August 19, 2019

CMS star ratings are coming to ACA health plans

Daily Briefing

    CMS on Thursday announced it will require state and federal exchange websites to display quality star ratings for Affordable Care Act exchange plans, starting with the 2020 open enrollment period.

    Cheat sheets: How CMS calculates its quality star ratings

    The move marks the first time CMS will require exchanges to publish quality ratings for the plans.

    Background

    CMS in 2016 first announced it would launch a star-ratings system for federal exchange plans, but the agency later postponed the ratings' release. CMS during the 2017 and 2018 open enrollment periods piloted five-star ratings for exchange plans sold through the federal exchange website, HealthCare.gov, in Virginia and Wisconsin. CMS expanded the pilot to include Michigan, Montana, and New Hampshire during the 2019 open enrollment period.

    CMS data show about 84% of consumers who enrolled in health plans through the federal exchange enrolled in a plan with a three-, four-, or five-star rating for the 2019 coverage year.

    CMS requires exchanges to publish star ratings

    CMS on Thursday said the agency now will require exchanges to display plans' star ratings in all states, starting with the upcoming open enrollment period, which is scheduled to begin Nov. 1.

    CMS said consumers will be able to compare the quality ratings for each plan sold on state exchange websites and HealthCare.gov in a manner similar to how consumers can view star ratings for Medicare Advantage plans. CMS said the exchange plan star ratings will range from one to five stars, with one star being the lowest rating and five stars being the highest. The ratings will be based on quality metrics in three categories:

    • Medical care, which will be based on how well a plan's in-network providers manage enrollees' care by providing regular screenings, vaccines, and other basic health care services;
    • Member experience, which will be based on surveys regarding member satisfaction with a plan's health care and in-network providers, as well as the ease of scheduling care appointments and services; and
    • Plan Administration, which will be based on how well the plan operates, including the plan's customer service, members' access to needed information, and in-network providers' ability to order appropriate tests and treatments.

    CMS said the star ratings might not be available when an exchange plan is new or there is low enrollment in an exchange plan, but that does not necessarily mean the health plan has a low rating.

    CMS said consumers can expect the star ratings to become available closer to the 2020 open enrollment period's launch, but noted that the agency has published star ratings and quality data based on the 2019 plan year in a public use file.

    Comments

    CMS Administrator Seema Verma said, "Knowledge is power, and for the first time, consumers will have access to meaningful, simple-to-use information to compare the quality, along with the price, of health plans on exchange websites, including HealthCare.gov. This addresses our strongly held commitment to equip consumers with the tools they need to find the best choice possible. Increasing transparency and competition drive better quality and cost, with consumers benefitting the most."

    However, observers have said the quality-rating system can be manipulated easily, and some of the system's measures are not the best indicators of quality, Axios' "Vitals" reports (Luthi, Modern Healthcare, 8/15; Owens, "Vitals," Axios, 8/16; King, FierceHealthcare, 8/15; Commins, HealthLeaders Media, 8/15; CMS release, 8/15).

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