Today many Medicaid stakeholders are challenged to identify health care programs that have both quality improvement and cost savings potential. To assist in these efforts, CHCS developed the ROI Forecasting Calculator for Quality Initiatives, a tool for estimating the financial implications of quality improvement initiatives. With support from The Commonwealth Fund and the Robert Wood Johnson Foundation, CHCS worked with eight states through the ROI Purchasing Institute to test the value of this tool, improve its functionality, and incorporate its use into the planning and analysis of proposed initiatives to improve care for Medicaid beneficiaries. This CHCS issue brief profiles state experiences in using the ROI Calculator and outlines how ROI forecasting can help Medicaid stakeholders identify initiatives that improve health care quality while also controlling cost growth.