A total of 974 Medicaid recipients met the definition of incident lupus nephritis. The mean age was 39 years (SD 12), 93% were female, and most were African American (African American 48%, White 27%, Hispanic 13%, Asian 6%). Individuals were geographically dispersed (20% Midwest, 22% Northeast, 34% South, 24% West), and 95% resided in partial or complete HPSAs. One hundred and sixty-four individuals resided in states with more restrictive Medicaid benefits. At 90 days, only 16% of patients met all numerator components of QM1; 45% of individuals received only steroids (mean prednisone dose 28 mg/day), and 3% received an immunosuppressant alone. Among those treated with an immunosuppressant, 31% received azathioprine, 47% received mycophenolate, 14% received cyclophosphamide, and 11% received a calcineurin inhibitor. For 20% (n = 192) of patients, the usual source of care was in the emergency setting. In multivariable logistic regression models, younger individuals were more likely to receive optimal treatment (OR for 18 to 34 years vs. 51 to 64 years = 3.5, CI = 1.6 to 7.6), while those living in the South and Midwest were less likely (OR = 0.49, CI = 0.24 to 0.67 and OR = 0.30 CI = 0.15 to 0.61, respectively). Those whose usual source of care was the emergency department were less likely to receive optimal treatment (OR = 0.47, CI = 0.28 to 0.81). In this adjusted analysis, we did not find significant associations for race/ethnicity, HPSA or Medicaid restrictiveness with QM performance.