CMS MA Proposed Rule: Star Ratings Updates

Last week, the Centers for Medicare & Medicaid Services (CMS) released a Proposed Rule allowing expanded access to telehealth services for Medicare beneficiaries, streamlining appeals processes for beneficiaries in Dual Eligible Special Needs Plans, helping CMS recover improper payments to plans based on Risk Adjustment Data Validation audits, and continuing to increase the stability and predictability for plans relative to Star Ratings.

CMS’ Star Ratings proposals demonstrate their willingness to evolve the Star Ratings program to eliminate at least some of the longstanding (and frustrating!) volatility and unpredictability within Star Ratings, which should be a welcome change for Medicare Advantage (MA) plans. Key Star Ratings proposals include:

  • Implementing cut point guard rails for non-Consumer Assessment of Healthcare Providers and Systems (CAHPS®) measures to prevent cut points from increasing or decreasing excessively from one year to the next,
  • Enhancing the cut point calculation methodology for non-CAHPS® measures to better eliminate the effect of outliers, and
  • Enhancing adjustments for extreme and uncontrollable circumstances.

CMS also presented proposed measure changes for future Star Ratings calculations:

  • Controlling Blood Pressure will be retired to display for the 2020 and 2021 Star Ratings, with a planned return as a 1x-weighted measure using the new Healthcare Effectiveness Data and Information Set (HEDIS®) 2019 measure specifications beginning with the 2022 ratings. The HEDIS® 2019 changes to this measure are substantive, including updates to reflect new hypertension treatment guidelines from the American College of Cardiology and American Heart Association and significant structural changes (including allowing two outpatient encounters to identify the denominator, allowing the use of telehealth for at least one of the denominator instances, adding an administrative approach to allow Current Procedural Terminology (CPT) Category II code collection, and allowing remote monitoring device readings for the numerator).
  • Plan All-Cause Readmissions will be substantially modified by the National Committee for Quality Assurance (NCQA) for HEDIS® 2020. As a result, this measure will be moved to display for the 2021 and 2022 ratings. HEDIS® 2020 measure changes are expected to include addition of observation stays in the measure, removal of individuals with high frequency admissions from calculations, and expansion of the calculation to include all members older than 18. Small plans may benefit from the proposed changes, as NCQA is also recommending a minimum denominator of 150 in the enhanced calculations.
    • The current MPF Price Accuracy measure will remain the 2020 and 2021 ratings using the current methodology, and the enhanced methodology will be used beginning in the 2022 ratings.  The proposed measure updates capture both the magnitude and frequency of differences between a contract’s Medicare Plan Finder (MPF) advertised prices and the actual pricing at the point of sale.

CMS seeks feedback and input from plans regarding these proposals and will accept comments through December 31, 2018. As we always do, we strongly encourage our clients and other MA plans to provide feedback and alternative proposals to CMS. We’ll provide an update as soon as these proposals are finalized. In the meantime, if you need help with your Star Ratings program or performance, we can help. Please contact us with questions or for more information.


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The 2019 Star Ratings Are Out!

The 2019 Star Ratings are out! While our experts crunch the numbers and analyze the data, here are a few “fast facts:”

Of the 360 contracts rated in both 2018 and 2019,

  • 80 earned higher overall ratings in 2019 compared to 2018
  • 90 earned lower overall ratings in 2019 than in 2018
  • 190 maintained the same rating in 2018 and 2019

The more things change, the more they stay the same.

  • 45% of Medicare Advantage Prescription Drug Plans (MA-PDs) (170 contracts) earned 4+ stars in 2019, compared to 44% (170 contracts) in 2018
  • Approximately 74% of MA-PD enrollees are currently in contracts that will have 4+ stars in 2019, compared to 73% in 2018
  • The 2019 average Star Rating (weighted by enrollment) is 4.05 in 2019, compared to 4.07 in 2018
  • 376 contracts met the criteria to receive an overall rating in 2019, compared to 385 in 2018
  • Humana (with 84% of its 3.5 million members in 4+ star contracts), United (with 70% of its 5.4 million members in 4+ star contracts), and Kaiser (with 100% of its members in 4+ star contracts) continue to dominate the competitive Medicare Advantage (MA) Star Ratings arena

Sponsors with the most members impacted by year-over-year changes in the overall ratings are among industry giants:

  • Some of the big winners in 2019 include Cigna, Highmark, MCS, Wellcare, and Centene
  • Among those with the most members in contracts earning lower ratings in 2019 are United, Anthem, and Blue Cross and Blue Shield of Minnesota

Although the Star Ratings headwinds are strong for new plans, sponsors continue flocking to MA:

  • 22% of contracts operating less than 5 years earned 4+ Star Ratings in 2019, compared to 41% of contracts operating between 5 and 10 years, and 54% of contracts operating more than 10 years
  • 210 contracts were not rated in 2019 because they were too new to receive a rating or did not have enough data to be rated, compared to 168 in 2018

See a trend in the Star Ratings you’d like us to comment on in our upcoming Star Ratings webinar? Get in touch with one of our experts, and we’ll address it in our webinar!


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