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Performance Improvement Projects (PIPs) are an integral part of Texas Medicaid's managed care quality strategy. The Balanced Budget Act of 1997 requires all states with Medicaid managed care to ensure health plans conduct PIPs. According to 42 CFR 438.330, projects must be designed to achieve, through ongoing measurements and interventions, significant improvement, sustained over time, in clinical care and nonclinical care areas that have a favorable effect on health outcomes and enrollee satisfaction