FAQ Directory: Marketplace Health Plans

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1.13.2017 Should Marketplace plans report the Relative Resource Use for People with Diabetes (RDI) measure for 2017?

Relative Resource Use for People with Diabetes

No. The RDI measure will be removed from the Quality Rating System. For Marketplace plans, CMS will issue guidance, including, but not limited to, FAQs, updates to the 2017 Technical Guidance and the 2017 Call Letter.

11.15.2016 For the Immunizations for Adolescents (IMA) measure, are issuers required to report Combination 1 for the Quality Ratings System?

Immunizations for Adolescents (IMA)

No. HEDIS for QRS requires collection of only Combination 2 and related antigens. IMA will not be scored this year.

4.15.2016 We are looking for external benchmarks for Marketplace results. When will they be available?

Marketplace Benchmarking Data

NCQA collects clinical data for the Quality Rating System (QRS) under contract for CMS, but does not collect or report Marketplace data for any other purpose.

Published CMS guidance (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Downloads/QRS-and-QHP-Enrollee-Experience-Survey-Technical-Guidance-for-2016-V20.pdf) states (page 19, Section 8, Quality Rating Information Preview Process), “The proof sheets will include benchmark information for measure results and an associated definition/rationale for any invalid/non-numeric results (e.g., NR).”
You can e-mail the Exchange Operations Support Center Help Desk at CMS_FEPS@cms.hhs.gov or phone 855-267-1515 if you have questions about benchmarks for Marketplace QRS data. Reference “Marketplace Quality Initiatives (MQI)-QRS” in the subject line.

1.07.2016 The Data Elements table for the W15 measure includes a field for required exclusions. Is this a mistake?

Well-Child Visits in the First 15 Months of Life (W15)

Yes. The W15 measure does not have exclusions and this data element was included in error. It will be deleted in future publications.

12.18.2015 Can organizations use the HEDIS for the Quality Rating System publication to report product lines other than Marketplace?

HEDIS for the Quality Rating System

No. The Marketplace product line is specifically for use with QRS reporting. There are differences between the HEDIS for the Quality Rating System and Volume 2 measure specifications. General Guideline 1 of the HEDIS for the Quality Rating System publication specifically states that QRS measure data must be collected separately for the Marketplace population. Future versions of the HEDIS for the Quality Rating System publication will only list the Marketplace product line. For those reporting on other product lines, the HEDIS Volume 2 publication must be used. 

9.30.2015 Should Off-Marketplace plans include their membership in QRS and in Marketplace accreditation?

QRS and Off-Market Commercial HEDIS Submission

No. Off-Marketplace plans should include its membership in its commercial HEDIS submission and in its commercial product line when submitting for health plan accreditation.

3.19.2015 Is QRS Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34) collected using the hybrid method or the administrative method?

Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life

Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life should be reported using only the administrative methodology as specified in the 2015 QRS Technical Specifications (http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Downloads/2015-QRS-Measure-Technical-Specifications.pdf). Hybrid specifications are not available for this measure in the QRS.  The W34 measure is listed as a measure in the sample size table of the QRS Sampling Guidelines and was a misprint which will be corrected in the 2016 QRS Measure Technical Specification. For organizations who have started medical record review for W34, please note, the IDSS will only accept the administrative elements of the measure for QRS.

2.26.2015 In the Quality Ratings System (QRS) Measure Technical Specifications, the RRU General Guidelines reference 13 risk groups, but there are only 8 risk groups referenced in Table RDI-B-4: Data Elements for Relative Resource Use for People With Diabetes. Which is correct?

Relative Resource Use for People With Diabetes

Table RDI-B-4 should include all 13 risk groups, to match the RRU General Guidelines in the QRS technical specifications.

12.22.2014 Should off-Marketplace enrollees in a QHP, be included in an organization’s NCQA HEDIS commercial submission?

QRS and Commercial HEDIS Submission

For 2015, QHP enrollees as defined by CMS should not be included in an organization’s NCQA HEDIS commercial submission; they should only be included in the organization’s QRS submission. However, if an organization has already completed programming, NCQA understands that off-Marketplace enrollees in a QHP may have been excluded from the QRS submission. In these instances, these enrollees should be included in the organization’s NCQA HEDIS commercial submission.With regard to requirements for reporting enrollee survey results and HEDIS measure results, NCQA plans to accept results that follow CMS reporting requirements. NCQA will review CMS beta-test results in fall 2015 before making final decisions on Accreditation reporting requirements for 2016.For 2015, NCQA HEDIS commercial submissions (which may include off-Marketplace enrollees) will be used to score commercial health plan accreditation (HPA). HEDIS submissions are not required for Marketplace HPA scoring in 2015. 

12.15.2014 Has the CAHPS survey sample frame validation process changed?

CAHPS Health Plan Survey 5.0H, Child & Adult Version

Yes. Starting in reporting year 2015, NCQA requires that all Licensed Organizations apply a password lock to the validated and approved sample frame file used for conducting the commercial and Medicaid Child and Adult CAHPS and the Qualified Health Plan (QHP) Enrollee surveys. Survey vendors may not pull a sample from an unlocked file.

5.15.2014 How will HEDIS work with the Marketplace products?


For Marketplace (Exchange) products, HEDIS will follow the federal Marketplace Quality Rating System (QRS). CMS will release QRS measure specifications and reporting guidelines (including HEDIS) in September 2014.