Health Insurance Exchange Quality Ratings System 101
Overview: Quality Ratings of Health Plans on the Exchanges
Consistent with section 1311(c)(3) of the Affordable Care Act, the Centers for Medicare & Medicaid Services (CMS) established a rating system for plans offered through an Exchange on the basis of quality and price. The purpose of the Quality Rating System (or star ratings) is to: (1) help consumers make informed healthcare decisions, (2) facilitate oversight of health plans, and (3) provide actionable information to health plans to improve the quality of services they provide.
Star ratings in the Exchange give consumers a snapshot of how each health plan’s quality compares to that of other Exchange plans in each state and across the country. Under the Quality Rating System, Exchange health plans are given an overall rating on a 5-star scale, with 5 stars representing highest quality. This rating is based on 3 categories: Member Experience, Medical Care, and Plan Administration. Each of these categories also has its own rating that is based on a 5-star rating scale. This provides consumers with an objective way to quickly compare plans, based on quality, as they shop for a plan that best meets their needs.
Quality Rating System Requirements
Issuers that offer plans through the Exchange are required to submit quality data to CMS. This applies to all issuers that offered coverage during the previous consecutive plan years and the current year, and have more than 500 enrollees. Issuers are required to collect and submit data for each unique product type offered in a state, called a reporting unit (Issuer ID-State-Product Type). Product types subject to the Quality Ratings System requirements include Exclusive Provider Organization (EPO), Health Maintenance Organization (HMO), Point of Service (POS), and Preferred Provider Organization (PPO). The star ratings measure data submitted to CMS is used to calculate each health plans rating. In some cases — like when plans are new or have low enrollment — star ratings may not be available.
Quality Rating System Measures
For the star ratings that will be displayed beginning with the 2020 Open Enrollment Period, the Quality Rating System includes a total of 38 quality measures including 28 clinical quality measures that assess general performance of the quality of healthcare services provided and 10 survey measures that assess enrollees’ experience with their health plan. The overall rating is based on Medical Care, Member Experience and Plan Administration. The Medical Care category is given the greatest weight, but these three categories are combined to create an overall rating.
- Medical Care is based on how well the plans’ network providers manage member healthcare, including providing regular screenings, vaccines, and other basic health services and monitoring some conditions.
- Member Experience is based on surveys of member satisfaction with their healthcare and doctors and ease of getting appointments and services.
- Plan Administration is based on how well the plan is run, including customer service, access to needed information and network providers ordering appropriate tests and treatment.
The full list of the measures is available here.
Quality Rating System Methodology
The Quality Rating System uses a methodology developed with input from key stakeholders and a technical expert panel. CMS calculates Quality Ratings System star ratings based on validated clinical quality and survey measure data that eligible issuers submit for each of their products in the Exchange.
The measures are organized into a hierarchy that serves as a foundation of the methodology. CMS calculates scores at each level of the hierarchy, resulting in one global score. The levels of the hierarchy are designed to make the health plan quality rating information more understandable to consumers, and allow consumers to review specific aspects of quality performance (e.g., Medical Care, Member Experience). CMS converts those scores into an overall global star rating using a 1-5 star scale (5 stars is the highest).
To learn more about the methodology, please see the Quality Rating System Technical Guidance available here.
Star Ratings Display on HealthCare.gov
Beginning with the 2020 Open Enrollment Period, quality ratings will be displayed on HealthCare.gov when consumers view the list of plans available in their area. Each plan will show the Overall Rating with the number of stars from 1 to 5 filled in towards the top of each plan within the list, or let the consumer know if the individual plan hasn’t been rated. Consumers can see three additional ratings for Member Experience, Medical Care, and Plan Administration with the Overall Rating when selecting an individual plan’s detailed information along with other coverage and benefits. The Overall Rating and the three additional quality rating categories are displayed as well when consumers choose to compare up to three plans side-by-side.
Star Ratings Display on State-based Exchanges
Similar to the Exchanges that use HealthCare.gov, State-based Exchanges (SBEs) are generally required to display the Overall Rating and the star ratings for the three categories which comprise the Overall Rating for each plan offered through the Exchange. However, SBEs will continue to have flexibility to display additional state or local quality information for their health plans. SBEs will also have some flexibility to customize the display of their health plan quality information and to adjust the display names of the star ratings. CMS will work with SBEs in preparation of the display of star ratings beginning with the 2020 Open Enrollment Period.
Quality Rating System Public Use File (PUF)
The nationwide Quality Rating System PUF includes underlying measure data as well as star ratings for all issuers, operating in all Exchange types that were eligible to receive star ratings for the specified plan year. This is primarily intended for researchers, but may also be used by the public, consumer groups, states or other entities. Today, CMS released the nationwide star ratings and quality measure level data from the 2019 Plan Year. The QRS ratings contained in this PUF were displayed only in pilot states and participating SBEs during Plan Year 2019. CMS intends to provide a similar nationwide PUF on an annual basis to promote transparency of data to the public. The Quality Rating System PUF for the 2020 Plan Year will be released closer to the Open Enrollment Period, which begins on November 1, 2019.
The Exchanges Quality Rating System guidance is available here: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Downloads/Quality-Rating-Information-Bulletin-for-Plan-Year-2020.pdf and https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/QualityRatingInformationBulletinforPlanYear2020.pdf
The Plan Year 2019 nationwide Quality Rating System PUF is available here: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Downloads/Plan-Year-2019-Nationwide-Quality-Rating-System-PUF.zip and https://www.cms.gov/CCIIO/Resources/Data-Resources/marketplace-puf.html
For the results at a glance of the Plan Year 2019 PUF data, visit here: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Downloads/Health-Insurance-Exchanges-QRS-Program-for-Plan-Year-2019-Results-At-A-Glance.pdf and https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/HealthInsuranceExchangesQRSforPY2020-ResultsataGlance.pdf