CMS Releases Draft QRS And QHP Enrollee Experience Call Letter

The Centers for Medicare and Medicaid Services (CMS) has released a draft 2016 call letter proposing refinements to the Quality Rating System (QRS) and Qualified Health Plan (QHP) Enrollee Experience Survey. The QRS and QHP Enrollee Experience Survey are used to derive a star rating that will be displayed (for 2017 only in five states) on the marketplace shopping site to signal to consumers the quality of the alternative health plans available to them. The call letter proposes an annual call letter process for future years and minor changes for the 2017 and 2018 rating years.

The 2016 draft call letter is being published with a very short turnaround for comments (which are due by July 28, 2016). A final call letter is expected yet this summer. The QRS and QHP Enrollee Survey Guidance and Measure Set Technical Specifications for 2017, reflecting the final call letter, will be published in the fall.

In the future, draft call letters will be published in December or January for the following year with a 30-day comment period, a final call letter will be published in March or April, and the technical guidance will be published in September. The call letter could contain refinements to rating methodology for the current ratings year, but refinements to participation requirements, measure set, significant rating methodology changes, or other significant program requirements, would not take effect until the following ratings year.

For example, the 2017 call letter, published in draft form late in 2016 or early in 2017 and in final form in the spring of 2017, could refine the ratings methodology applied to data collected in 2017 (which would be based on experience from 2016 or earlier years) for ratings displayed for the 2018 plan year, but changes to participation or measure set changes would apply at the earliest for data collections during 2018.

The 2016 draft call letter also proposes a few refinements for data collection during the 2017 ratings year. These apply to all federally facilitated and state-based marketplaces. First, in the event of mergers or acquisitions that take effect by January 1 of a ratings year, the enrollees of the acquired insurer are subject to the QRS and QHP survey requirements applied to the acquiring insurer and should be included by the acquiring insurer for determining whether participation requirements are met.

Currently insurers are required to submit rating data for a year if they have at least 500 enrollees in a specified product type (EPO, HMO, POS, or PPO) enrolled through a marketplace as of July 1 of the prior year. Recognizing that insurers can experience significant drops in enrollment from one enrollment year to the next, the draft call letter would only require submission of rating data if an insurer met the 500 enrollee participation requirements for a product both on July 1 of the prior year and January 1 of the ratings year. The draft also proposes that CMS will not accept voluntary submissions of QRS and QHP Enrollee Survey data for rating year 2017.

Finally, following changes that the NCQA is proposing for its 2017 HEDIS measures, CMS proposes to combine the current clinical measures for Immunization for Adolescents and Human Papillomavirus Vaccine for Female Adolescents into a single measure for rating year 2017. For 2018 it is also proposing to drop a question from the QHP enrollee survey regarding access to care after hours which performed poorly on the 2015 Beta Test and is not included in other Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys.

More information on the QRS and QHP enrollee experience survey is included at the CMS Health Insurance Marketplace Quality Initiatives homepage.

Transparency Instructions For Insurers In The Federally Facilitated Marketplace

CMS also released on July 25 at its REGTAP.info website (registration required) its Transparency in Coverage QHP Issuer Instruction Guide for Plan Year 2017 and transparency template. QHP insurers in the Federally Facilitated Marketplace (including in states with state-based marketplaces that use the FFM enrollment platform) must submit preliminary transparency information to CMS for 2017 by August 15, 2016 and final information by September 15. There are no federal reporting requirements at this point for insurers in state-based marketplaces that do not use the FFM enrollment platform.

QHP insurers must submit identification and contact information and URLs to a web page on their websites that explain their policies regarding:

1. Out-of-network liability (including exceptions, such as for emergency care) and balance billing;
2. Enrollee claim submission in situations where enrollees rather than providers submit claims;
3. Grace periods pending of claims;
4. Retroactive denials (when an insurer denies a claim already paid and the enrollee becomes liable);
5. Recoupment by enrollees of premium overpayments;
6. Medical necessity and prior authorization timeframes and enrollee responsibilities;
7. Drug exception timeframes and enrollee responsibilities;
8. Explanation of benefits (EOBs); and,
9. Coordination of benefits (COB).

Insurers must also submit date for reporting year January 1, 2015 to December 31, 2015 regarding:

1. Number of in-network claims received;
2. Number of in-network claims denied (claim meaning any individual line of service within a bill for services);
3. Number of internal appeals filed;
4. Number of internal appeals in which a final determination adverse to a consumer was overturned in whole or in part;
5. Number of external appeals filed in calendar year 2015; and,
6. Number of final adverse determinations overturned on external appeal in whole or in part.

Claims and denials are reported by insurers and do not track directly to any particular plan of that insurer. They do not include out-of-network claims. Denials do not include claims pended for additional information that were subsequently paid. The form requests data on internal and external appeals filed and overturned during 2015. Filed appeals could be for claims denied in an earlier year and appeal decisions could be for appeals filed in an earlier year, so there is not a direct correlation between the claim, denial, and appeal information that will be reported.

An ACA transparency data reporting requirement has been in effect since 2010, but the federal government is only now beginning to collect this data, and for 2017 the requirement only applies to QHP insurers, not to all insurers and group health plans. The claims and appeals information will not be available as part of the shopping information provided to consumers on the healthcare.gov website, but will be publicly available and can be used to compare the performance of QHP insurers.

The Departments of Labor and Treasury have recently proposed collecting some of the same data from ERISA plans but not until 2019. Perhaps the next administration will finally fully implement the ACA's transparency requirement.

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