CMS Announces Quality Rating System for Qualified Health Plans

Beginning in 2016, all Qualified Health Plan (QHP) issuers operating in healthcare exchanges will be required to submit strict quality data on a number of measures under the Center for Medicare and Medicaid’s (CMS’) Quality Ratings System (QRS).

Yet, while CMS won’t require QHPs to submit this data for another year, beta testing will being in 2015, meaning health plans have only a few short weeks to prepare.

This program will closely resemble the Medicare Advantage (MA) Five-Star Quality Rating System, which rates MA plans based on their performance in a number of key measures. Similarly, through the QRS, all QHPs in the exchanges will be subject to such measures as access to care, access to information, plan administration and overall rating of the health plan.

This may come as a shock to commercial health plans, as many have not dealt with the challenges that MA plans have faced in achieving acceptable ratings in the similar Five-Star system.

Yet, success in the QRS program is vital to plans’ success in the exchanges.

During the 2016 exchange enrollment period, health plan ratings will appear on exchanges for all to see. Poor performance in any of these areas could be potentially damaging to a carrier’s enrollment numbers or ability to offer coverage.

Insurers must get their ducks in a row now, especially if they plan to have any level of success during the 2015 beta test.

To properly prepare, plans must:

  • Understand key measures as it pertains to their business
  • Identify which areas of patient care and/or satisfaction influence these measures
  • Determine a game plan for collecting and monitoring data
  • Proactively address any issues that may arise

Doing so will ensure that plans are proactively addressing any issues that may affect their quality ratings in 2016, and in turn, enrollment numbers.

If you are unsure of how to address these changes, contact Cody Consulting today.