The
Centers for Medicare and Medicaid Services (CMS) recently announced they will
require the public display of quality ratings for health plans participating on
health insurance exchanges starting with the 2020 open enrollment period (OEP)
which starts on November 1, 2019. Although not directly mentioned in the President’s June executive order,
this announcement is in line with the Trump Administration’s continued push for
transparency. According to a CMS bulletin on the
matter, “exchanges will be required to publicly report 2019 quality rating
information on their websites beginning with the individual market OEP for the
2020 plan year to help consumers compare and shop for qualified health plans
(QHPs).”
For
background, the quality rating system (QRS) was a provision outlined in §
1311(c)(3) of the Affordable Care Act. Per
CMS’s fact sheet, the
purpose of the QRS is to “help consumers make informed health care decisions,
facilitate oversight of health plans and provide actionable information to
health plans to improve the quality of services they provide.” The QRS is often
referred to as the star ratings system because health plans are rated on a
scale of 1 to 5 stars with 5 indicating the highest level of quality.
As
noted on CMS’s fact sheet, under the QRS, health plans are compared on the
following categories:
- Medical
Care
- Member
Experience
- Plan
Administration
The
Medical Care category has the greatest weight assigned in terms of calculating
the overall score, but all three categories are assessed on a scale of 1 to 5.
After each category has a score assigned, CMS coverts this into an overall
quality rating. Issuers with over 500 enrollees that have been operating for a
minimum of three consecutive years (including the current plan year) must
submit quality data to CMS to have their score calculated. Furthermore, they
have to submit quality data for all product types or reporting unit (i.e. –
issuers will have data for both health maintenance organizations and preferred
provider organizations). Healthcare.gov will display both the overall rating
and the rating for each individual category for each QHP by product type.
State-based exchanges will also be required to publicly display quality
information on their websites starting with the 2020 OEP.
In
addition to announcing that QRS reporting will now be public, CMS also released
a summary of the 2019 results.
Out of 185 reporting units, 175 received at least 3 stars, 124 received at
least 4 stars and 36 received the highest 5-star rating. Of those that received
a 5-star rating, there was an even split with 18 participating on individually
state-based exchanges and 18 participating on the federally-facilitated
exchange (FFE). In terms of individual categories, only eight percent of
reporting units received a 5-star medical care rating. For member experience,
only six percent received a 5-star rating and for plan administration, 12
percent received a 5-star rating.
URAC-accredited
health plans that participate on the Exchanges, including the FFE and
state-based exchanges must comply with this requirement. CMS’s August 2019 bulletin
includes detailed guidance on the quality rating information that must be
displayed, the form to display it in and how to account for QHPs that do not
have a rating. QHPs with questions regarding the QRS should direct them to the
CMS Marketplace Service Desk at CMS_FEPS@cms.hhs.gov and
include Marketplace Quality Initiatives or MQI-QRS in the subject as noted on CMS’s website.
CMS
will continue to make updates to the QRS in their annual QRS and QHP call
letters. If you’re interested in reading the final 2019 call letter, click here.
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