Under the Affordable Care Act, an eligible insurance company participating in the Exchange for two or more consecutive years must implement a quality improvement strategy (QIS) and report to the Exchange on its progress regularly. A QIS must incentivize quality by tying payments to provider performance measures or measures related to incentivizing enrollees to make healthy choices or exhibit healthy behaviors.

Which Issuers Must Submit a QIS to the Exchange for 2018?

Issuers who offer certified QHPs for the 2018 plan year must submit a QIS to the Exchange if:

  • The issuer offered a QHP through the Exchange in 2015 and 2016, and
  • The issuer had more than 500 enrollees in a product type as of July 1, 2016.

QHP issuers in the individual and SHOP markets, including issuers of Multi-State Plans and QHPs compatible with health savings plans, are subject to the QIS requirements. Child-only plans and stand-alone dental plans are not subject to the QIS requirements at this time.

QIS Requirements

  • Issuers must develop a QIS, which is a payment structure providing increased reimbursement or other market-based incentives for improving health outcomes of plan enrollees
  • The QIS must include activities that address at least one of the following:
    • Improving health outcomes
    • Preventing hospital readmissions
    • Improving patient safety and reducing medical errors
    • Wellness and health promotion
    • Reducing health and health care disparities
  • The QIS may be directed toward the needs of an entire QHP population or to the needs of a subpopulation (e.g., improving health outcomes within a QHP’s population of diabetic enrollees)
  • Issuers must use data to identify and describe the health outcome needs and priorities included in their QIS, and their methodology must be included in their QIS submission
  • An issuer may submit one QIS (or more) to address all eligible QHPs offered in the Exchange
  • Issuers must comply with federal QIS requirements released by HHS, including the QIS Technical Guidance and User Guide for the 2018 Coverage Year, located at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Downloads/QIS-Technical-Guidance-and-User-Guide-.pdf

Learn more about the QIS strategies insurance companies are conducting for 2018: