Quality Rating System: What you need to know

When open enrollment begins for Qualified Health Plans (QHP) offered through a Marketplace in 2017, eligible individuals and families will—for the first time—have access to health plan quality ratings. The Affordable Care Act (ACA) “Quality Rating System” (QRS) star ratings will be published on each QHP issuer’s website as well asHealthCare.gov.

Similar to the Stars program for Medicare Advantage plans, the goal of the Quality Rating System program is to provide ACA Marketplace enrollees with comparative information about the quality of available plans and to encourage those health plans to focus on continuous quality improvement. The QRS program is comprised of 43 clinical and member survey measures. A majority of the measures are NCQA HEDIS measures. Twenty-nine of the measures were included in a beta test using 2014 data.

The QRS ratings to be published by November will be based on 2015 data – in other words, care documented or provided to ACA plan members during the calendar year 2015. ACA plans must submit their clinical data no later than June 15 and member survey results by May 25.

CMS will share preliminary QRS ratings with health plans in August. By the time the health plan sees those results, more than half of the next measurement year will have passed.

A key to success for the QRS is efficient and accurate collection of data from the providers caring for ACA members. Those providers may be different from the providers accustomed to completing HEDIS documentation for Medicare Advantage members. One way to make it easier for providers to meet this new ACA requirement is to integrate HEDIS data capture with existing Payer-Provider communication processes such as checking eligibility and benefits and submitting claims. Managing those processes electronically has dramatically reduced paper, fax, phone calls, and lag times. Why not leverage the same digital channel for risk and quality?