Brief: Data Collection and Use in the New Health Insurance Marketplaces

Introduction

Implementation of the 2010 health reform law, the Patient Protection and Affordable Care Act (ACA), is in full swing with the recent opening of state and federally-facilitated health insurance marketplaces (a.k.a. exchanges) where individuals and small businesses can purchase health insurance plans from participating companies.  Coupled with the many insurance market reforms under the ACA, the creation of the new regulated health insurance marketplaces may have far-reaching effects on the content, quality, and price of health plans sold in the small group and individual markets because new regulations require these marketplaces to create structures and processes to ensure the overall quality and value of plans sold.  These processes include data reporting requirements for plans sold in marketplaces that will result in the provision of significant information to the marketplaces themselves, quality accreditation entities, HHS, and the public. Through the process of “certifying” and “accrediting” health plans as qualified to be sold in the new marketplaces, as discussed below, information about health insurance policies, practices, cost, and quality that was not previously required to be reported will now be disclosed.

Under the ACA, insurers seeking to sell plans in the marketplaces (whether state-based, partnership, hybrid or fully federally facilitated marketplaces) must pass a two-part test before any products can be listed for sale.  First, each health plan must be certified as a “Qualified Health Plan” (QHP) by the applicable marketplace, with certification criteria spelled out in federal regulation1 and supplemented by any additional standards that may be imposed under state law.  Second, QHPs are required to meet quality accreditation standards and must implement a quality improvement strategy.  Because it is not feasible to independently accredit every single QHP, the regulations instead require each product type offered by a QHP issuer (e.g., Marketplace HMO, Marketplace point of service (POS), Marketplace PPO) to be periodically reviewed and accredited by a quality accreditation entity recognized by HHS.2   

Both steps require the collection of information from insurers, which is expected to result in greater public availability of health plan performance data.  Taken together, these two new data reporting requirements – certification and quality accreditation –  have the potential to improve the quality of marketplace health insurance products, since issuers will be subject to quality measurement at two points: prior to the time that their products are sold (certification) and periodically (as established by each marketplace) through performance reviews (quality accreditation).  Importantly, many of the results of this two-pronged data review, along with some of the data elements themselves, will be posted on the marketplace websites for consumers to use in selecting plans.3

This brief discusses the certification and accreditation process and the impact it will have on the availability of health plan performance data.