Comments on the 2016 QHP Enrollee Experience Survey

The Association for Community Affiliated Plans (ACAP) thanks the Centers for Medicare and Medicaid Services (CMS) for providing us with an opportunity to comment on the notice concerning the 2016 Qualified Health Plan Enrollee Experience Survey released April 28, 2015.

ACAP is an association of 59 not-for-profit and community-based Safety Net Health Plans (SNHPs) located in 24 states. Our member plans provide coverage to approximately 15 million individuals enrolled in Medicaid, the Children’s Health Insurance Program (CHIP) and Medicare Special Needs Plans for dually-eligible individuals. Nationally, ACAP plans serve roughly one-third of all Medicaid managed care enrollees. Eighteen of ACAP’s Safety Net Health Plan members have elected to offer qualified health plans (QHPs) in the Marketplaces in 2015.

ACAP notes that CMS has added nine new questions to the 2016 survey. Our reading of the notice and other documentation leads us to believe that CMS intends to report on results related to the new questions. ACAP feels strongly that untested survey questions should not contribute to publicly reported quality scores for health plans. Instead, scores should reflect only those elements that have been rigorously tested. New questions should be fully tested, then included in future reporting efforts only after efficacy is demonstrated.

Our specific positions on the draft 2016 QHP Enrollee Survey follow:

 Test all new survey questions. As previously stated, ACAP strongly disagrees with inclusion of untested survey questions in publicly reported quality scores, and feels strongly that all new survey questions should be rigorously tested. Our concerns apply to all nine new survey questions included in the 2016 Qualified Health Plan Enrollee Experience Survey: 53, 54, 55, 56, 57, 77, 81, 82, and 83.

 Eliminate or modify question #54 to avoid bias. ACAP recommends either eliminating Question #54 or modifying it to exclude the doctor reference, so that it reads “In the last 6 months, how often did your health plan not pay for a service that you thought the health plan would pay for?” The current draft’s wording of the new survey question #54 follows:

“In the last 6 months, how often did your health plan not pay for a service that your doctor said you needed?”

We believe that this language contains embedded bias by including a reference to a doctor, since it is possible not all doctors fully understand the health plan’s benefit coverage details. Furthermore, since there is a chance a doctor may not submit sufficient medical necessity documentation when requesting a prior authorization for a service, the responsibility for some resulting denials may rest with the provider. The modified wording we suggest above focuses instead on the member’s understanding of the health plan’s benefits, rather than on the doctor’s understanding of the member’s benefit coverage.

 Provide examples of terms in question #82. ACAP supports the inclusion of question #82 and believes that surveying QHP members on health literacy will yield critical and useful results. However, we believe that the question will be more useful – and respondents will be better able to respond – if CMS includes specific insurance terms in the question. For example, the question could be altered in the following way:

“How confident are you that you understand health insurance terms, such as “premium,” “deductible,” “copay,” “coinsurance,” and “maximum out-of-pocket limit”?

 Make the survey understandable by average plan enrollee. Numerous Marketplace regulations related to enrollee-facing documents establish that such documents must be presented in a manner that is easily understandable by the average plan enrollee. ACAP supports these requirements. ACAP members have substantial experience providing coverage to people with low literacy skills. In order to ensure that critical materials are understandable, many state Medicaid programs require documents to be produced at a sixth grade reading level or lower. What is known currently about Marketplace enrollees suggests that the population is in many ways similar to the Medicaid population. Approximately 87 percent of Marketplace enrollees, for example, have low to moderate incomes, which enable them to receive premium tax credits to purchase coverage. Given this, we harbor general concerns that many Marketplace enrollees may not find the QHP enrollee survey understandable.

ACAP urges CMS to examine the draft survey for understandability for the average Marketplace consumer, and, if necessary, revise the survey to ensure that it is accessible for health care consumers.

ACAP thanks CCIIO for your willingness to discuss this issue with us. If you have any additional questions or comments, please do not hesitate to contact Jenny Babcock (202-204-7518 or

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