HPR Fundamentals
What does HPRS stand for in NCQA’s rating system?
Health Plan Ratings System
4 Benefits to Employee
1) Personalized choice. Employees can choose the medical and pharmacy plans that work best for them and their family.
2) Potential savings. Employees may find lower cost plans that meet their needs in the individual market.
3) Tax advantages. In many instances, the ICHRA benefit can be tax-free, similar to the traditional company-paid portion of medical premiums.
4) Control. Employees own their health plans, so they can keep their coverage even if they change jobs.
What is the maximum number of stars a plan can receive in HPR?
5 Stars
What are the three types of measures used in HPR scoring?
HEDIS, CAHPS, and Accreditation
What is the minimum enrollment for an ICHRA plan to avoid the “Low Enrollment” display code?
15,000 members
Which lines of business are included in HPR ratings?
Medicaid, Medicare, Commercial, and Off-Exchange
What are the six States currently involved in ICHRA (2025)?
GA, IN, MO, MS, OH, SC
How are Accreditation bonus points applied in HPR scoring?
Added to the weighted average score before rounding (Full accreditation: 0.5 pt, interim 0.15 pts)
How many measures are tracked for ICHRA
48 total measures
How many measures fall into the Risk-Adjusted Utilization domain (and what are they)?
What is the rating scale used in HPR?
0 to 5 stars, (in 0.5-point increments)
How is ICHRA governed and regulated?
1) Governed by IRS and Department of Labor rules.
2) ICHRA is an off exchange commercial product eligible for NCQA Commercial Rating (not CMS Quality Rating System).
What is the rounding rule for a final HPR score of 4.74?
Rounded to 4.5 stars
How many measures are unique to ICHRA?
18 (38% of all measures).
If the organization did not offer the health benefit required by the measure (e.g., mental health, chemical dependency), what is the audit result that gets reported?
No Benefit (NB)
What are the three composite domains used in HPR scoring?
Patient Experience, Prevention and Equity, and Treatment
What is ICHRA (and it's purpose)?
An alternative way for employers to offer health benefits that allows employers to reimburse employees for individual health insurance premiums and qualified medical expenses on a tax-free basis.
What happens if a plan does not have a numerical rating in all three composite domains?
It receives “Partial Data Reported” or “Insufficient Data”
What is the minimum denominator required for CAHPS survey measures to be scored?
100
If the organization followed these specifications, but the eligible population (denominator) was too small (e.g., <30 for Effectiveness of Care measures) to report a valid rate, what is the result that is reported?
Small Denominator (NA).
What is the minimum percentage of scorable measures required for a plan to receive an HPR rating?
At least 50% of required measures by weight
What is the function of ICHRA?
Instead of buying a traditional group insurance plan for all employees, the employer can give employees an allowance each month — tax free — to buy their own health insurance. Employees then shop for an individual health insurance plan, like Ambetter Health, through an ICHRA benefits administrator.
How are measures weighted?
1) Outcome and intermediate outcome measures (e.g., HbA1c or blood pressure control and childhood immunizations) are given a weight of 3.
2) Patient experience measures are given a weight of 1.5.
3) Process measures (such as screenings) along with RDM/LDM are given a weight of 1
4) Typically, new measures used for scoring are assigned a measure weight of 1.0 and then reassessed to determine their weight going into the second year.
What is the minimum denominator for all other measures to be scored?
30 responses
For CAHPS measures, if the survey sample frame was incomplete or materially biased, what is the result that is reported?
Not Reportable (NR).