CMS Continues Push for Transparency and Requires Health Plan Quality Ratings for Exchanges

| Brittany McCullough
Many stars in relief on black paper background with focus on five golden ones

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:  

  1. Medical Care
  2. Member Experience
  3. 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.

Brittany McCullough

Brittany McCullough, Health Policy Associate.

Brittany McCullough, URAC's health policy associate, focuses on tracking and analyzing legislation and regulations of importance to URAC stakeholders. Brittany considers herself an early careerist but most of her policy and research work has been centered on the ACA, Medicaid, CHIP, and mental health. She holds a B.S. in Neuroscience and a Master of Health Administration.

Views, thoughts and opinions expressed in my articles belong solely to me, and not necessarily to my employer.

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