Instructions for 2017 Plan Year Accreditation Requirements, Submission of Quality Assurance and Improvement Plans and Quality Improvement Strategy
62K.09 Accreditation Standards
For Issuers offering individual and small group plans outside of MNSure, Minnesota Statutes, Sec. 62K.09 (a) requires issuers to submit proof of accreditation from NCQA, URAC or AAAHC by January 1, 2018. Accreditation information will be required for all carriers offering individual or small group products off MNSure beginning with the 2018 product offerings in SERFF.
It is not necessary for all affiliated entities of a carrier to be accredited as long as one of the affiliates of the carrier is accredited. However, the non-accredited affiliate must use the same quality assurance and improvement program as the accredited affiliate. For example, if the HMO is accredited and the insurance company is not, the accreditation standard may still be met as long as the entity issuing the product uses the same quality assurance program as the HMO.
In addition, all health issuers offering individual or small group health plans in Minnesota must have written internal quality assurance and improvement programs that meet the requirements of 62K.12.
For QHP Issuers entering the MNSure individual or small group market, or seeking recertification on MNsure, the following accreditation instructions apply:
All QHP Issuers are required to be fully accredited no later than the third year that the Issuer offers a QHP through MNSure.
QHP Issuers may be accredited by:
- NCQA and are considered accredited with any of the following: excellent, commendable, accredited, provisional, and/or interim status;
- URAC with full, provisional or conditional status;
- AAAHC with accredited status.
It is not necessary for all affiliated entities of an issuer to be accredited as long as one of the affiliates of the issuer is accredited. However, the non-accredited affiliate must use the same quality assurance and improvement program as the accredited affiliate. For example, if the HMO is accredited and the insurance company is not, the accreditation standard may still be met as long as the entity issuing the product uses the same quality assurance program as the HMO.
If the QHP Issuer or its affiliate is already accredited by NCQA or URAC or AAAHC under either its HMO or insurance license, please use the corresponding accreditation template in SERFF: Qualified Health Plan Application Instructions, Templates and Materials.
If neither the QHP carrier nor its affiliate(s) is accredited please submit the following documentation under the Supporting Documents tab in SERFF:
- A narrative description of the plan to gain accreditation and any actions taken toward accreditation;
- Timelines for completion of each step of accreditation;
- Person(s) responsible for each step; and
- If the carrier claims an exception to accreditation requirements due to low volume of enrollees, please submit documentation supporting low expected enrollment.
Quality Improvement Program
In addition, all issuers must submit a written internal quality and improvement program that meets the requirements of 62K.12 to the “supporting documents” tab of SERFF, unless the carrier has obtained accreditation through URAC for network management; quality improvement; credentialing; member protection; and utilization management, or has achieved an excellent or commendable level ranking from the NCQA pursuant to Minn. Stat. 62K.12, subd. 3. Please note this statute was drafted before the addition of AAAHC as an accepted accrediting body. Therefore, carriers who have obtained accreditation with AAAHC may also qualify for this exception.
The written internal quality and improvement plan must include documentation that the program:
- provides for ongoing evaluation of the quality of health care provided to its enrollees;
- conducts focused studies directed at problems, potential problems, or areas with potential for improvements in care;
- conducts enrollee satisfaction surveys and monitors oral and written complaints submitted by enrollees or members; and
- collects and reports Health Effectiveness Data and Information Set (HEDIS) measures and conducts other quality assessment and improvement activities as directed by the commissioner of health.
New for 2017
Quality Improvement Strategy (QIS)
For issuers offering products on MNSure, a new requirement for the 2017 plan year is the submission of the Quality Improvement Strategy.
Issuers must submit a Quality Improvement Strategy (“QIS”) for the 2017 plan year if they have offered coverage through the Exchange for two or more consecutive years, provide family and/or adult-only medical coverage, and meet the QIS minimum enrollment threshold. An issuer meets the QIS minimum enrollment threshold if it had more than 500 enrollees within a product type as of July 1, 2015. When calculating minimum enrollment, issuers should include both SHOP and individual Marketplace enrollees within a product type. Additionally, each eligible QHP within a product type (e.g., HMO, PPO) that has more than 500 enrollees as of July 1, 2015, must be included in a QIS. An issuer may choose to implement a single QIS to cover all of its eligible health plans and product types, or may choose to implement multiple quality improvement strategies.
Issuers must complete a QIS Implementation and Progress Report, which provides the structure for an Issuer to show that the QIS includes all the necessary components and adequately addresses the QIS criteria. By submitting information in response to all the elements and meeting the criteria, an issuer will demonstrate that it has examined its enrollee population and designed a QIS that provides market-based incentives to drive quality improvement and improved health outcomes.
The QIS form is available at: QIS Implementation Plan and Progress Report Form (PDF)
Detailed instructions for completing the forms are available at: Quality Improvement Strategy: Technical Guidance and User Guide for the 2017 Coverage Year (PDF)
Issuers should upload the completed form to the “Quality Improvement Strategy” section of the Supporting Documents tab of the binder. The QIS must be included in the binder submission and submitted no later than May 11, 2016.
Quality Rating System (QRS)
The Quality Rating System (QRS) and Enrollee Satisfaction Survey System (ESS) required in 2017 for certain Exchange products under 45 CFR 156.1120 and 1125 is not submitted through the plan management binder.
For the purposes of the 2017 QRS requirements, Minnesota will apply the federal requirements regarding posting of quality data.