Agenda Qualified Health Plan Enrollee Experience Survey QHP Enrollee Survey Quality Rating System QRS Quality Improvement Strategy QIS Patient Safety Standards 2 QHP Enrollee Survey Section 1311c4 of the Affordable Care Act ACA directs the Secretary to establish an enrollee satisf ID: 935627
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Slide1
Marketplace Quality Initiatives (MQI)
Slide2Agenda
Qualified Health Plan Enrollee Experience Survey (QHP Enrollee Survey)
Quality Rating System (QRS)Quality Improvement Strategy (QIS)Patient Safety Standards
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Slide3QHP Enrollee Survey
Section 1311(c)(4) of the Affordable Care Act (ACA) directs the Secretary to establish an enrollee satisfaction survey system for QHPs offered through a Marketplace with more than 500 enrollees in the prior year
To implement, CMS developed the QHP Enrollee SurveyResults from the QHP Enrollee Survey feed into the overall Quality Rating System (QRS) for QHPs offered through a Marketplace mandated by section 1311(c)(3) of ACAThe survey was fielded nationally in the 2015 beta test and 2016 pilot to evaluate survey systems, processes, and procedures. Consumer display was also tested as part of the 2016 pilot during the 2017 open enrollment period for the individual Marketplace in select States
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Slide4QHP Enrollee Survey Requirements
Must be administered by HHS-approved QHP Enrollee Survey vendors
QHP issuer provides a validated sample frame and the survey vendor draws the sample and administers the surveyMinimum sample size will be specified by CMS, but issuers have the option to draw a larger sample (oversample) Survey employs a mixed mode of administration, including mail, telephone and InternetSurvey conducted in three languages—English, Spanish, Chinese (optional)
Questionnaire includes questions in core CAHPS® Health Plan 5.0 (Medicaid) Survey with additional questions specific to the Marketplace population
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Slide5Quality Rating System
Based on Section 1311(c)(3) of the ACA, CMS developed the QRS to:
Provide comparable and useful information to consumers about the quality of health care services and enrollee experience of QHPs offered through the Marketplaces,Facilitate oversight of QHP issuer compliance with quality reporting standards set forth in the ACA and implementing regulations, andProvide actionable information that QHP issuers can use to improve quality and performance.
CMS calculates quality ratings for each eligible QHP issuer’s product type (e.g., HMO, PPO) using clinical measure data and QHP Enrollee Survey response data
Based on results, CMS assigns a quality rating on a 5-star rating scale for each QHP offered through a Marketplace that meets the participation criteria
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The
Quality Rating System and Qualified Health Plan Enrollee Experience Survey: Technical Guidance for 2017
can be downloaded from the MQI website
:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Downloads/2017_QRS_and_QHP_Enrollee_Survey_Technical_Guidance.pdf
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Slide6Preview of QHP Quality Rating Information
QHP issuers will be able to preview their 2017 QRS ratings and submit inquiries to CMS during the QRS preview period, currently scheduled for August 2017
QHP issuers will also receive their complete 2017 QHP Enrollee Survey results, including results for those survey measures not used in the QRSCMS will also provide State-based Marketplaces (SBMs) with the 2017 QRS ratings and the 2017 QHP Enrollee Survey results for the QHP issuers operating within their respective Marketplaces
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Slide7Display of QHP Quality Rating Information
In 2017, CMS will provide guidance to SBMs regarding the display of QHP quality rating information to consumers on their respective websites in time for the annual Individual Market Open Enrollment Period for 2018
CMS is currently considering the timing and approach for displaying the 2017 QRS global ratings on Healthcare.gov and will communicate any display decisions before the start of the Individual Market Open Enrollment Period for 2018CMS will issue further communication to alert stakeholders if CMS decides to display additional quality rating information
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Slide8Quality Improvement Strategy
Issuers that meet the QIS participation criteria must:
Implement and report on a quality improvement strategy (QIS) consistent with the standards described in Affordable Care Act section 1311(g)(1) (45 CFR 156.200(b)(5)).Adhere to guidelines, including the QIS Technical Guidance and User Guide for the 2018 Plan Year
, established by HHS in consultation with experts in health care quality and stakeholders.
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For the 2018 Plan Year, a QIS
must address at least one of five topic areas identified in the Affordable Care Act and must include a market-based incentive, among other requirements
. The five topic areas are:
Improve health outcomes
Prevent hospital readmissions
Improve patient safety and reduce medical errors
Implement wellness and health promotion activities
Reduce health and health care disparities
Slide9Issuers that Must Submit QIS Information
Issuers applying for QHP certification in the Marketplaces for the 2018 Plan Year that meet the QIS participation criteria are required to submit a QIS Implementation Plan and Progress Report form in 2017 in HIOS to either: (a) implement a new QIS beginning no later than January 2018, and/or (b) provide a progress update on an existing QIS.
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Stand-alone dental plans (SADPs) and child-only plans that are offered on the Marketplaces are not subject to the QIS reporting requirements for the 2018 Plan Year.
The QIS requirements have been revised for the 2018 Plan Year to include QHPs that are compatible with health savings accounts (HSAs) (also known as HSA-eligible plans). Issuers are therefore required to include HSA-eligible plans that meet the other QIS participation criteria in their 2018 Plan Year QIS submissions.
* Followed by annual Progress Report submission.
Issuer’s Initial QHP Certification Application Year
Two Consecutive Years of Providing Coverage
Calendar Year of Initial QIS Implementation Plan Submission*
Initial QIS Implementation Plan Year
Initial
QIS Progress Report Plan Year
2013
2014
and
2015
2016
2017
2018
2014
2015 and 2016
2017
2018
2019
2015
2016 and 2017
2018
2019
2020
2016
2017
and 2018
2019
2020
2021
2017
2018 and 2019
2020
2021
2022
Slide102018 QIS Issuer Participation Criteria
An issuer (including co-ops and MSP issuers) must submit a QIS Implementation Plan and Progress Report form to each Marketplace in which it is applying to offer coverage during 2018 if:
The issuer offered coverage through the Marketplace in 2015 and 2016;The issuer provides family and/or adult-only medical coverage through the Individual Marketplace or
Small Business Health Options Program (SHOP) Marketplace; and
The issuer meets the QIS minimum enrollment threshold (more than 500 enrollees within a product type per State, as of July 1, 2016).
Each eligible QHP offered through a Marketplace within a product type that has more than 500 enrollees as of July 1, 2016, must be covered by a QIS.
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The
Quality Improvement Strategy: Technical Guidance and User Guide for the 2018 Plan Year
and
the 2018 QIS Implementation and Progress Report form
can be downloaded from the MQI website
:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Health-Insurance-Marketplace-Quality-Initiatives.html
Slide11QIS Marketplace Oversight Responsibilities
Marketplace
Oversight Responsibilities
Federally-facilitated Marketplaces
(
FFMs)
CMS will evaluate the QIS submissions for issuers applying to offer QHPs in FFMs.
FFMs will follow the QHP Application and Certification process and timeframe outlined in the addendum to 2018 Letter to Issuers for evaluation of QIS submissions.
FFMs where States perform
plan management
The State will evaluate the QIS submissions of the issuers applying to offer QHPs in their State’s Marketplace using the federal QIS evaluation methodology. This includes ensuring issuers that meet the QIS participation criteria and operate in their respective Marketplaces comply with the federal minimum reporting requirements. Issuers should contact the States for additional details.
CMS will also review the QIS submissions of issuers offering coverage in FFMs where the State performs plan management.
CMS will also evaluate the QIS submissions of issuers applying to offer coverage in FFMs where the State performs plan management, with the final determination being made by the FFM.
State-based Marketplace (SBMs), including SBM
s on the Federal Platform (SBM-FPs)
SBMs will evaluate the QIS submissions of the issuers applying to offer QHPs in their State’s Marketplace. The SBM must ensure issuers that meet the QIS participation criteria and operate in their respective Marketplaces comply with the federal minimum reporting requirements.
SBMs are encouraged to use the reporting manner and frequency requirements for
the FFMs
, but may establish their own reporting forms and evaluation methodologies, as well as their own reporting manner and frequency requirements.
Slide12Patient Safety Standards
Based on Section 1311(h)(1) of the Affordable Care Act, a QHP may contract with hospitals with more than 50 beds only if they meet certain patient safety standards including use of a patient safety evaluation system and a comprehensive hospital discharge program
The Final Rule (2017 HHS Payment Notice) published March 8, 2016:
Establishes the patient safety requirements for plan years on or after January 1, 2017
Amends 45 CFR 156.1110, directing a QHP issuer to only contract with a hospital with more than 50 beds that:
Utilizes a patient safety evaluation system and implements a mechanism for comprehensive person-centered discharge planning (e.g., works with a Patient Safety Organization (PSO)); or
Meets the reasonable exception criteria by implementing an evidence-based initiative to improve healthcare quality through the collection, management, and analysis of patient safety events that:
Reduces all-cause preventable harm,
Prevents hospital readmission, or
Improves care coordination (i.e., hospital participation and tracking documentation, such as hospital attestations or current agreements to partner with Hospital Innovation Improvement Networks (formerly HENs) and with Quality Innovation Networks-Quality Improvement Organizations)
NOTE:
Access the Final Rule (2017 HHS Payment Notice) at:
https://www.federalregister.gov/articles/2016/03/08/2016-04439/patient-protection-and-affordable-care-act-hhs-notice-of-benefit-and-payment-parameters-for-2017
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Slide13MQI: 2017 and Beyond
CMS will continue to engage stakeholders and provide technical assistance through the following channels:
Informational webinarsTraining sessionsHelp desk support
Public comment forums, including draft and final Call Letters
CMS will publish annual technical guidance and supplemental resources (e.g., FAQs) to communicate and clarify requirements
CMS is currently exploring ways to refine the MQI programs for future years
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Slide14Resources for Additional Information on Marketplace Quality Initiatives
Exchange Operations Support Center (XOSC) Help Desk (reference “Marketplace Quality Initiatives”):
CMS_FEPS@cms.hhs.gov
or 1-855-CMS-1515 (1-855-267-1515)
Marketplace Quality Initiatives Website:
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Health-Insurance-Marketplace-Quality-Initiatives.html
QHP Enrollee Survey Website:
http://qhpcahps.cms.gov
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Slide15Questions
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