Health Insurance Marketplace Quality Initiatives
- CMS has posted the Quality Rating System and Qualified Health Plan Enrollee Experience Survey: Technical Guidance for 2018 (PDF). QHP issuers certified to offer coverage through the Exchanges in 2018 are required to comply with QRS and QHP Enrollee Survey requirements as a condition of certification. QHP issuers with questions regarding the QRS or the QHP Enrollee Survey should contact the Marketplace Service Desk (MSD) and reference the Marketplace Quality Initiatives or "MQI-QRS."
- CMS has posted the 2018 Quality Rating System Measure Technical Specifications (PDF), which describes what QHP issuers will need to do to collect and submit QRS measure data to CMS in 2018. QHP issuers with questions regarding the QRS or the QHP Enrollee Survey should contact the Marketplace Service Desk (MSD) and reference the Marketplace Quality Initiatives or "MQI-QRS."
- CMS releases the 2017 Quality Rating Information Bulletin (PDF) to announce the continuation of the consumer testing pilot of the display of quality rating information by the Federally-facilitated Exchanges (FFEs), including FFEs where the State performs plan management functions and State-based Exchanges on the Federal Platform (SBE-FPs), for the 2018 plan year. CMS will continue to pilot the display of the Quality Rating System (QRS) star ratings in the same two FFE States as the previous year. The Bulletin also notes that guidance for issuers and State-Based Exchanges articulated in 2016 will continue to apply to the second year of consumer pilot testing, with the applicable year references revised to reflect the extension of the consumer pilot test for a second year.
- CMS posted the Quality Improvement Strategy (QIS): Technical Guidance and User Guide for the 2018 Plan Year (PDF) and the 2018 Quality Improvement Strategy Implementation Plan and Progress Report form (PDF) . An issuer that meets the QIS participation criteria, and has offered coverage in a Exchanges for two or more consecutive years, must implement and report on at least one QIS. Beginning in 2017 for the 2018 Plan Year, issuers will use the 2018 QIS Implementation Plan and Progress Report form to either: (a) implement a new QIS, or (b) provide a progress update on an existing QIS (e.g., a QIS submitted in 2016 for the 2017 Plan Year). The QIS Technical Guidance and User Guide for the 2018 Plan Year provides comprehensive background information about the QIS requirements, as well as step-by-step instructions to comply with the QIS requirements. Issuers with questions about the QIS requirements should contact the MSD Help Desk and reference the Marketplace Quality Initiatives-QIS or "MQI-QIS."
About the Marketplace Quality Initiatives
The Affordable Care Act authorizes the creation of Health Insurance Exchanges (Exchanges) to help individuals and small employers shop for, select, and enroll in high quality, affordable private health plans. Only qualified health plans (QHPs) may be offered within the Exchanges.
The Affordable Care Act requires the U.S. Department of Health & Human Services (HHS) to develop quality data collection and reporting tools and set QHP quality-related certification standards such as a Quality Rating System (QRS), a Quality Improvement Strategy (QIS), an enrollee satisfaction survey system and patient safety standards. Health care quality information will inform consumer selection of a QHP, decisions about QHP certification, and the Federal and State Exchanges’ monitoring of QHP performance. HHS intends a phased approach to public reporting of QHP-specific quality information.
Webinar slides describing the Marketplace Quality Initiatives, including the QRS, consumer experience surveys, the QIS, and patient safety standards can be accessed in the Downloads section at the bottom of this page:
- Marketplace Quality Initiatives Update March 2016 (PDF) – slides that provide an overview of the Marketplace Quality Initiatives
Quality Rating System (QRS)
About the QRS
Section 1311(c)(3) of the Affordable Care Act directs the HHS Secretary to develop a system that rates QHPs based on relative quality and price. It also requires Exchanges to display QHP quality ratings on Marketplace websites to assist in consumer selection of QHPs. Based on this authority, CMS established standards and requirements related to QHP issuer data collection and public reporting of quality rating information in every Exchange. QHP issuers must submit quality rating information (specifically QRS clinical measure data and QHP Enrollee Response data) for its QHPs in accordance with CMS guidelines as a condition of certification and participation in the Exchanges.
In 2017, CMS will conduct a limited pilot with the display of Quality Rating System (QRS) star ratings on HealthCare.gov for QHPs in two Federally-facilitated Exchanges States – Virginia and Wisconsin – for the 2018 individual market open enrollment period. More information on the display of quality ratings can be found at https://www.healthcare.gov/quality-ratings/.
Documents available on this page are updated periodically. For inquiries related to archived materials, such as QRS Measure Technical Specifications for previous years, and/or other QRS-related materials, please contact the Marketplace Service Desk (MSD) Help Desk.
Data Collection Guidelines
Documents describing the QRS requirements, technical specifications, and the QRS measures are available in the Downloads section at the bottom of this page. Answers to frequently asked questions related to QRS can be found at https://REGTAP.info under “FAQs” and “Library.”
The documents for 2018 include:
- Quality Rating System and Qualified Health Plan Enrollee Experience Survey: Technical Guidance for 2018 – specifies 2018 QRS and QHP Enrollee Survey requirements for QHP issuers offering coverage through the Exchanges.
- 2018 Quality Rating System Measure Technical Specifications – describes what QHP issuers will need to do to collect and submit QRS measure data to CMS in 2018.
Note: Certain materials provided on this website may be subject to third party copyrights.
Qualified Health Plan Enrollee Experience Survey (QHP Enrollee Survey)
About the QHP Enrollee Surveys
Section 1311(c)(4) of Affordable Care Act requires the HHS Secretary to develop an enrollee satisfaction survey system that assesses consumer experience with QHPs offered through an Exchange. It also requires public display of information by each Marketplace to allow individuals to assess enrollee experience among comparable plans.
CMS developed the QHP Enrollee Survey to assess enrollees’ experiences with QHPs offered through the Exchanges. The survey underwent preliminary testing in 2014 and 2015. Utilizing data from the 2016 QHP Enrollee Survey, CMS conducted a pilot test of displaying quality ratings on healthcare.gov
Detailed information about the QHP Enrollee Survey, processes, protocols, and measures can be found in the 2018 QHP Enrollee Survey Quality Assurance Guidelines and Technical Specifications (PDF). CMS anticipates publication of the QHP Guidelines and foreign language supplements in October 2018.
2018 HHS-Approved Conditional Survey Vendors:
QHP Issuers must contract with an HHS-approved survey vendor. The list of 2018 conditionally approved vendors can be found here (PDF).
2018 QHP Enrollee Survey Instruments :
The templates for all English survey materials, such as the pre-notification letter, cover letters, reminder letter, and telephone script are available in the 2018 QHP Enrollee Survey Quality Assurance Guidelines and Technical Specifications (PDF).
Templates for foreign language materials (Spanish and Chinese) can be found in the QHP Enrollee Survey 2018 Foreign Language Supplement, to be published in October 2016.
Technical Assistance related to the QHP Enrollee Survey
Technical Assistance for QHP Issuers and HHS-approved Survey Vendors is available by emailing: MQITier2HelpDesk@bah.com
QHP Enrollee Survey Quality Improvement (QI) Reports for QHP Issuers
QHP issuers and State Exchange administrators will receive QI Reports for each reporting unit and will be able to preview their respective QHP QI results via the CMS Health Insurance Oversight System-Marketplace Quality Module (HIOS-MQM) website during a two-week preview period each fall. Users must register for access to HIOS and the MQM via https://portal.cms.gov.
QHP issuers who are requesting their QI Report for previous administrations of the QHP Enrollee Survey should email MQITier2HelpDesk@bah.com and provide the HIOS ID(s) for the reporting unit(s) being requested.
Issue briefs on the following topics are available in the Downloads section at the bottom of this page:
- Issue Brief 1: 2016 QRS Requirements for Issuers (PDF)
- Issue Brief 3: Changes to the QHP Enrollee Experience Survey for 2017 (PDF)
Quality Improvement Strategy (QIS)
About the QIS
An issuer participating in an Exchange for two or more consecutive years must implement and report on a quality improvement strategy (QIS), in accordance with section 1311(g) of the Affordable Care Act entitled “Rewarding Quality Through Market-Based Incentives”. A QIS should incentivize quality by tying payments to measures of performance when providers meet specific quality indicators or enrollees make certain choices or exhibit behaviors associated with improved health. The QIS requirements apply to all issuers offering QHPs and Multi-State Plan (MSP) options through a Marketplace, whether through the Individual Exchange or through the Small Business Health Options Program (SHOP) Exchange.
All QIS activities must be linked to a market-based incentive. An issuer may choose to implement a provider market-based incentive, an enrollee market-based incentive, or both.
A QIS is described in section 1311(g)(1) as a payment structure that provides increased reimbursement or other incentives to improve health outcomes, reduce hospital readmissions, improve patient safety and reduce medical errors, implement wellness and health promotion activities, and/or reduce health and health care disparities. The QIS standards align with the National Quality Strategy, the CMS Quality Strategy, and other federal, State and private sector quality improvement initiatives, where possible, to help reinforce national health care quality priorities.
Data Collection Guidelines
Documents describing the QIS requirements and technical guidelines are available later in the Downloads section at the bottom of this page. Answers to frequently asked questions related to QIS can be found at https://REGTAP.info under “FAQs” and “Library.”
The documents for 2018 include:
- QIS Technical Guidance and User Guide for the 2018 Plan Year (PDF) – specifies the 2018 QIS requirements for QHP issuers offering coverage through the Marketplaces.
- 2018 QIS Implementation Plan and Progress Report form (PDF) – form that will be used by QHP issuers to either: (a) implement a new QIS, or (b) provide a progress update on an existing QIS (e.g., a QIS submitted in 2016 for the 2017 Plan Year).
- QIS Overview and Summary of Requirements for the 2018 Plan Year webinar slides (PPTX) – provides details related to the 2018 QIS timeline and requirements and highlight the steps QHP issuers must take to comply with the 2018 QIS requirements.
CMS intends to release QIS materials for the 2019 plan year in Spring 2018
Patient Safety Standards
Section 1311(h) of the Affordable Care Act requires QHPs to contract with certain hospitals that use patient safety evaluation systems (PSES) and implement comprehensive hospital discharge programs; and requires QHPs to contract with health care providers who implement health care quality improvement mechanisms. CMS finalized implementation of the patient safety standards, for plan years beginning on or after January 1, 2017, to require that a QHP issuer may only contract with a hospital with more than 50 beds if the hospital: (a) works with a Patient Safety Organization; or (b) meets the reasonable exception criteria by implementing an evidence-based initiative to improve health care quality through the collection, management and analysis of patient safety events that reduces all cause preventable harm, prevents hospital readmission, or improves care coordination. A QHP issuer also has to collect information to demonstrate that these contracted hospitals implement mechanisms for comprehensive person centered hospital discharge to improve care coordination and health care quality for each patient.
Marketplace Quality Initiatives Listserv
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