Health Reform WK-EDGE Health plan quality ratings go live on exchanges for upcoming enrollment period
Wednesday, August 28, 2019

Health plan quality ratings go live on exchanges for upcoming enrollment period

By Rebecca Mayo, J.D.

After a three year limited pilot program, CMS has announced that it will begin displaying quality ratings on and require state-based exchanges and direct-enrollment sites that facilitate enrollments through to display the ratings on their sites.

CMS has developed a five-star Quality Rating System (QRS) to rate health plans on the Health Insurance Exchanges, in an effort to help consumers compare and shop for qualified health plans. In accordance with the Patient Protection and Affordable Care Act and related regulations, all exchanges will now be required to publicly report 2019 quality rating information on their websites beginning with the individual market open enrollment period for the 2020 plan year. CMS has published a bulletin to serve as guidance for the display of 2019 quality rating information, which includes requirements for the display of the rating information, the form and manner for the display of the ratings, details for what to display where a plan did not receive a rating, and how rating information may be used in marketing materials (CCIIO Letter, August 15, 2019).

QRS goals. The QRS was designed to offer comparable and useful information to consumers about the quality of health care services and enrollee experiment with QHPs offered through the Exchanges. CMS’s goal is to empower consumers through data, minimizing cost and burden on QHP issuers, and supporting state flexibility. Ratings are based on an enrollee survey based on the Consumer Assessment of Healthcare Provider’s and Systems surveys and principals. The surveys and ratings were initially rolled out in pilot states before moving to nationwide availability and CMS will continue to obtain feedback from consumers about the topics that are most useful and their experience with QRS star ratings in the marketplace.

Rating display. This ratings will be displayed on during the individual market open enrollment period for the 2020 plan year, which begins on November 1, 2019. State-based exchanges that do not use will also be required to display the quality rating information on their respective websites for the individual market open enrollment period for the 2020 plan year. Health plan issuer and web-broker direct enrollment entities that use direct enrollment to facilitate enrollments through must also display rating information. CMS will provide a prototype of the API along with sample data files to support ratings integration with other websites, as well as a stare ratings data file that includes ratings down the to QRS composite level.

CMS will display a global rating, an overall rating and ratings of medical care and plan administration on the website. Health plans that have not been in operation for at least three consecutive years will note "new plan – quality ratings unavailable" in place of the ratings and plans that did not receive for any other reason will display "not rated" in place of the rating.

Marketing rating information. Health plans may reference the QRS quality ratings and enrollee survey results for their plans in marketing materials in a manner specified by CMS. Marking guidelines were communicated in the annual letter to Issuers in the Federally-facilities Exchanges. It includes information about the disclaimers that must be used in marketing materials referencing the ratings or enrollee survey information, the use of the most up-to-date information, how specific the content should be and how to comply with state laws and regulations.

2019 ratings. Issuers operating QHPs though the Exchanges that meet participation criteria are required to submit quality a data to CMS for each unique product type offered in a state, called a reporting unit. Exclusive Provider Organizations, Health Maintenance Organizations, Point of Service, and Preferred Provider Organizations are all subject to the QRS requirements. For plan year 2019, 95 percent of reporting units eligible for scoring received an overall rating. The overall rating is comprised of three categories, including Medical Care, Member Experience, and Plan Administration, with Medical Care given the greatest weight. Of those that received an overall rating, 95 percent received a rating of 3-stars or more.

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