PMSC Webinar slides - HHS.gov

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Patient Safety Instructions for Submission of Qualified Health Plan (QHP), Plan Preview Updates & Plan Year Comparison Report

June 12, 2019

This communication was printed, published, or produced and disseminated at U.S. taxpayer expense.

The information provided in this presentation is not intended to take the place of the statutes, regulations, and formal poli cy guidance that it is based upon. This presentation summarizes current policy and operations as of the date it was shared. Links to certain sour ce documents may have been provided for your reference. We encourage persons attending the presentation to refer to the applicable statute s, regulations, and other guidance for complete and current information.


Agenda

• Session Guidelines • Key Dates • Patient Safety Standards for QHP Issuers • Plan Preview at a Glance • Plan Year Comparison Report • Live Q&A Session • Closing Remarks

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Intended Audience

• Please be advised that this is not an open press call.

• Members of the press or a media outlet should disconnect the call at this time and contact the Centers for Medicare & Medicaid Services (CMS) Press Office for further information.

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• This is a 45 - minute webinar session.

• Throughout the webinar, you may submit questions via the Q&A Panel.

• We will address questions during the Q&A session at the end of the presentation.

• For questions regarding content or logistics, contact the Registration for Technical Assistance Portal (REGTAP) Registrar at [email protected] or (800) 257-9520.

Session Guidelines

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mailto:[email protected]


Date Category Activity

April 25 – June 19, 2019 QHP Certification QHP Application Initial Submission Window

May 23 – June 11, 2019 Early Bird Review Round

CMS Reviews Early Bird QHP Application Data as of 5/22/19 and Releases Results

Monday, June 17, 2019 QHP Certification Deadline 2019 QRS Clinical Data Submission Deadline

Wednesday, June 19, 2019 at 12:01 p.m. ET

QHP Certification Deadline Initial QHP Application Deadline (Pre-Rates)

Wednesday, June 26, 2019 Plan Confirmation CMS Posts Initial State Plan Confirmation Tables

to the PM Community

Upcoming Key Dates for Plan Year (PY) 2020 QHP Certification

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Announcements


Patient Safety Standards for QHP Issuers

Section 1311(h) of the Patient Protection and Affordable Care Act (PPACA)


Purpose

This presentation will provide information on the annual QHP certification requirements outlined in the patient safety standards, Section 1311(h) of the PPACA.

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Objectives

Participants will be able to: • Obtain an overview of the QHP issuer patient

safety standards. • Clarify issuer annual requirements in the patient

safety standards finalized in the 2017 Department of Health and Human Services (HHS) Payment Notice Final Rule.

• Discuss any feedback/questions.

Note: Currently, these QHP issuer patient safety standards apply to eligible issuers in all Exchange types. They do not apply to Stand - alone Dental Plans (SADPs).

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CMS Quality Priorities: Meaningful Measures Framework

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Section 1311(h) of the PPACA: Enhancing Patient Safety

Beginning on January 1, 2015, a QHP may contract with the following: • A hospital with greater than 50 beds, if the hospital:

– Utilizes a patient safety evaluation system, as described in part C of Title IX of the Public Health Service Act; and

– Implements a mechanism to ensure that each patient receives a comprehensive program for hospital discharge that includes patient - centered education and counseling, comprehensive discharge planning, and post discharge reinforcement by an appropriate healthcare professional

• A health care provider, if such provider implements mechanisms to improve healthcare quality as the Secretary may require by way of regulation

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Section 1311(h) of the Affordable Care Act (ACA): Exceptions and Adjustment

• The Secretary may establish reasonable EXCEPTIONS to the QHP patient safety standards.

• The Secretary may ADJUST by way of regulation the number of beds that triggers the QHP patient safety standards for hospitals.

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QHP Issuer Patient Safety Standards

Standards for QHP Patient Safety are: • Built on the foundation of the CMS quality priorities and the

National Quality Strategy for Improvement in Health Care • Aligned with the following priority and Meaningful Measure

Areas – Quality Priority: Make care safer by reducing harm caused in the

delivery of care. – Meaningful Measure Area: Healthcare - associated infections – Meaningful Measure Area: Preventable healthcare harm

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Current Patient Safety Standards for QHP Issuers

The 2017 HHS Payment Notice Final Rule, published March 8, 2016: • Established the QHP patient safety standards for plan years on or after

January 1, 2017. • Amended 45 CFR 156.1110, directing a QHP issuer to only contract with a

hospital with more than 50 beds that: – Utilizes a patient safety evaluation system as defined in 42 CFR 3.20

and implements a mechanism for comprehensive hospital person-centered discharge; or

– Meets the reasonable exception criteria by implementing an evidence - based initiative to improve healthcare quality through the collection, management, and analysis of patient safety events that: o Reduces all - cause preventable harm; o Prevents hospital readmission; or o Improves care coordinationNOTE: Access the 2017 HHS Payment Notice Final Rule at:

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https://www.federalregister.gov/articles/2016/03/08/2016-04439/patient-protection-and-affordable-care-act-hhs-notice-of-benefit-and-payment-parameters-for-2017.

https://www.federalregister.gov/articles/2016/03/08/2016-04439/patient-protection-and-affordable-care-act-hhs-notice-of-benefit-and-payment-parameters-for-2017


Clarification #1

• 45 CFR 156.1110 standards apply to contracted hospitals, as defined in 1861(e) of the Social Security Act, that have greater than 50 beds, are Medicare-certified or have been issued a Medicaid-only CMS Certification Number and are subject to the Medicare Hospital Conditions of Participation requirements.

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Clarification #2

• If a provider undertakes activities to improve patient safety and health care quality but does not do so in conjunction with a Patient Safety Organization (PSO) subject to the requirements of the Patient Safety and Quality Improvement Act (PSQIA) and its implementing regulation, 42 CFR part 3, the patient safety and quality information involved in such initiatives would not be subject to the PSQIA’s privilege and confidentiality protections.

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Clarification #3

• PSO contracts with hospitals for the purpose of receiving and reviewing patient safety work product do not meet the definition of “patient safety work product,” and thus, are not subject to the protections and requirements in the PSO statute and regulations.

• CMS does not intend to collect and publish data on the patient safety evaluation system, nor does CMS generally permit publication of patient safety work product.

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Clarification #4

The documentation requirement for Plan Years beginning on or after January 1, 2017, call for examples that are intended to be broad and inclusive of various initiatives [e.g., hospital attestations or current agreements to partner with a PSO, Hospital Improvement Innovation Network (HIIN), or Quality Innovation Network - Quality Improvement Organization (QIN-QIO)].

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Resources

Marketplace Quality Initiatives website:

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http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Health-Insurance-Marketplace-Quality-Initiatives.html

CMS Meaningful Measures Framework: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/CMS-Quality-Strategy.html

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Health-Insurance-Marketplace-Quality-Initiatives.html

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/CMS-Quality-Strategy.html


Plan Preview At a Glance


What is Plan Preview?

• Module in the Health Insurance Oversight System (HIOS)• Displays plans to issuers similar to how Plan Compare

displays plans to consumers on Healthcare.gov • QHP and SADP issuers use Plan Preview to preview how

plans will display to consumers and verify plan data • Gives issuers the chance to change incorrect plan information

until the Deadline for issuers to change QHP applications • States use Plan Preview to preview plan benefit displays for

all issuers in the state • Plan Year 2020 Plan Preview opens 6/7/2019.

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Who Participates in Plan Preview?

• Any issuers who applied to have QHP or SADP plans available on Healthcare.gov o All Federally - Facilitated Exchange (FFE) issuers o Issuers in states performing plan management functions and State-

Based Exchange on the Federal Platform (SBE-FP) whose plans appear on Healthcare.gov (NOTE: Data is available only after the state transfers data to HIOS)

• Issuer users assigned a role of Submitter and/or Validator in any of the QHP modules (Issuer, Rating, and Benefits & Service Area modules)

• State Department of Insurances (DOIs) with HIOS State Reviewer access

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SBEs and Multi-State Plans (MSPs)

• SBE issuers will not participate in FFE Plan Preview. • SBE issuers should consult with issuers’ state

Marketplace for any equivalent Plan Preview functionality.

• Plan Preview for MSPs in the HIOS Plan Preview module will be available after Office of Personnel Management (OPM) transfers MSP data.o OPM will contact MSP applicants with more details.

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Small Business Health Options Program (SHOP) Plan Preview

• SHOP issuers should use Plan Preview to confirm that their data will display as expected in Window Shopping, which has a similar display to Individual Market Plan Compare.

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2019 vs 2020 Plan Preview

• 2019 and 2020 versions of Plan Preview have different functionality. o 2019 Plan Preview will remain available for issuers to view

2019 plans through the end of July 2019, then be disabled due to IT security updates.

o Use 2020 Plan Preview to preview 2020 plans after 2020 QHP data submission.

• This presentation covers 2020 Plan Preview functionality.

• Some features of this presentation do not apply to 2019 Plan Preview.

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PY2020 Plan Preview Improvements

Plan Details Page Updates • Removal of ‘Main Costs’, ‘Doctors & Hospitals’, and ‘Other

Services & Prescriptions’ headers for SADPs • Updated display logic for child and adult dental benefits • Display age of subscriber in rating scenario table • Display limits and exclusions for all benefits in one location • Updated page layout to mimic Plan Compare 2.0

These updates are shown in the following slides, which detail Plan Preview functionality.

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Sample Enrollment Scenarios for Medical Plans

Scenario/Goal Possible Enrollment Group

Verify correct handling of rates for family with more than 3 children.

• Primary age 55, child age 19, child age 16, child age 12, child age 8

Verify correct handling of base/child-only rates. • Primary age 12

Verify correct handling of adult dependent under age 26.

• Primary age 50, spouse age 45, child age 25, child age 18, child age 14

Verify correct handling of smoker/self-only rates. • Primary age 35 (smoker – 0 months since last tobacco use), spouse 30

Verify correct handling of life partner relationship. • Primary age 30, life partner age 28

Verify correct handling of individual over age 65. • Primary age 60, spouse age 66

Verify correct handling of base/self-only rates. • Primary age 55

Verify correct handling of child-only plan eligibility with multiple dependents.

• Primary age 18; brother/sister age 17; brother/sister age 15

Verify correct handling of allowed relationship of ward. • Primary age 68; ward age 34

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Sample Enrollment Scenarios for Dental Plans

Scenario/Goal Possible Enrollment Group

Verify correct handling of MOOP/Deductibles when there are no enrollees under 19. • Primary age 21

Verify correct handling of MOOP/Deductibles when there is exactly one enrollee under 19. • Primary age 18

Verify correct handling of MOOP/Deductibles when there is one enrollee under 19 and one enrollee over 19.

• Primary age 30, child age 5

Verify correct handling of MOOP/Deductibles when there are at least two enrollees under 19 and no enrollees over 19.

• Primary age 14, brother/sister age 12

Verify correct handling of MOOP/Deductibles when there are at least two enrollees under 19 and at least one enrollee over 19.

• Primary age 31, child age 12, child age 7

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Dates for Network Breadth and Quality

• Until ratings are available: – Network Breadth Ratings will display as “Not

Available” – Quality ratings will display as “Not rated”

• CMS expects to display Network Breadth and Quality ratings in September 2019.

• CMS will notify issuers when ratings are available to preview.

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Uploads and Corrections – Data Flow

• Issuers upload data or make changes in HIOS (for HIOS submitters) and System for Electronic Rate and Form Filing (SERFF) (for SERFF submitters).

• States push SERFF templates to HIOS. • Once in HIOS, data changes typically appear in

Plan Preview within 24 hours. • Issuers can change data until August 21, 2019.

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Plan Preview Tips

Possible Issue ResolutionPlans will not display when effective date is the same as the rate expiration date.

Do not use rate expiration date for effective date.

Issuer ID does not display on status page.

HIOS QHP application must be in Cross Validation Complete status,or at least one plan must be transferred from SERFF.

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Plan Year Comparison Report


Agenda

• Overview of Plan Year (PY) Comparison Report • Data Fields of Report • Demo of Report • Accessing the Report • Q&A

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Overview

The Plan Year Comparison Report is an issuer resource to confirm specific data changes in a QHP application for plans submitted for PY2020 certification that were also offered in PY2019.

The objective of the report is to assist issuers in identifying and confirming data changes between plan years.

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Overview (continued)

The PY Comparison Report flags benefit package, benefit cost - sharing, service area, and business rules changes for Plan IDs offered in both PY2020 and PY2019.

The report compares PY2019 data against current PY2020 QHP application data submitted to CMS as of June 19, 2019.

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Market and Exchange Type

For PY2020, the PY Comparison Report is limited to data comparisons for individual market QHPs. The report excludes Small Group Health Options (SHOP) market plans and SADP.

This report will be available for QHP issuers in FFE states, SPE states, and SBE-FP.

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Crosswalked Plans

The PY Comparison Report will not consider plan crosswalk information. A PY2019 plan that will be crosswalked to a different plan ID in PY2020 will not be included in the report.

The report excludes Plan IDs that do not exist in both plan years.

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Data Fields of PY Comparison Report


Benefit Package (BP) Fields

The report compares the number of covered benefits for plans in both plan years and shows a change analysis of covered benefits.

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Benefit Package (BP) Fields (continued)

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Tab Name Description

1.1 BP PY Benefits

This table shows the number of plans in PY2019 and PY2020 that cover each benefit, as well as the number of plans that cover the benefit in both years.

1.2 BP Covered-Not Covered

This table shows changes to benefit coverage for plans in both plan years. The comparison is done for plans in both years using the "Is this Benefit Covered?" variable.

1.3 BP ChangesThis table shows changes in covered benefits for plans in both years. The change analysis is conducted for "Covered" benefits in both plan years.


Benefit Cost-Sharing (BCS) Fields

The report compares the number of covered benefits by plan variants in both plan years and shows a change analysis of cost-sharing differences.

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Benefit Cost-Sharing (BCS) Fields (continued)

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2.1 BCS PY Benefits

This table shows the number of plan variants in PY2019 and PY2020 that cover each benefit, as well as the number of plan variants that cover the benefit in both years.

2.2 BCS Changes

This table shows changes in benefit copay or coinsurance for plan variants in both plan years. The change analysis is conducted for "Covered" benefits in both plan years.

2.3 DedMOOP Changes

This table shows changes in deductible and maximum out - of - pocket (MOOP) for plan variants in both plan years. The change analysis is conducted for the deductible and MOOP for both plan years.


Service Area (SA) Fields

The report shows a change analysis of service areas for plans in both plan years including changes in partial county, entire state, and zip code data fields.

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Service Area (SA) Fields (continued)

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3.1 Service Area Changes

This table shows whether there was a service area change, and the added and dropped counties a plan covered if there was a change, between PY2019 and PY2020.

3.2 Plan-County Comparison

This table shows the "Cover Entire State", "Partial County", and "Zip Code" comparison for plan - counties in both plan years. The change analysis is conducted for plan-counties in both plan years.

3.3 PY20 SA Visual

This visual shows PY2020 Service Area coverage by the count of plans in each county.

3.4 PY19 SA Visual

This visual shows PY2019 Service Area coverage by the count of plans in each county.


Business Rules (BR) Fields

The report shows a change analysis of Dependents and Dependent Maximum Age business rules for plans offered in both plan years.

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Business Rules (BR) Fields (continued)

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4.1 Business Rules Changes

This table shows changes in Dependents and Dependent Maximum Age business rules for plans in both plan years.


Plan Year Comparison Report Demo


Accessing the Plan Year Comparison Report


Accessing the Plan Year Comparison Reports

CMS encourages issuers to use the PY Comparison Report to help ensure accuracy of their PY2020 QHP applications.

Issuers and states can download the PY Comparison Report and User Guide via the Plan Management (PM) Community.

The report will be available the first week of August 2019.

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Live Q&A


Questions

Please help us provide an accurate response by identifying your State when asking a question. To submit or withdraw questions by phone: • To submit a question, dial ‘star(*) pound(#)’ on your phone’s

keypad. • To withdraw a question, dial ‘star(*) pound(#)’ on your

phone’s keypad. To submit questions by webinar: • Type your question in the text box under the ‘Q&A’ tab and

click ‘Send.’

If you are not able to ask your question during today’s session, or if your question is best answered by subject matter experts (SMEs) outside Plan Management (PM), you may submit it via [email protected] with

the subject line “State Question.”

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mailto:[email protected]


State Regulators Webinar Session Survey

• CMS welcomes your feedback regarding this webinar series and values any suggestions that will allow us to enhance this experience for you.

• Shortly after this call, we will send a link to you for a convenient way to submit any ideas or suggestions you wish to provide that you believe would be valuable during these sessions.

• Please take time to complete the survey and provide CMS with any feedback.

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Closing Remarks

Documents

PMSC Webinar slides - HHS.gov