April - QRS Bulletin

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
200 Independence Avenue SW
Washington, DC 20201

Date:
From:
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I.

April 29, 2016
Center for Consumer Information and Insurance Oversight and Center for Clinical
Standards and Quality, Centers for Medicare & Medicaid Services
Quality Rating Information Bulletin
CMS Bulletin on display of Quality Rating System (QRS) star ratings and
Qualified Health Plan (QHP) Enrollee Survey results for QHPs offered through
Marketplaces
Purpose

The Centers for Medicare & Medicaid Services (CMS) is releasing this bulletin to announce that
public reporting of quality rating information by the Federally-facilitated Marketplaces (FFMs),
including FFMs where the State performs plan management functions, and State-based
Marketplaces on the Federal Platform (SBM-FPs), will begin during the open enrollment period
for the 2018 plan year, with a limited pilot in place for the 2017 plan year. CMS will use this
time to conduct additional testing to inform the public display of quality rating information 1 for
Qualified Health Plans (QHPs) on Marketplace websites. State-based Marketplaces (SBMs)
whose consumers do not use HealthCare.gov may display QHP quality information for the 2017
open enrollment period or follow the revised timeframe.
In January 2016, CMS published the Quality Rating System (QRS) and QHP Enrollee Survey
Technical Guidance for 2016 (2016 Technical Guidance), which included details about the
content, process, and timing of the required display of Qualified Health Plan (QHP) quality
rating information. This bulletin revises the timeline previously released in the 2016 Technical
Guidance. 2 This bulletin also clarifies the continuing QHP certification requirements for issuers
to submit QRS clinical measure and QHP Enrollee Survey response data to CMS. Finally, this
bulletin outlines the options for public display of the 2016 QHP quality rating information by
State-based Marketplaces (SBMs) whose consumers do not use HealthCare.gov.
The term QHP quality rating information includes the Quality Rating System (QRS) scores and ratings and the
Qualified Health Plan (QHP) Enrollee Survey results. During the initial years of implementation, Marketplaces can
satisfy the requirement to display the QHP Enrollee Survey results by displaying the QRS star ratings (which
incorporate member experience data from the QHP Enrollee Survey). See, Patient Protection and Affordable Care
Act; Exchange and Insurance Market Standards for 2015 and Beyond; Final Rule; (May 27, 2014), (79 FR 30240,
30310), available at: https://www.gpo.gov/fdsys/pkg/FR-2014-05-27/pdf/2014-11657.pdf.
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In the 2016 Technical Guidance, CMS announced that the quality ratings for QHPs offered through the
Marketplaces should be displayed in time for the individual market open enrollment period for the 2017 plan year.
See the Quality Rating System and Qualified Health Plan Enrollee Experience Survey: Technical Guidance for
2016, Version 2.0 (January 2016), available at: https://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/QualityInitiativesGenInfo/Downloads/QRS-and-QHP-Enrollee-Experience-SurveyTechnical-Guidance-for-2016-V20.pdf.
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CMS remains committed to providing information about the quality of health insurance coverage
offered through Marketplaces consistent with 45 CFR 155.1400 and 45 CFR 155.1405. The
approach described in this bulletin will inform our understanding of the impact of QRS star
ratings on consumer behavior and about consumers’ priorities for QHP quality data as they shop
for QHPs on HealthCare.gov.
II.

Background

CMS designed the QRS to provide comparable and useful information to consumers about the
quality of health care services and enrollee experience with QHPs offered through the
Marketplaces. In addition, CMS developed the QHP Enrollee Survey, whose subset of survey
measures is included within the QRS, to obtain enrollees’ perspectives on the services provided
by QHPs. The QHP Enrollee Survey is based on the Consumer Assessment of Healthcare
Providers and Systems (CAHPS®) surveys and principles, which are the national standard for
assessing patient and consumer experience. The QRS star rating program supports CMS’ goal to
achieve quality care that is affordable for individuals, families, and employers by using public
reporting to improve health care quality, while also empowering consumers to make choices that
best suit their health care needs. The QRS star ratings provide health plan quality information on
important topics, such as how well doctors coordinate with enrollees and other doctors to provide
the best care, whether the plan’s network providers give members health care that achieves the
best results, and how other enrollees rate their doctors and the care they receive.
CMS recently completed the 2015 QRS and QHP Enrollee Survey beta test, which successfully
assessed the operational processes for issuer data submission, survey vendor operations, data
validation, ratings calculations, QRS results preview, and the provision of feedback to QHP
issuers and Marketplaces. Throughout the development and testing of the QRS and QHP
Enrollee survey – from choosing the quality measures set and survey questions to refining the
rating methodology – CMS focused on providing useful, reliable health plan quality information
to help consumers choose a plan to meet their needs. CMS engaged consumers and other
industry stakeholders throughout the development process, and continues to leverage knowledge
and experiences from established quality reporting programs, such as the Medicare Star rating
system.
The QRS will add to existing supports for consumer decision-making while shopping in the
Marketplaces, including the out-of-pocket cost calculator and searchable provider and formulary
information.
CMS continues to obtain feedback from consumers across Marketplaces about the quality topics
they find most useful for shopping for Marketplace plans. We will continue to test consumer use
and experience with QRS star ratings to enhance and improve the display of QHP quality rating
information to consumers through a pilot during the 2017 open enrollment period.
III.

Guidance

This guidance announces that there will be an additional year of QRS and QHP Enrollee Survey
testing to inform the public display of quality rating information on Marketplace websites. As the
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Marketplaces continue to mature, CMS remains focused on strategies to improve the experience
for consumers and QHP issuers.
CMS is conducting an additional year of focused consumer testing of the display of QRS star
ratings to maximize the clarity and consistency of the information provided and to assess how
the QHP quality rating information is displayed on HealthCare.gov. Although public reporting of
QRS results in the FFMs (including FFMs where the State performs plan management functions)
and SBM-FPs will now begin with the 2018 open enrollment period, we do not anticipate major
changes to the QRS methodology for the 2018 plan year, which is designed to encourage the
delivery of high quality health care services and improve health outcomes of QHP enrollees over
time. The revised timeframe for the public display will also provide QHP issuers additional time
to measure and improve the quality of QHPs offered through Marketplaces using the current
QRS measure set and methodology.
SBMs whose consumers do not use HealthCare.gov may choose to display QHP quality
information on their websites for the 2017 open enrollment period or to follow the revised
timeframe, using the additional time to refine their technical processes to integrate QRS star
ratings into their website infrastructure, and use CMS’ additional consumer testing results to help
inform the display of QHP quality rating information on their websites.
Guidance for the QRS and QHP Enrollee Survey Consumer Testing Limited Pilot
CMS will pilot the display of QRS star ratings in five States whose consumers use
HealthCare.gov during the 2017 open enrollment period. CMS’ goals with the 2016 consumer
pilot testing include:
• Obtaining further details about consumer access and use of QHP quality rating
information during an actual open enrollment period, so as to inform display of QRS star
ratings; and
• Informing the development of comprehensive technical assistance and education related
to the QRS for assisters, navigators, agents, brokers and consumer groups prior to QRS
public reporting.
Piloting Marketplace QRS star ratings is consistent with phased implementations of other tools
launched by CMS to compare health care quality data. QHP quality rating information is an
integral tool for consumer decision-making while shopping for health insurance coverage in a
Marketplace and the consumer pilot testing will further enhance the utility of this information.
Additionally, the phased approach of displaying the QRS star ratings will allow CMS to conduct
more in-depth, targeted assessments of consumers’ use of quality information to select a QHP, as
well as to learn more about the effectiveness and usability of the QHP quality rating information
during an open enrollment period.
Details of the Pilot
CMS has selected five States whose consumer use HealthCare.gov to pilot the display of QRS
star ratings to consumers. The States selected are Michigan, Ohio, Pennsylvania, Virginia, and
Wisconsin. CMS selected these States because they have ample participation of QHP issuers on
their respective Marketplaces and relative variation in QRS star ratings based on 2015 beta test
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results. These characteristics are necessary to assess the impact of QHP quality rating
information on consumer behavior. CMS will be able to collect data to support the above stated
goals and inform the display of QHP quality rating information to consumers in future years by
beginning with a limited pilot approach. QHP issuers participating in the Marketplaces in the
selected States will receive targeted outreach from CMS Account Managers with additional
information. CMS has conducted targeted outreach to State regulators in pilot States.
Guidance for Issuers
QHP issuers, including those issuers offering Multi-state Plan options, 3 should continue to
follow the guidance outlined in the 2016 Technical Guidance and comply with the qualityrelated QHP issuer participation standards in 45 CFR 156.200 and quality reporting requirements
in 45 CFR 156.1120 and 45 CFR 156.1125. QHP issuers should proceed with submitting the
specified QRS clinical measure and QHP Enrollee Survey response data to CMS according to the
processes and timeframes noted in the 2016 Technical Guidance. CMS will apply the 2016 QRS
ratings methodology and will provide results to issuers and Marketplaces during the plan
preview period. CMS will use the 2016 QHP quality rating information to inform future
refinements for the QRS and the QHP Enrollee Survey.
QHP issuers that participate in the pilot or in SBMs whose consumers do not use HealthCare.gov
that choose to display QRS star ratings for the 2017 open enrollment period may reference the
2016 QRS quality ratings and QHP Enrollee Survey results for its QHPs in its marketing
materials in accordance with the guidelines outlined in the 2016 Technical Guidance; however,
CMS will provide supplemental disclaimer language that issuers must include in all marketing
materials referencing the 2016 QRS quality ratings or QHP Enrollee Survey results to note that
CMS is conducting additional consumer testing regarding the public display of this quality rating
information. CMS will conduct additional outreach to issuers as it rolls out public reporting for
the QRS.
Guidance for State-based Marketplaces
SBMs whose consumers do not use HealthCare.gov may choose to display QHP quality rating
information on their websites for the 2017 open enrollment period or to follow the revised
timeframes established in this bulletin.4 As noted in the 2016 Technical Guidance and
communications with SBMs, CMS will continue to provide the QHP quality rating information
to SBMs via the Quality Ratings Application Program Interface (API) and the State Ratings Data
File for the States’ respective issuers. States that choose to display the 2016 QHP quality rating
information should display at least the QRS global rating on their websites by the start of the
2017 open enrollment period. CMS will provide supplemental disclaimer language that SBMs
whose consumers do not use HealthCare.gov that choose to display the 2016 QHP quality rating
An MSP option, certified by and under contract with the U.S. Office of Personnel Management (OPM), is
recognized as a QHP for purposes of 45 CFR 155.1010. Therefore, this bulletin and the 2016 Technical Guidance
also apply to QHP issuers offering MSP options. Additional MSP quality reporting requirements and guidance, if
required, will be specified by OPM.
4
The individual market open enrollment period for 2017 will begin on November 1, 2016. See the Patient
Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2017; Final Rule; (March
8, 2016), (81 FR 12204), available at: https://www.gpo.gov/fdsys/pkg/FR-2016-03-08/pdf/2016-04439.pdf.
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information should include, to note that CMS is conducting additional consumer testing
regarding the public display of this quality rating information.
SBMs whose consumers do not use HealthCare.gov may also want to align with the revised
timeline established in this bulletin and leverage the additional information and potential
refinements that will be obtained from the 2016 consumer pilot testing of the display of QRS star
ratings, prior to displaying QHP quality rating information on their Marketplace websites. CMS
intends to continue to share current and future consumer testing information with all SBMs to
help inform decision-making by consumers and enhance their experience in the Marketplaces.
CMS encourages SBMs to update their CMS State Officers and respective issuers if they choose
to display the quality rating information for their issuers for the 2017 open enrollment period.

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