Exchange Product Line Moves to Outcome Measures for Continuity & Coordination of Care

By Nancy Ross Bell, RN

Estimated time to read: 3 minutes

With the 2025 Health Plan Accreditation standards, NCQA has changed how health plans are evaluated for coordination and continuity of care (C&C). This blog emphasizes what is unique to the Exchange product line. It applies to all health plan surveys on or after July 1, 2025.

Read below as we explain:

• how performance on C&C is measured (QI 3D Explanation)
• what is required in an improvement plan (QI 3D Explanation)
• how organizations are scored (QI 3 Scoring)
• when documentation is required for data exchange for (C&C) (QI 3A)

Performance is Assessed Using QRS Measures (QI 3D Explanation)

For the Exchange product line, health plans are required to collect and submit Quality Rating System (QRS) measures data to the Centers for Medicare & Medicaid Services (CMS) unless they are not required according to Participation Criteria for QHP Issuers.

The QRS is a quality reporting program that compares the performance of Qualified Health Plans (QHP) offered on Exchanges. Three broad categories are measured: Medical Care, Member Experience, and Plan Administration. (About the Quality Rating System).

For organizations reporting QRS data, performance on C&C is assessed by eight specific measures, as listed in QI 3D (Explanation).  Coordination of Care is one measure from member experience surveys, and the remaining seven measures are from medical care data.

Scoring Depends on Documented Improvement Plan (QI 3D Documentation)

Organizations undergoing Renewal Surveys for the Exchange product line demonstrate performance for C&C based on eight required QRS measures from the most recent year.

Results of the QRS measures are produced and monitored annually. The organization documents an improvement plan for any of the measures required for QRS reporting (QI 3D Explanation).

Organizations must act on one of the required QRS measures (QI 3).

Improvement Plan Must Include All Components

Organizations are scored as Met if the documented improvement plan contains all the required components, as listed below. The organization is scored as Not Met if any part of the required components is missing.

• Actions taken to improve each measure’s rating (If appropriate, one action may be used to address all measures.)
• How progress will be monitored
• How frequently progress will be monitored
• Parties responsible for performing the tasks (e.g., staff, department, committee)

When developing a C&C Improvement Plan, you may gain insights from organizational analyses on subpopulations, health equity needs, availability/accessibility of network providers, grievances, and appeals.

Annual Collection of Data on the Exchange of Information (QI 3A)

The process for annually collecting data on the exchange of information on C&C for QI 3A Factors 1-3 has not changed. Element A applies to all product lines for Interim and First Surveys.

For organizations undergoing a Renewal Survey for the Exchange product line and are not required to report QRS measures, the organization is unable to demonstrate C&C by the annual QRS ratings and, therefore, must submit a report on data exchange for QI 3A Factors 1-3 at least once during the prior year (Scope of Review).

Tying it All Together

Now is the time to step back and see the bigger picture by integrating C&C for the Exchange product line into the organization’s overall quality structure.

• Designate the QI Committee responsible for C&C for the Exchange product line (QI 1D).
• Incorporate the C&C Improvement Plan for the Exchange product line into the Annual Work Plan (QI 1B) by doing one of the following:
  • Make the C&C Improvement Plan a supplement of the Annual QI Work Plan, or,
  • Keep the C&C Improvement Plan independent from the Annual QI Work Plan. Add and track individual actions in the C&C plan. Monitor that the C&C plan is on track through the Annual QI Work Plan.
• Plan for and conduct an Annual Evaluation of C&C, completed and ongoing activities (QI 1C).
• Assess how changes in C&C activities may affect transitions to other care (QI 3E).
• Determine if changes to Delegated Agreements may be warranted (QI 4).
• Communicate new programs and activities to members and providers.

For more information, see the following:

• Health Insurance Exchange. Quality Rating System and Qualified Health Plan Enrollee Experience Survey: Technical Guidance for 2025
• Health Insurance Exchange. 2025 Quality Rating System Measure Technical Specifications
• MHR’s blog for Commercial, Medicare and Medicaid: NCQA’s Continuity and Coordination of Care Moves to Outcomes

Call to Action:

Ensure the Exchange product line is treated uniquely from Commercial, Medicare, and Medicaid product lines.

• Let us know how we can assist you in updating your quality plans compliant with the 2025 standards.
• Contact your MHR Consultant or [email protected]

MHR follows a quality review process for all blogs. This blog was written with insights from Monique Fields and Kim Carpenter Petit. Please read more about the MHR Consultants at ManagedHealthcareResources.com/About Our Consultants.  

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