Quality Rating FAQs

Q1: Is an issuer required to report QRS and QHP Enrollee Survey data for a reporting unit (defined by the unique issuer-state-product network type combination) when the issuer makes a change to an existing product that results in the product being offered as a different product network type (e.g., an issuer discontinues their HMO product in 2018 and is offering a POS product in its place in 2019)?

As a general matter, per the guaranteed renewability regulations set forth at 45 CFR 147.106, and the definition of product set forth at 45 CFR 144.103, changes to a product offering that result in the product being offered as a different product network type (e.g., health maintenance organization [HMO], preferred provider organization [PPO], exclusive provider organization [EPO], point of service [POS], or indemnity) donot fall within the uniform modification exceptions specified in the regulations identified above, and trigger a discontinuation of the former product. Therefore, if a change occurs that impacts the reporting unit’s product network type, the former product is considered discontinued, and the new product is considered a new offering. States generally are the primary enforcers of these guaranteed renewability and product definition standards, and generally would determine whether a product network type change has occurred, triggering a product discontinuance. CMS recommends QHP issuers work with the state in which their reporting unit(s) operate if they need assistance to determine whether a change in a product’s network type triggering a product discontinuation has occurred.

For QRS and QHP Enrollee Survey reporting purposes, if a product network type change has not occurred, the QHP issuer would be required to submit QRS and QHP Enrollee Survey data for the POS reporting unit for the 2019 ratings year, and the QHP issuer should review the annual QRS and QHP Enrollee Survey: Technical Guidance available on the Marketplace Quality Initiatives website. If a product network type change triggers a product discontinuation and introduction of a new product, the new product offering will not be required to report data until its second consecutive year of operation through the Exchange, consistent with the regulations at 45 CFR 156.1120(a) and 156.1125(b). Please note, the new product offering will not be eligible to receive a QRS rating until its third consecutive year of operation, per the QRS ratings eligibility criteria described in the annual QRS and QHP Enrollee Survey: Technical Guidance.