Health Insurance Marketplace Quality Initiatives

The Patient Protection and Affordable Care Act (PPACA) authorizes the creation of Health Insurance Exchanges (also known as Health Insurance Marketplaces) to help individuals and small employers shop for, select, and enroll in high quality, affordable private health plans.

The Marketplace Quality Initiatives (MQIs) includes four programs established by the PPACA which requires the U.S. Department of Health & Human Services (HHS) to develop quality data collection and reporting tools. The Marketplace Quality Rating System (QRS), QHP Enrollee Experience Survey (QHP Survey), Quality Improvement Strategy (QIS), and patient safety standards are Qualified Health Plan (QHP) quality-related certification requirements across all Marketplaces.

Scroll below to “Program Overview” for a description of each program.

Spotlight News

QRS and QHP Survey

• QRS and QHP Enrollee Experience Survey Technical Guidance for 2024 (September 2023): CMS posted the QRS and QHP Enrollee Survey: Technical Guidance for 2024. The Technical Guidance provides QHP issuers certified to offer coverage through the Exchanges in 2024 with the QRS and QHP Enrollee Survey guidance required as a condition of certification.
• 2024 Quality Rating System Measure Technical Specifications (September 2023): CMS has posted an updated version of the 2024 Quality Rating System Measure Technical Specifications, which includes guidance on the finalized data submission requirements for the 2024 QRS measure set. Specifically, CMS added callout boxes summarizing the final decision regarding measures and/or measure rates proposed for addition and those proposed for removal in the Draft 2023 Call Letter and finalized in the Final 2023 Call Letter. 
• Final 2023 Call Letter (June 2023): CMS has posted the Final 2023 Call Letter for the Quality Rating System and the Qualified Health Plan Enrollee Experience Survey to communicate finalized refinements to the QRS and QHP Enrollee Survey programs for the 2024 ratings year and beyond. This document also summarizes comments received on the Draft 2023 Call Letter.
• Quality Rating Information Bulletin (May 2023): CMS released the Quality Rating Information Bulletin to provide guidance for public display of Qualified Health Plan (QHP) quality rating information by all Exchanges, including the Federally-facilitated Exchange (FFEs), State-based Exchanges on the Federal Platform (SBE-FPs), and State-based Exchanges (SBEs) that operate their own eligibility and enrollment platform, during the individual market Open Enrollment Period (OEP) for the 2024 Plan Year.

QIS

The Quality Improvement Strategy (QIS) materials for the 2024 Plan Year are now available for issuers to download on the Downloads page under the QIS heading.

• QIS Issuer List for the 2024 Plan Year (March 2023): The QIS Issuer List includes issuers operating in Federally-facilitated Exchanges (FFEs) and FFEs where states perform plan management that meet the QIS participation criteria and are required to implement and report on at least one QIS as a condition of QHP certification for the 2024 Plan Year.
• QIS Implementation Plan form, Progress Report form, and Modification Summary Supplement form for the 2024 Plan Year (QIS forms) (April 2023): The QIS forms collect QIS information from issuers in order to demonstrate compliance with section 1311(c)(1)(E) of the Patient Protection and Affordable Care Act.
• QIS Technical Guidance and User Guide for the 2024 Plan Year (April 2023): The QIS Technical Guidance and User Guide communicates finalized QIS requirements and instructions to issuers on to complete the QIS form.

Program Overview

Quality Rating System - QRS

The Quality Rating System (QRS) is a 5-star rating system used to rate QHPs based on relative quality and price. The goals of the QRS are to provide comparable and useful information to consumers, facilitate oversight of QHPs, and provide actionable information to QHPs to improve quality and performance.

QHP Enrollee Experience Survey

The QHP Enrollee Experience Survey assesses consumer experience with QHPs offered through the Exchanges. The QHP Enrollee Survey aims to provide comparable and useful information to consumers about the quality of health care services and enrollee experience with QHPs offered through the Exchanges.

Quality Improvement Strategy - QIS

A Quality Improvement Strategy (QIS) is 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.

Patient Safety

QHPs are required to contract with certain hospitals that use patient safety evaluation systems and implement comprehensive hospital discharge programs. QHPs are also required to contract with health care providers who implement health care quality improvement mechanisms.

Upcoming Deadlines and Events for Issuers

• QRS/QHP Enrollee Survey Deadlines
  • October 2, 2023: QHP issuer contracts with a HEDIS® Compliance Organization (NCQA-licensed) for validation of the QHP Enrollee Survey sample frame and the QRS clinical measure data. 

Resources  

• Learn more about Quality Ratings: Information about the quality ratings of health plans is available on HealthCare.gov.
• Learn more about Quality Measures: The CMS Measure Management System (MMS) Hub is the home for content related to quality measures, quality measure development and maintenance information. Explore the following links to MMS resources learn more about quality measures:  
  • CMS Measure Management System Hub (cms.gov)
  • Quality Measures: How They Are Developed, Used, & Maintained (cms.gov) – Last updated May 2022
  • Blueprint QuickStart Guide (cms.gov) – Last updated July 2023.
• Marketplace Quality Initiatives Listserv: We encourage you to let others know about the CMS Marketplace Quality Initiatives, and to subscribe to Marketplace Quality Initiatives Listserv to be included in future communications and updates.
• Registration for Technical Assistance Portal (REGTAP): Register for REGTAP for training and resources related to the Health Insurance Exchanges.  
• Center for Consumer Information and Insurance Oversight (CCIIO) website: Navigate to the CCIIO website for more information about the Health Insurance Exchanges and QHP certification.
• Qualified Health Plan (QHP) website: For QHP issuers operating in the FFE, find the QHP application, materials, and resources on CMS’ QHP certification website. 
• Marketplace Quality Initiatives FAQs: Answers to frequently asked questions related to the MQI can be found on CMS’ QHP certification website.
• MQI Regulations: The following final regulations established the quality reporting standards related to the Marketplace Quality Initiatives (MQI):
  • Quality Rating System and Enrollee satisfaction survey system standards 
  • Quality Rating System and Enrollee satisfaction survey system standards for application and approval of survey vendors
  • Quality Improvement Strategy standards
  • Patient safety standards

Marketplace Service Help Desk (MSD) (reference “Marketplace Quality Initiatives”)

QHP issuers and Exchanges with questions regarding the QRS, QIS, or the QHP Enrollee Survey should contact the MSD
CMS_FEPS@cms.hhs.gov or 1-855-CMS-1515 (1-855-267-1515)