2018 Quality Star Rating Details

Federal Requirements

  • The Affordable Care Act (ACA) requires carriers participating in Exchanges to report on quality data for the purpose of improving health care quality and performance.
  • To comply with ACA requirements, CMS developed the “Quality Rating System” (QRS), which calculates quality ratings for each carrier based on a 5-star scale.

Washington Implementation

  • Washington implemented a modified quality rating program for 2018, with approval from CMS.
  • Each carrier received an overall plan quality star rating and ratings in three sub-categories: Medical Care, Patient Experience and Insurance Company Service.
    • Medical Care = 2/3 of overall plan quality rating
    • Patient Experience = 1/6 of overall plan quality rating
    • Insurance Company Service = 1/6 of overall plan quality rating
  • Medical Care is based on HEDIS measures submitted by carriers, while Patient Experience is based on enrollee responses to the QHP Enrollee Survey administered by CMS. Insurance Company Service is based on a combination of HEDIS measures and QHP Enrollee Survey responses.
  • Washington’s modified quality ratings are based on 42 clinical and enrollee survey measures.

Quality Rating Methodology