COI 

estimate for the Child and Adult Core 

Sets to reflect the issue raised by this 

public comment and added additional 

time to program, synthesize, analyze, 

and review the data. We are working 

with States to develop strategies to 

reduce the burden of implementing 

reporting guidance and for FFY 2021 

reporting introduced a new reporting 

system to help reduce the burden of 

Core Set reporting. We will continue to 

work with States to identify best 

practices and strategies to further reduce 

this burden and incorporate this 

information into reporting guidance and 

technical assistance materials. 

Table 9 sets out our annual burden 

estimates. 

TABLE 9—SUMMARY OF ANNUAL REQUIREMENTS AND BURDEN

[OMB Control Number: 0938–1188] 

Section 437 under Title 42 of the CFR Number of 

respondents 

Total 

responses 

Time per 

response 

(hours) 

Total time 

(hours) 

Labor cost 

($/hr) 

Total cost 

($) 

Adjusted cost 

($) 

(50% FMAP 

or FFP) 

CMS–10434 #26 

§ 437.20—One-time SPA Submission * ....................... 54 .................. 54 2 .................... 108 Varies ........... 10,019 5,009 

§ 437.15—Medicaid Expansion CHIP Programs ......... 14 .................. 14 525.25 ........... 7,354 Varies ........... 602,248 301,124

§ 437.15—CAHPS survey: Medicaid Expansion CHIP 

Programs.

5,754 ............. 5,754 0.33 ............... 1,904 21.98 ............. 41,846 NA 

§ 437.15—States with combination CHIP programs or 

separate CHIP programs only.

40 .................. 40 945 ................ 37,800 Varies ........... 2,956,462 1,478,231 

§ 437.15—CAHPS survey: States with combination 

CHIP programs or separate CHIP programs only.

32,880 ........... 32,880 0.33 ............... 10,840 21.98 ............. 238,280 NA 

§ 437.15—(Adult Core Set) .......................................... 54 .................. 54 437.5 ............. 23,625 Varies ........... 1,789,599 894,800 

§ 437.15—CAHPS: (Adult Core Set) ........................... 22,194 ........... 22,194 0.33 ............... 7,344 21.98 ............. 161,406 NA 

Subtotal (#26) ....................................................... ....................... 60,990 Varies ........... 88,975 Varies ........... 5,799,860 2,679,164 

CMS–10434 #22 

§ 437.20—One-time SPA Submission * ....................... 54 .................. 54 1 .................... 54 Varies ........... 5,009 2,505 

Subtotal (#22) ....................................................... 54 .................. 54 1 .................... 54 Varies ........... 5,009 2,505 

CMS–10434 #47 

§ 437.15—(1945 Health Home Core Set) ................... 40 .................. 40 125 ................ 5,000 Varies ........... 570,103 285,052 

§ 437.15—(1945A Health Home Core Set) ................. 10 .................. 10 70 .................. 700 Varies ........... 80,829 40,415 

Subtotal (#47) ....................................................... 50 .................. 50 Varies ........... 5,700 Varies ........... 650,932 325,467 

CMS–10867 

§ 437.15(a)(6)—Annual Exemption Request * ............. 54 .................. 54 4 .................... 216 Varies ........... 29,879 14,940 

Total ............................................................... Varies ........... 61,148 Varies ........... 94,945 Varies ........... 6,485,680 3,022,076 

* States will be required to submit a SPA that attests that the State will be in compliance with Child, Adult, and Health Home Core Sets reporting. Every State would 

complete the SPA and States with a Health Home would only have to identify as applicable. 

IV. Regulatory Impact Statement 

We have examined the impact of this 

rule as required by Executive Order 

12866 on Regulatory Planning and 

Review (September 30, 1993), Executive 

Order 13563 on Improving Regulation 

and Regulatory Review (January 18, 

2011), Executive Order 14094 on 

Modernizing Regulatory Review (April 

6, 2023), the Regulatory Flexibility Act 

(RFA) (September 19, 1980, Pub. L. 96– 

354), section 1102(b) of the Act, section 

202 of the Unfunded Mandates Reform 

Act of 1995 (March 22, 1995; Pub. L. 

104–4), Executive Order 13132 on 

Federalism (August 4, 1999) and 

Executive Orders 12866 and 13563 

direct agencies to assess all costs and 

benefits of available regulatory 

alternatives and, if regulation is 

necessary, to select regulatory 

approaches that maximize net benefits 

(including potential economic, 

environmental, public health and safety 

effects, distributive impacts, and 

equity). Section 3(f) of Executive Order 

12866 as amended by Executive Order 

14094 defines a ‘‘significant regulatory 

action’’ as an action that is likely to 

result in a rule: (1) having an annual 

effect on the economy of $200 million 

or more in any 1 year, or adversely and 

materially affecting a sector of the 

economy, productivity, competition, 

jobs, the environment, public health or 

safety, or State, local or tribal 

governments or communities; (2) 

creating a serious inconsistency or 

otherwise interfering with an action 

taken or planned by another agency; (3) 

materially altering the budgetary 

impacts of entitlement grants, user fees, 

or loan programs or the rights and 

obligations of recipients thereof; or (4) 

raising legal or policy issues for which 

centralized review would meaningfully 

further the President’s priorities, or the 

principles set forth in the Executive 

Order. OIRA has determined that this 

final rule is significant, and it was 

accordingly reviewed by OMB. 

The RFA requires agencies to analyze 

options for regulatory relief of small 

entities. For purposes of the RFA, small 

entities include small businesses, 

nonprofit organizations, small 

pharmaceutical manufacturers 

participating in the Medicaid Drug 

Rebate Program, and small 

governmental jurisdictions. Most 

hospitals and most other providers and 

suppliers are small entities, either by 

nonprofit status or by having revenues 

of less than $8.0 million to $41.5 

million in any 1 year. Individuals and 

States are not included in the definition 


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of a small entity. This final rule applies 

to new mandatory reporting 

requirements for information collection 

from State Medicaid and CHIP agencies 

who do not meet the definition of a 

small business. Therefore, we are not 

preparing an analysis for the RFA 

because we have determined, and the 

Secretary certifies, that this final rule 

would not have a significant economic 

impact on any small entities. In 

addition, section 1102(b) of the Act 

requires us to prepare an RIA if a rule 

may have a significant impact on the 

operations of a substantial number of 

small rural hospitals. This analysis must 

conform to the provisions of section 604 

of the RFA. For purposes of section 

1102(b) of the Act, we define a small 

rural hospital as a hospital that is 

located outside of a Metropolitan 

Statistical Area for Medicare payment 

regulations and has fewer than 100 

beds. This proposed rule applies to 

State Medicaid and CHIP agencies and 

would not add requirements to rural 

hospitals or other small providers. 

Therefore, we are not preparing an 

analysis for section 1102(b) of the Act 

because we have determined, and the 

Secretary certifies, that this final rule 

would not have a significant impact on 

the operations of small rural hospitals. 

Section 202 of the Unfunded Mandates 

Reform Act of 1995 also requires that 

agencies assess anticipated costs and 

benefits before issuing any rule whose 

mandates require spending in any 1 year 

of $100 million in 1995 dollars, updated 

annually for inflation. In 2023, that 

threshold is approximately $177 

million. This rule would have no 

consequential effect on State, local, or 

tribal governments or on the private 

sector. Executive Order 13132 

establishes certain requirements that an 

agency must meet when it issues a 

proposed rule (and subsequent final 

rule) that imposes substantial direct 

compliance costs on State and local 

governments, preempts State law, or 

otherwise has federalism implications. 

Since this regulation does not impose 

any substantial direct compliance costs 

on State or local governments, preempt 

State law, or otherwise have federalism 

implications, the requirements of 

Executive Order 13132 are not 

applicable. In accordance with the 

provisions of Executive Order 12866, 

this regulation was reviewed by the 

Office of Management and Budget. 

Chiquita Brooks-LaSure, 

Administrator of the Centers for 

Medicare & Medicaid Services, 

approved this document on August 23, 

2023. 

List of Subjects 

42 CFR Part 433 

Administrative practice and 

procedure, Child support, Claims, Grant 

programs—health, Medicaid, Reporting 

and recordkeeping requirements. 

42 CFR Part 437 

Administrative practice and 

procedure, Claims, Grant programs— 

health, Medicaid, Reporting and 

recordkeeping requirements. 

42 CFR Part 457 

Administrative practice and 

procedure, Grant programs-health, 

Health insurance, Reporting and 

recordkeeping requirements. 

For the reasons set forth in the 

preamble, the Centers for Medicare & 

Medicaid Services amends 42 CFR 

chapter IV as set forth below: 

PART 433—STATE FISCAL 

ADMINISTRATION 

■ 1. The authority citation for part 433 

continues to read as follows: 

Authority: 42 U.S.C. 1302. 

■ 2. Amend § 433.112 by revising 

paragraph (b)(12) to read as follows: 

§ 433.112 FFP for design, development, 

installation or enhancement of mechanized 

processing and information retrieval 

systems. 

* * * * * 

(b) * * * 

(12) The agency ensures alignment 

with, and incorporation of, standards 

and implementation specifications for 

health information technology adopted 

by the Office of the National 

Coordinator for Health IT in 45 CFR part 

170, subpart B. The agency also ensures 

alignment with: the HIPAA privacy, 

security, breach notification and 

enforcement regulations in 45 CFR parts 

160 and 164; and the transaction 

standards and operating rules adopted 

by the Secretary under HIPAA and/or 

section 1104 of the Affordable Care Act. 

The agency meets accessibility 

standards established under section 508 

of the Rehabilitation Act, or standards 

that provide greater accessibility for 

individuals with disabilities, and 

compliance with Federal civil rights 

laws; standards and protocols adopted 

by the Secretary under section 1561 of 

the Affordable Care Act; standards and 

protocols for reporting on the Child and 

Adult Core Sets as adopted by the 

Secretary under sections 1139A, 1139B, 

and 1902(a)(6) of the Act, and 42 CFR 

part 437 subpart A; and standards and 

protocols for reporting on the Health 

Home Core Sets as adopted by the 

Secretary under sections 1902(a)(6), 

1945(c)(4)(B) and (g), and 1945A(g) of 

the Act and 42 CFR part 437 subpart A. 

* * * * * 

■ 3. Part 437 is added to read as follows: 

PART 437—MEDICAID QUALITY 

Subpart A—Child, Adult, and Health Home 

Health Care Quality Measures 

Sec. 

437.1 Basis, scope, purpose, and 

applicability. 

437.5 Definitions. 

437.10 Child, Adult, and Health Home Core 

Sets. 

437.15 Annual reporting on the Child, 

Adult, and Health Home Core Sets. 

437.20 State plan requirements. 

Subpart B [Reserved] 

Authority: 42 U.S.C. 1320b–9a, 42 U.S.C. 

1320b–9b, 42 U.S.C. 1396a(a)(6), 42 U.S.C. 

1396w–4, and 42 U.S.C. 1396w–4a. 

Subpart A—Child, Adult, and Health 

Home Health Care Quality Measures 

§ 437.1 Basis, scope, purpose, and 

applicability. 

(a) Statutory basis. This subpart is 

based on sections 1139A, 1139B, 

1902(a)(6), 1945(c)(4)(B), 1945(g), and 

1945A(g) of the Act. 

(b) Scope. This subpart sets forth 

specifications for issuance and updates 

to the Core Set of Children’s Health Care 

Quality Measures for Medicaid and 

CHIP (Child Core Set), the Core Set of 

Adult Health Care Quality Measures for 

Medicaid (Adult Core Set), and the 1945 

and 1945A Core Sets of Health Home 

Quality Measures for Medicaid (Health 

Home Core Sets) by the Secretary. It also 

sets forth requirements related to annual 

reporting by States of measures in all of 

the Core Sets, and requirements related 

to provider reporting to States on the 

Health Home Core Sets. 

(c) Purpose. (1) The purpose of the 

Medicaid and CHIP Child Core Set and 

the Medicaid Adult Core Set is to 

measure the overall national quality of 

care for beneficiaries, monitor 

performance at the State-level, and 

improve the quality of health care. 

(2) The purpose of the Health Home 

Core Sets is to measure the overall 

program quality of health home services 

for Medicaid beneficiaries enrolled in a 

health home program under section 

1945 or 1945A of the Act, monitor the 

impact of these two optional State plan 

benefits, monitor performance of these 

two benefits at the program level, and 

improve the quality of health care. 

(d) Applicability. The provisions of 

this subpart apply as follows: 

(1) For the Child and Adult Core Sets, 

State includes the 50 States, the District 


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of Columbia, Puerto Rico, the Virgin 

Islands, and Guam. 

(2) For the Health Home Core Sets, 

State includes any State (as defined 

under section 1101 of the Act for 

purposes of Title XIX of the Act) with 

an approved Medicaid Health Home 

State Plan Amendment under section 

1945 or 1945A of the Act. 

(e) Applicability dates. States must 

comply with the requirements of this 

subpart by no later than State reporting 

on the 2024 Core Sets, which must be 

submitted and certified by December 31, 

2024. 

§ 437.5 Definitions. 

As used in this subpart— 

1945 Health Home Core Set means the 

Core Set of Health Home Quality 

Measures related to the Medicaid health 

home benefit under section 1945 of the 

Act, established and updated annually 

as described in § 437.10(a). 

1945A Health Home Core Set means 

the Core Set of Health Home Quality 

Measures related to the Medicaid health 

home benefit under section 1945A of 

the Act, established and updated 

annually as described in § 437.10(a). 

Adult Core Set means the Core Set of 

Adult Health Care Quality Measures for 

Medicaid established and updated 

annually as described in § 437.10(a). 

Attribution rules means the process 

Medicaid and CHIP and other payers 

use to assign beneficiaries to a specific 

health care program or delivery system 

for the purpose of calculating the 

measures on the Core Sets. 

Behavioral health means a 

beneficiary’s whole emotional and 

mental well-being, which includes, but 

is not limited to, the prevention, 

treatment, and recovery of mental 

disorders including substance use 

disorders. 

Behavioral health measure means a 

quality measure that could be used to 

evaluate the quality of and improve the 

health care provided to beneficiaries 

with, or at-risk for a behavioral health 

disorder(s). 

Child Core Set means the Core Set of 

Health Care Quality Measures for 

Children in Medicaid and CHIP, 

established and updated annually as 

described in § 437.10(a). 

Core Sets means the Child Core Set, 

the Adult Core Set, the section 1945 

Health Home Core Set, and the section 

1945A Health Home Core Set, 

collectively. 

Health Home Core Sets means, 

collectively, the two Core Sets of Health 

Home Quality Measures related to the 

two Medicaid health home benefits 

under sections 1945 and 1945A of the 

Act, established and updated annually 

as described in § 437.10(a). 

Standardized format means the 

format provided by the reporting system 

that States are required to utilize to 

submit Core Sets data to CMS. 

§ 437.10 Child, Adult, and Health Home 

Core Sets. 

(a) The Secretary shall— 

(1) Identify, and annually update, the 

quality measures to be included in the 

Child, Adult, and Health Home Core 

Sets; and update the Child and Adult 

Core Sets beginning no later than 

January 1, 2024 and annually no later 

than January 1 thereafter. 

(2) Consult annually with States and 

other interested parties identified in 

paragraph (e) of this section to— 

(i) Establish priorities for the 

development and advancement of the 

Core Sets; 

(ii) Identify any gaps in the measures 

included in the Core Sets; 

(iii) Identify measures which should 

be removed as they no longer strengthen 

the Core Sets; and 

(iv) Ensure that all measures included 

in the Core Sets reflect an evidencebased process including testing, 

validation, and consensus among 

interested parties; are meaningful for 

States; and are feasible for State-level 

and/or Health Home program level 

reporting, as appropriate. 

(3) In consultation with States, 

develop and update annually the 

reporting guidance described in 

paragraph (b) of this section. 

(4) Not later than September 30, 2025 

and annually by September 30 

thereafter, collect, analyze, and make 

publicly available the information 

reported by States on the Child and 

Adult Core Sets as described in 

§ 437.15. 

(5) Annually, collect, analyze, and 

make publicly available the information 

reported by States on the Health Home 

Core Sets as described in § 437.15. 

(b) Annual reporting guidance will 

include all of the following: 

(1) Identification of all measures in all 

the Core Sets, including: 

(i) Measures newly added and 

measures removed from the prior year’s 

Core Sets; 

(ii) Measures included in the Adult 

Core Set that are identified as behavioral 

health measures; 

(iii) The specific measures for which 

reporting is mandatory for the Child, 

Adult, and 1945 and 1945A Health 

Home Core Sets; 

(iv) The measures for which the 

Secretary will complete reporting on 

behalf of States and the measures for 

which States may elect to have the 

Secretary report on their behalf; and 

(v) The frequency of reporting for 

survey-based measures, which will be 

no more frequent than annually. 

(2) Guidance to States on how to 

collect and calculate the data on the 

Core Sets. 

(3) Standardized format for reporting 

measure data required under this 

subpart. 

(4) Procedures that State agencies 

must follow in reporting measure data 

required under this subpart. 

(5) Identification of the populations 

for which States may, but are not 

required to, report the Child and Adult 

Core Set measures identified by the 

Secretary under paragraph (b)(1) of this 

section for a specific year in accordance 

with paragraph (c) of this section. 

(i) Additionally, CMS will include 

guidance to States on how to request a 

1-year exemption from reporting one or 

more Child and/or Adult Core Set 

measures for specific populations in 

accordance with § 437.15(a)(4)(ii) and 

(6) of this part. 

(ii) [Reserved] 

(6) Attribution rules for determining 

how States must report on measures for 

beneficiaries who are included in more 

than one population, during the 

reporting period. 

(7) The subset of measures within the 

measures in the Child Core Set, among 

the behavioral health measures in the 

Adult Core Set, and among the measures 

in the Health Home Core Sets that must 

be stratified by race, ethnicity, sex, age, 

rural/urban status, disability, language, 

or such other factors as may be specified 

by the Secretary and informed by 

annual consultation with States and 

interested parties in accordance with 

paragraphs (a)(2) and (d) of this section. 

(c) In issuing the guidance described 

in paragraph (b) of this section, the 

Secretary may provide that Child and 

Adult Core Sets reporting for certain 

populations of beneficiaries described 

in paragraph (b)(5) of this section will 

be voluntary for a specific year, 

considering the level of difficulty in 

accessing the data required for such 

Child and Adult Core Sets State 

reporting. 

(d) In specifying which measures, and 

by which factors, States must report 

stratified measures consistent with 

paragraph (b)(7) of this section, the 

Secretary will consider whether 

stratification can be accomplished based 

on valid statistical methods and without 

risking a violation of beneficiary privacy 

and, for measures obtained from 

surveys, whether the original survey 

instrument collects the variables 

necessary to stratify the measures, and 

such other factors as the Secretary 

determines appropriate; the Secretary 


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will require stratification of 25 percent 

of the measures on each of the Core Sets 

(the Child Core Set, behavioral health 

measures within the Adult Core Set, and 

Health Home Core Sets) for which the 

Secretary has specified that reporting 

should be stratified by the second year 

of annual reporting after the effective 

date of these regulations, 50 percent of 

such measures for the third and fourth 

years of annual reporting after the 

effective date of these regulations, and 

100 percent of measures beginning in 

the fifth year of annual reporting after 

the effective date of these regulations. 

(e) For purposes of paragraph (a)(2) of 

this section, the Secretary must consult 

with interested parties as described in 

this paragraph to include the following: 

(1) States; 

(2) Pediatricians, children’s hospitals, 

and other primary and specialized 

pediatric health care professionals 

(including members of the allied health 

professions) who specialize in the care 

and treatment of children and 

adolescents, particularly children with 

special physical, mental, and 

developmental health care needs; 

(3) Dental professionals, including 

pediatric dental professionals; 

(4) Health care providers that furnish 

primary health care to children and 

families who live in urban and rural 

medically underserved communities or 

who are members of distinct population 

sub-groups at heightened risk for poor 

health outcomes; 

(5) National organizations 

representing children and/or 

adolescents, including children with 

disabilities and children with chronic 

conditions; 

(6) National organizations 

representing consumers and purchasers 

of children’s health care; 

(7) National organizations and 

individuals with expertise in pediatric 

health quality measurement; 

(8) Voluntary consensus standards 

setting organizations and other 

organizations involved in the 

advancement of evidence-based 

measures of health care; 

(9) With respect only to guidance on 

the Health Home Core Sets, providers of 

health home services under sections 

1945 and 1945A of the Act; 

(10) Such other interested parties as 

the Secretary may determine 

appropriate. 

§ 437.15 Annual reporting on the Child, 

Adult, and Health Home Core Sets. 

(a) General rules. (1) Except as 

provided in paragraphs (a)(2) and (a)(4) 

of this section, the agency— 

(i) Must report by December 31, 2024, 

on all measures on the 2024 Child Core 

Set and the behavioral health measures 

in the Adult Core Set; 

(ii) In subsequent years, must report 

annually, by December 31st, on all 

measures on the Child Core Set and the 

behavioral health measures in the Adult 

Core Set that are identified by the 

Secretary pursuant to § 437.10(b)(1)(iii); 

(iii) Must report annually, by 

December 31st, on all measures in the 

1945 or 1945A Health Home Core Sets 

(as applicable) that are identified by the 

Secretary pursuant to § 437.10(b)(1)(iii), 

if the agency has elected to offer health 

home services under the State plan 

under section 1945 or section 1945A of 

the Act, and if the applicable health 

home program has an effective date and 

has been implemented more than 6 

months prior to the December 31st 

reporting deadline; and 

(iv) May report on all other measures 

in the Adult Core Set that are not 

described in paragraphs (a)(1)(i) and (ii) 

of this section. 

(2) Measures identified per 

§ 437.10(b)(1)(iv) will be reported by the 

Secretary on behalf of the agency. 

(3) The agency must adhere to the 

reporting guidance described in 

§ 437.10(b), except as described in 

paragraph (a)(4) of this section, when 

reporting on measures in the Core Sets. 

(4) In reporting on all Child and Adult 

Core Set measures, the agency is 

required to report on all Medicaid and 

CHIP beneficiaries, including those 

enrolled in fee-for-service and managed 

care, unless— 

(i) The Secretary specifies in annual 

guidance that the population is not 

required to be reported in accordance 

with § 437.10(b)(5); or 

(ii) The Secretary grants the agency an 

exemption from reporting one or more 

Child and Adult Core Set measures for 

a specific population in accordance 

with paragraph (a)(6) of this section. 

(5) In reporting on all 1945 and 1945A 

Health Home Core Sets measures, the 

agency is required to report on all 

beneficiaries enrolled in an approved 

health home program. 

(6)(i) The agency may request a 1-year 

exemption from reporting for a specific 

population defined by the State for one 

or more Child and/or Adult Core Set 

measures if the agency demonstrates 

that it: 

(A) Is unable to obtain access to data 

required to report the relevant Child and 

Adult Core Set measure or measures for 

that population despite making 

reasonable efforts to do so; and 

(B) Has a reasonable timeline of 

actions underway to resolve data access 

problems. 

(ii) The agency must submit a request 

for an exemption by September 1st of 

the applicable reporting year. 

(iii) If the Secretary determines that 

the agency satisfies the conditions set 

forth in paragraph (6)(i) of this section, 

the Secretary will approve the 

exemption only for that year’s Child 

and/or Adult Core Set reporting and the 

exemption will apply only for the 

specific population for which the State 

requests an exemption. If the Secretary 

determines that the agency does not 

satisfy the conditions set forth in 

paragraph (a)(6)(i) of this section, the 

Secretary will communicate a denial of 

the exemption request to the agency, 

and the agency will be expected to 

include the relevant population in that 

year’s Child and Adult Core Sets 

reporting. 

(iv) The agency may request an 

exemption to reporting Child and Adult 

Core Set measures for the same 

population in accordance with this 

paragraph in more than one reporting 

year. 

(b) Reporting of Medicaid and CHIP 

beneficiaries. In States that have 

implemented a separate child health 

program (‘‘separate CHIP’’) under part 

457 of this chapter: 

(1) The agency must report, in 

accordance with attribution rules 

established by the Secretary pursuant to 

§ 437.10(b)(6), on measures included in 

the Child Core Set for— 

(i) The Medicaid beneficiaries 

(including those for whom the State 

claims Federal financial participation 

under both Title XIX and Title XXI) in 

the age range to which the measure 

applies, as per reporting guidance 

described in paragraph § 437.10(b)(2); 

and 

(ii) The beneficiaries in the State’s 

separate CHIP in the age range to which 

the measure applies, as per reporting 

guidance described in paragraph 

§ 437.10(b)(2). 

(2) If the separate CHIP elects to 

report on Adult Core Set measures for 

individuals enrolled in their separate 

CHIP, the agency must report on 

individuals described in paragraphs 

(b)(1)(i) and (ii) of this section. 

§ 437.20 State plan requirements. 

(a) The State plan must specify that: 

(1) The agency will report on the 

Child and Adult Core Sets in 

accordance with § 437.15. 

(2) If health home services are covered 

under the State plan pursuant to section 

1945 or 1945A of the Act, the agency 

will report on the applicable Health 

Home Core Set or Sets in accordance 

with § 437.15 of this subpart. 


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(3) If health home services are covered 

under the State plan pursuant to section 

1945 or 1945A of the Act, the agency 

requires health home services providers 

to report to the agency on all 

populations served by the health home 

providers and on the measures in the 

applicable Health Home Core Set or Sets 

that are identified by the Secretary 

pursuant to § 437.10(b)(1)(iii), as a 

condition for receiving payment for 

health home services. 

(b) [Reserved] 

PART 457—ALLOTMENTS AND 

GRANTS TO STATES 

■ 4. The authority citation for part 457 

continues to read as follows: 

Authority: 42 U.S.C. 1302. 

■ 5. Amend § 457.700 by 

■ a. In paragraph (a)(2) removing the 

word ‘‘and’’ at the end of the paragraph; 

■ b. In paragraph (a)(3) by removing the 

period at the end of the paragraph and 

replacing it with ‘‘; and’’; and 

■ c. Adding paragraph (a)(4). 

The addition reads as follows: 

§ 457.700 Basis, scope, and applicability. 

* * * * * 

(a) * * * 

(4) Section 1139A and 1139B of the 

Act, which set forth the requirements 

for child and adult health quality 

measures and reporting. 

* * * * * 

■ 6. Add § 457.770 to read as follows: 

§ 457.770 Reporting on Health Care 

Quality Measures. 

(a) Reporting the Child Core Set. The 

State must report on the Core Set of 

Health Care Quality Measures for 

Children in Medicaid and CHIP (Child 

Core Set) for a separate child health 

program in accordance with part 437 of 

this chapter. 

(b) Reporting the Adult Core Set. The 

State may elect to report on the Core Set 

of Adult Health Care Quality Measures 

in Medicaid (Adult Core Set) 

established by the Secretary in 

accordance with part 437 of this 

chapter. If the State reports measures on 

the Adult Core Set, such reporting must 

be in accordance with part 437 of this 

chapter, except that reporting on 

behavioral health measures on the Adult 

Core Set is not mandatory. 

(c) Reporting of Medicaid and CHIP 

beneficiaries. The State must report 

measures included in the Child Core Set 

and, if applicable, Adult Core Set for 

individuals enrolled in a separate CHIP 

separately from individuals enrolled in 

Medicaid in accordance with § 437.15(b) 

of this chapter, regardless of whether 

the State claims Federal financial 

participation for such Medicaidenrolled individuals under title XIX or 

title XXI of the Act. 

Xavier Becerra, 

Secretary, Department of Health and Human 

Services. 

[FR Doc. 2023–18669 Filed 8–28–23; 4:15 pm] 

BILLING CODE 4120–01–P 


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