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CMS to Bring Health Plan Quality Ratings to All Exchanges for the First Time

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For the first time, the Centers for Medicare & Medicaid Services (CMS) will require the display of the five-star Quality Rating System (or star ratings) available nationwide for health plans offered on the Health Insurance Exchanges beginning with the 2020 Open Enrollment Period. Beginning with this year’s Open Enrollment Period, consumers will be able to compare health coverage choices using a five-star quality rating of each plan on Exchange websites, including, similar to other CMS star rating programs.

Under the five-star Quality Rating System, Exchange health plans are given a rating on a 1 to 5 scale, with 5 stars representing highest quality. Star ratings are based on a number of important factors, including how other enrollees rate the doctors in the plan’s network and the care they receive, how well the plan’s network providers coordinate with enrollees and other doctors to give members healthcare that achieves the best results, and the overall administration of the plan including customer service and availability of information. In some cases — like when plans are new or have low enrollment — star ratings may not be available in all areas of the country. The lack of a star rating does not mean the plans have a low quality rating.

The overall star rating is based on three categories: Medical Care, Member Experience and Plan Administration.  Medical Care is based on how well the plans’ network providers manage member healthcare, including providing regular screenings, vaccines, and other basic health services.  Member Experience is based on surveys of member satisfaction with their healthcare and doctors and ease of getting appointments and services.  Plan Administration is based on how well the plan is run, including customer service, access to needed information and network providers ordering appropriate tests and treatment.

CMS has posted star ratings and quality measure level data from the 2019 Plan Year in a Public Use File (PUF). The star ratings data for the 2020 Plan Year will be released closer to Open Enrollment.

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