How to explain quality star ratings to ACA clients
Beginning with the 2022 Open Enrollment Period (OEP), all Qualified Health Plan (QHP) issuers and web-broker direct enrollment (DE/EDE) entities will be required to display Quality Ratings System (QRS) star ratings.
In this article, we’ll cover how these ratings are calculated and how they will be displayed on HealthSherpa, so you are prepared to explain them to your clients.
Key points:
- The Centers for Medicare and Medicaid Services (CMS) created an annual survey that carriers with 500+ members must distribute and report the results to the CMS.
- The displayed ratings are for all of a carrier’s plans of the same network type (e.g. HMO, PPO, etc) in a state.
- HealthSherpa and other sites that facilitate FFM enrollments must display the overall rating and the following sub-ratings: Medical Care, Member Experience, and Plan Administration.
- When using HealthSherpa, quality ratings will appear in the Plan List, Plan Details, and Plan Comparison pages.
What are the QRS star ratings
The ACA requires Federal and State Based Exchanges to publicly report quality rating information, and EDE/DE entities (such as HealthSherpa) will also be required to display this information for plan year 2022.
This 1 to 5 star scale (5 is the highest) is meant to provide additional comparative information for consumers. While shopping, consumers and agents will see an “Overall Rating” as well as these 3 sub-ratings:
- “Medical Care”: how well does the plans’ network providers manage member healthcare, including providing regular screenings, vaccines, and other basic health services and monitoring some conditions.
- “Member Experience”: how satisfied are members with their healthcare, doctors, and ease of getting appointments and services.
- “Plan Administration”: how well the plan is run, including customer service, access to needed information, and network providers ordering appropriate tests and treatment.
How the QRS star ratings are calculated
The QHP Enrollee Survey (more details here) is a set of questions CMS developed to gauge enrollees’ perspectives on the services provided by QHPs. These survey results become QRS star ratings, which provide information on important topics such as how other enrollees rate their doctors and their care.
You can find more information on the QRS’s methodology here. Generally, questions that fall under the “Medical Care” category are given more weight than “Member Experience” or “Plan Administration”.
Any carrier with 500+ members must distribute this survey to their enrollees and report the results back to CMS between May and June, so ratings can be displayed for the same type of plan next year. As an example, survey results from May 2021 will turn into the star ratings shown for 2022 plans.
Carriers with one or more QHPs (or network types) will be assigned a specific QRS global rating for each. In other words, QRS star ratings are for all of a carrier’s plans in a state of the same network type (e.g. HMO, PPO, etc).
Some QHPs will not have a rating. They will fall into two buckets:
- “New plan — Not rated” means the QHP was ineligible for rating because it had not been in operation for at least three consecutive years.
- “Not rated” means the plan did not receive a rating for other reasons such as not meeting the participation criteria.
These ratings come directly from QHP Enrollee Survey results, and they are not recommendations or endorsements by the Federal Government, the Exchanges, or HealthSherpa.
Quality star ratings on HealthSherpa
Starting with Plan Year 2022, all EDE/DE entities (including HealthSherpa) are required to display the most up-to-date quality rating information provided by CMS and use the same consumer friendly descriptors that CMS displays on HealthCare.gov (i.e., “Overall Rating”, “Medical Care,” “Member Experience,” and “Plan Administration”).
When shopping for plans on HealthSherpa, you and your clients will notice QRS star ratings on the following pages:
1. Plan list
2. Plan details
3. Compare plans
Please note that the sub-ratings will only appear on the Plan Details page.
How to interpret the QRS star ratings
As an ACA agent, you’re no stranger to choosing the best plan for a client’s medical needs, and the addition of these comparative ratings may hasten or hamper your client’s decision making process.
If a client becomes hyper focused on the QRS star ratings, these are some important points for them to keep in mind:
- Before focusing on ratings, clients should only be selecting from plans that best cover their needed providers, prescriptions, and services.
- QRS star ratings are based on enrollee experiences from the prior year. If a carrier has a relatively lower rating compared to other plans in their area, they may be motivated to improve their offerings.
- The displayed ratings are based on the average enrollee’s reported experience. If you (or your Agency) provide year-round service to your clients, you should stress that you are available to help them make the most of their QHP.
New to HealthSherpa?
Don’t worry — it’s easy to get started with a free HealthSherpa for Agents account. HealthSherpa is an approved direct enrollment pathway for healthcare.gov, and we are able to help you enroll your clients directly on our site with Enhanced Direct Enrollment (EDE). Through a HealthSherpa account, you can enroll, track, and service your ACA clients year-round. Visit our HealthSherpa for Agents page today to learn more and sign up for an account.
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