TABLE 3-1 Overview of Regulatory Requirements in Medicare, Medicaid, and SCHIP





Fee-for-Service (FFS)

Managed Care

Medicaid FFS

Medicaid Managed Carea


Target entities

Institutional providers and clinicians that receive Medicare reimbursement.

Medicare+Choice plans

Institutional providers and clinicians that receive Medicaid reimbursement

State Medicaid programs and managed care plans that enroll Medicaid beneficiaries

State SCHIP programs


Must meet standards for physical structure, governance, quality assurance, staff credentialing, infection control, etc.

Participation in external review projects is voluntary; other health care institutions must respond to data requests from QIOs.

Must implement a quality improvement process and show results using the Medicare HEDIS, CAHPS, and the Health Outcomes Survey.

Participation in external review is mandatory.

Medicare rules apply for institutional providers.

The Medicaid program must ensure that managed care plans use a quality improvement process that collects, assesses, and reports performance data to clinicians. States must contract with an EQROb for annual quality reviews and conduct annual medical audits of each managed care contractor.

The State Child Health Plan must describe performance goals; how progress will be assessed; and assure CMS that the state will collect, assess, and report standardized data.

External review requirements are at states’ discretion.

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