Health Insurance Marketplace Quality Initiatives

Health Insurance Marketplace Quality Initiatives

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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

  • 2025 QRS and QHP Enrollee Survey Operational Instructions (November 2024) (PDF):  CMS posted the 2025 QRS and QHP Enrollee Survey Operational Instructions. The Operational Instructions provide directions to issuers to determine eligibility for the submission of QRS clinical measure data and QHP Enrollee Survey data, validate information included in the preliminary 2025 QRS QHP List, and access the QHP Enrollee Survey Website to complete the attestation to the 2025 QRS and QHP Enrollee Survey eligibility criteria by January 31, 2025.
  • Plan Year 2025 Public Use Files (PUFs) (October 2024): CMS posted the Enrollee Survey PUF for Plan Year 2025, Plan Year 2025 Nationwide QRS PUF, and Plan Year 2025 Quality PUF to the CMS MQI Downloads page. The Nationwide QRS PUF outlines underlying measure data as well as star ratings for all eligible QHP issuers, operating in all Exchange types, that received QRS star ratings. The Quality PUF includes star ratings assigned to plans that will be available on HealthCare.gov. Additionally, CMS released the Health Insurance Exchanges QRS Program for Plan Year 2025: Results At-A-Glance (PDF) document, which summarizes the nationwide QRS results for the 2025 Plan Year, including a summary of QRS reporting and QRS eligibility for the 2025 Plan Year.
  • QRS and QHP Enrollee Experience Survey Technical Guidance for 2025 (September 2024) (PDF):  CMS posted the QRS and QHP Enrollee Survey: Technical Guidance for 2025. The Technical Guidance provides QHP issuers certified to offer coverage through the Exchanges in 2025 with the QRS and QHP Enrollee Survey guidance required as a condition of certification.
  • 2025 Quality Rating System Measure Technical Specifications (September 2024) (PDF):  CMS has posted an updated version of the 2025 Quality Rating System Measure Technical Specifications, which includes guidance on the finalized data submission requirements for the 2025 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 2024 Call Letter and finalized in the Final 2024 Call Letter. 
  • Quality Rating Information Bulletin (April 2024) (PDF): CMS released the Quality Rating Information Bulletin (PDF) to announce guidance for public display of 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 2025 Plan Year.

QIS: 

  • Plan Year 2025 QIS Materials Available for Download (April 2024): The Quality Improvement Strategy (QIS) materials for the 2025 Plan Year are now available for issuers to download on the Downloads page.
  • Issuers should submit questions about QIS to CMS' Marketplace Service Desk (MSD) by phone at 1-855-CMS-1515 (1-855-267-1515) or by email at CMS_FEPS@cms.hhs.gov. When submitting inquiries via email, please include "MQI-QIS" and your HIOS Issuer ID in the subject line or body of the email.
     

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, prevent 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.

For a more detailed overview of each of these programs, refer to the Marketplace Quality Initiatives (MQI) 101 (PDF).

Upcoming Deadlines and Events for Issuers

  • QRS/QHP Enrollee Survey Deadlines:
    • January 31, 2025: QHP issuer contracts with an HHS-approved QHP Enrollee Survey vendor to conduct the QHP Enrollee Survey and submit survey response data to CMS.
    • January 31, 2025: QHP issuer works with HEDIS® Compliance Auditor (auditor) to complete validation of the QHP Enrollee Survey sampling frame.
    • January 31, 2025: QHP issuer completes attestation to the QRS and QHP Enrollee Survey Issuer Eligibility Criteria and authorizes a QHP Enrollee Survey vendor via the QHP Enrollee Survey website.

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)

Resources

 

Page Last Modified:
11/13/2024 06:35 PM
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