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The Five Star Quality Rating System for Medicare Advantage Plans is run by the Centers for Medicare and Medicaid Services (CMS), and was put in place as part of an effort to help educate consumers on quality and make quality data more transparent. The ratings consist of over 50 measures hailing from 5 different rating systems: HEDIS (Healthcare Effectiveness Data and Information Set), CAHPS (Consumer Assessment of Healthcare Providers and Systems), CMS (Centers for Medicare and Medicaid Services), HOS (Health Outcomes Survey), and IRE (Independent Review Entity). These systems rate Medicare Advantage plans according to 5 domains: staying healthy via preventive services such as screenings and vaccines; managing chronic conditions; ratings of plan responsiveness and care; complaints, appeals, and voluntary disenrollment; and telephone customer service. Data to support these star ratings come from surveys, empirical observation, administrative (claims) data, and medical records. Based on criteria provided in technical specs outlined by CMS, rates and scores are calculated and stars are awarded on a contract level. CMS Stars ratings are published annually and are available for viewing by all Medicare members prior to Open Enrollment.
The health reform legislation (the Patient Protection and Affordable Care Act of 2010) ties federal reimbursement rates for insurance carriers administering Medicare Advantage products to performance, as measured by the Stars rating system. Bonus payments are attached to stars ratings, and bonus revenue will be awarded, gradually increasing with maximum bonus opportunity in 2014. According to the Congressional Budget Office, payment reforms for Medicare Advantage plans based on Stars scores are projected to save billions of dollars in federal health care spending.
CMS provides quality related information to beneficiaries (members) to help them choose the highest quality plans available in their area. To do this, CMS measures how well health and prescription drug plans (PDPs) perform on over 50 measures. These measures are grouped into several domains - five for health plans (Medicare Advantage plans) and four for PDP plans.
Each contracted plan receives an overall rating that summarizes all categories and measures into a single star rating. Quality ratings are assigned at the contract level, rather than the individual plan level (most contracts cover multiple plans), and every Medicare Advantage plan covered under the same contract receives the same rating.
Ratings are given between 1 and 5 stars:
Beneficiaries can use the star ratings as a quick way to get an overview of health plans performance and compare one to another, when choosing their upcoming enrollment. CMS also encourages users to look at the ratings to see if the plan performed better in the current year over the last, and to see how the plan compares to Original Medicare.
Consumers can view plan ratings on the Medicare Plan Finder web site at https://www.medicare.gov/find-a-plan/questions/home.aspx
After completing a short questionnaire (zip code, current enrollment, financial assistance, optional information on current medications and pharmacies), users are shown a list of Original Medicare and Medicare Advantage plans available in their area.
The plan results screen shows the plan name as well as other key information in an easy to read, comparative format :
Beginning in 2012, Medicare Advantage plans will receive bonus payments based on their quality ratings.
A bonus payment for plans receiving 4 or more stars was introduced in the 2010 health care reform law. These bonus payments are also available to plans who are not rated, either because they were too new or had too few enrollees. Payments must be used for further improvements to the plan’s benefit offerings.
A plan’s star ratings as the result of 2011 will impact the payments they receive in 2012.
Plans who don’t measure up have the potential to lose members.
Beginning December 8, 2011, consumers have a new option to join or switch to a 5-star Medicare plan at any time during the year, instead of only during the normal enrollment timeframe.
CMS is launching a 3-year demonstration with progressive bonus payments based on ratings, as well as offering bonus payments to plans with average ratings.
CMS is also launching a demonstration beginning in 2012 that will last for 3 years, and will increase the size of the bonus payments to these high rated plans (4 or more stars), and will also provide bonuses to plans who have average ratings (3 to 3.5 stars). The intent of the demonstration is to encourage plans at all levels of performance to work on quality improvement, and to test the impact on scaled bonuses on expediting year-over-year improvement across plans, in comparison to the health reform law payments.
Bonus payments must be reinvested into plan members to provide additional benefits – and thus increase plan ratings over the competition.
Payments made under the health reform law must be used for further improvements to the plan’s quality or benefits. The belief is that as plans continue to reinvest in improving their offerings, and develop a more attractive set of benefits than competitors, giving them an advantage in attracting new enrollees, while continuously improving quality.
Medicare Advantage plans submit bids to CMS annually for their cost of providing benefits in a given county. If the bid is below the county benchmark, the plan receives a percentage share of the difference between the bid and the benchmark, called the rebate.
The bonus payment is derived from an addition to the benchmark. For example, a plan with a 5-star rating will receive an increase of 5% to the benchmark, and their rebate payment is based on that new benchmark. A plan with a 3-star rating would receive an increase of 3% to the benchmark, and the rebate payment is again based on the new benchmark.
The rebate percentage varies based on the plans rating as well – for a 5-star plan, the rebate for 2012 is 70%, and for a 3-star plan the 2012 rebate is 67%.
|Plan Rating||Bonus (Health reform law)||Bonus (CMS demonstration)|
|4 to 4.5 star||1.5%||4%|
|2 and 2.5 star||None||None|
|Unrated (plans that are too new, or have too few enrollees)||1.5%||3%|
|Benchmark bonus is applied to...||New benchmark||Blended benchmark|
A summary of rebates for 2012 is included in the table below :
|4.5 or 5 stars||70%|
|3.5 or 4 stars||65%|
|Less than 3.5 stars||50%|
The health reform law increases the bonus payments made through 2014 for plans with high ratings.
|Plan Rating||2012 Bonus Payment||2013 Bonus Payment||2014 Bonus Payment|
|4 or more stars||1.5%||3.0%||5.0%|
Payments are available to plans who have received 4 or more stars, as well as plans who are not rated by CMS (either because they are too new, or have too few enrollees).
The bonus payments are calculated as a percentage share of the Medicare Advantage benchmarks. These benchmarks vary by county; as such, the bonus payments will also vary by county. The bonus payments are tied to the local benchmarks to recognize that the fee-for-service costs vary, and thus the bonus payments used to cover additional fee-for-service offerings needs to vary as well to ensure plans are able to adequately reinvest these payments into new benefits.
Bonuses are doubled for plans offered in counties that meet the following criteria:
In 2012, there will be 210 counties that qualify for bonus payments.
The CMS demonstration expands the number of plans eligible for bonus payments from those eligible under the health reform law by providing bonuses to plans with average performance ratings. The CMS demonstration also increases the size of the bonus payments for all eligible plans with an increased percentage payment from the local benchmarks. Under the CMS demonstration, the bonus payment is applied under a blended local benchmark, rather than how the health reform law applies the bonus to a new (lower) benchmark. Double bonus counties are maintained under the CMS demonstration, with the same requirements as in the health reform law.
Benchmarks are the maximum amount Medicare will pay a Medicare Advantage plan for delivering Part A and B benefits in a specific geographic area. The benchmarks for each county are determined each year.
Under the Affordable Care Act, the calculation for local benchmarks will change through a phased approach through 2, 4 or 6 years, depending on the magnitude of the change in benchmark rates. During this transition period, two benchmarks will be used to determine payment :
Below is a sample of the bonus payments that could be received by a 5-star plan in 2012 under both the health care reform bonus payments and the CMS demonstration payments.
For this illustration, the plan bid is set at $100,000 with a local benchmark of $125,000, at a 70% rebate.
Plans are measured on multiple domains, each of which is compose of a series of individual measures. Part C plans have 5 domains, and Part D plans have 4 domains.
Based on the contract type, there is a minimum number of measures per domain that the contract must report on to receive a rating.Domain ratings are calculated as a weighted average of the star ratings of the individual measures within the domain.
CMS has assigned the highest weight to outcomes and intermediate outcomes measures, followed by patient experience/complaints and access measures. Process measures are weighted the least.
|Outcome measures||focus on improvement to a beneficiary’s health as a result of the care that is provided||3|
|Intermediate outcome measures||concentrate on ways to help beneficiaries move closer to achieving a true outcome||3|
|Patient experience measures||represent beneficiaries’ perspectives about the care they receive||1.5|
|Access measures||reflect processes or structures that may create barriers to receiving needed health care||1.5|
|Process measures||capture a method by which health care is provided||1|
|Breast cancer screening||Breast cancer screening||1||Domain 1: Staying healthy - screenings, tests and vaccines|
|Colorectal cancer screening||Colorectal cancer screening||1||Domain 1: Staying healthy - screenings, tests and vaccines|
|Cardiovascular Care – Cholesterol Screening||Cholesterol screening for patients with heart disease||1||Domain 1: Staying healthy - screenings, tests and vaccines|
|Glaucoma testing||Glaucoma testing||1||Domain 1: Staying healthy - screenings, tests and vaccines|
|Annual flu vaccine||Annual flu vaccine||1||Domain 1: Staying healthy - screenings, tests and vaccines|
|Pneumonia vaccine||Pneumonia vaccine||1||Domain 1: Staying healthy - screenings, tests and vaccines|
|Improving or maintaining physical health||Improving or maintaining physical health||3||Domain 1: Staying healthy - screenings, tests and vaccines|
|Improving or maintaining mental health||Improving or maintaining mental health||3||Domain 1: Staying healthy - screenings, tests and vaccines|
|Monitoring physical ability||Monitoring physical ability||1||Domain 1: Staying healthy - screenings, tests and vaccines|
|Access to primary care doctor visits||At least one primary care doctor visit in the last year||1.5||Domain 1: Staying healthy - screenings, tests and vaccines|
|Adult BMI assessment||Checking to see if members are at a healthy weight||1||Domain 1: Staying healthy - screenings, tests and vaccines|
|Care for older adults – medication review||Yearly review of all medications and supplements being taken (for Special Needs Plans only)||1||Domain 2: Managing Chronic Conditions|
|Care for older adults – functional status assessment||Yearly assessment of how well plan members are able to do activities of daily living (for Special Needs Plans only)||1||Domain 2: Managing Chronic Conditions|
|Care for older adults – Pain screening||Yearly pain screening or pain management plan (for Special Needs Plans only)||1||Domain 2: Managing Chronic Conditions|
|Osteoporosis management in women who had a fracture||Osteoporosis management||1||Domain 2: Managing Chronic Conditions|
|Diabetes care – eye exam||Eye exam to check for damage from diabetes||1||Domain 2: Managing Chronic Conditions|
|Diabetes care – kidney disease monitoring||Kidney function testing for members with diabetes||1||Domain 2: Managing Chronic Conditions|
|Diabetes care – blood sugar controlled||Plan members with diabetes whose blood sugar is under control||3||Domain 2: Managing Chronic Conditions|
|Diabetes care – cholesterol controlled||Plan members with diabetes whose cholesterol is under control||3||Domain 2: Managing Chronic Conditions|
|Controlling blood pressure||Controlling blood pressure||3||Domain 2: Managing Chronic Conditions|
|Rheumatoid arthritis management||Rheumatoid arthritis management||1||Domain 2: Managing Chronic Conditions|
|Improving bladder control||Improving bladder control||1||Domain 2: Managing Chronic Conditions|
|Reducing the risk of falling||Reducing the risk of falling||1||Domain 2: Managing Chronic Conditions|
|Plan all-cause readmissions||Readmission to a hospital within 30 days of being discharged||1||Domain 2: Managing Chronic Conditions|
|Getting needed care||Ease of getting needed care and seeing specialists||1.5||Domain 3: Ratings of Plan Responsiveness and Care|
|Getting appointments and care quickly||Getting appointments and care quickly||1.5||Domain 3: Ratings of Plan Responsiveness and Care|
|Customer service||Customer service||1.5||Domain 3: Ratings of Plan Responsiveness and Care|
|Overall rating of health care quality||Overall rating of health care quality||1.5||Responsiveness and Care|
|Overall rating of plan||Overall rating of health plan||1.5||Domain 3: Ratings of Plan Responsiveness and Care|
|Complaints about the health plan||Complaints about the health plan||1.5||Domain 4: Member Complaints, Problems Getting Services, and Choosing to Leave the Plan|
|Beneficiary access and performance problems||Problems Medicare found in members’ access to services and in the plan’s performance||1.5||Domain 4: Member Complaints, Problems Getting Services, and Choosing to Leave the Plan|
|Members choosing to leave the plan||Members choosing to leave the plan||1.5||Domain 4: Member Complaints, Problems Getting Services, and Choosing to Leave the Plan|
|Plan makes timely decision about appeals||Health plan makes timeline decision about appeals||1.5||Domain 5: Health Plan Customer Service|
|Reviewing appeals decisions||Fairness of health plan’s denials to member appeals, based on an independent reviewer||1.5||Domain 5: Health Plan Customer Service|
|Call center – foreign language interpreter and TTY/TDD availability||Availability of TTY/TDD services and foreign language interpretation when members call the health plan||1.5||Domain 5: Health Plan Customer Service|
|Call center – pharmacy hold time||Time on hold when pharmacist calls plan||1.5||Domain 1: Drug Plan Customer Service|
|Call center – foreign language interpreter and TTY/TDD availability||Availability of TTY/TDD services and foreign language interpretation when members call the drug plan||1.5||Domain 1: Drug Plan Customer Service|
|Appeals auto-forward||Drug plan makes timely decisions about appeals||1.5||Domain 1: Drug Plan Customer Service|
|Appeals upheld||Fairness of drug plan’s denials to member appeals, based on an independent reviewer||1.5||Domain 1: Drug Plan Customer Service|
|Enrollment timeliness||Plan handles new enrollment requests within 7 days||1||Domain 1: Drug Plan Customer Service|
|Complaints about the drug plan||Complaints about the drug plan||1.5||Domain 2: Member Complaints, Problems Getting Services, and Choosing to Leave the Plan|
|Beneficiary access and performance problems||Problems Medicare found in member’s access to services and in the plan’s performance||1.5||Domain 2: Member Complaints, Problems Getting Services, and Choosing to Leave the Plan|
|Members choosing to leave the plan||Members choosing to leave the plan||1.5||Domain 2: Member Complaints, Problems Getting Services, and Choosing to Leave the Plan|
|Getting information from drug plan||Drug plan provides clear information or help when members need it||1.5||Domain 3: Member Experience with Drug Plan|
|Rating of drug plan||Members’ overall rating of drug plan||1.5||Domain 3: Member Experience with Drug Plan|
|Getting needed prescription drugs||Members’ ability to get prescriptions filled easily when using the plan||1.5||Domain 3: Member Experience with Drug Plan|
|MPF composite||Plan provides accurate price information for Medicare’s Plan Finder website and keeps drug prices stable||1||Domain 4: Drug Pricing and Patient Safety|
|High risk medication||Plan members 65 and older who received prescriptions for certain drugs with a high risk of side effects, when there may be safer drug choices||3||Domain 4: Drug Pricing and Patient Safety|
|Diabetes treatment||Using the kind of blood pressure medication that is recommended for people with diabetes||3||Domain 4: Drug Pricing and Patient Safety|
|Part D medication adherence for oral diabetes medications||Taking oral diabetes medication as directed||3||Domain 4: Drug Pricing and Patient Safety|
|Part D medication adherence for hypertension||Taking blood pressure medication (ACEI or ARB) as directed||3||Domain 4: Drug Pricing and Patient Safety|
|Part D medication adherence for cholesterol||Taking cholesterol medication (statins) as directed||3||Domain 4: Drug Pricing and Patient Safety|
On April 2, 2012, CMS issued the final Call Letter to all MA/MAPDP plans, outlining revisions to the Plan Ratings program for 2013.
CMS plans to review the quality of the data across all measures in the summer of 2012 before making the final determination of measures for inclusion. The assessment will look at the measures’ accuracy, validity, and variation of scores across plans.
Survey of measures of care coordination from the CAHPS survey administered in 2012 (Part C and Part D) Questions related to the following areas would be included:
Quality Improvement (Part C and Part D) Year-over-year changes at the measure level would be calculated at the measure for significant improvement of declines in ratings. Only measures that have been in place for two years using the same specifications will be included.
High-Risk Medication (HRM) measure (Part D)(Part D) CMS will incorporate changes from PQA or NCQA about the types of fills that will be included, and will also increase the number of HRM fills from 1 to 2.
CMS is testing revised specifications and medication list, based on the AGS update to the Beers list. These updates will be used for either 2012 or 2013 PDE data (for 2014 or 2015 ratings).Based on the results of the testing, plans will be notified when the changes will become effective.
CMS is also evaluating the inclusion or exclusion of benzodiazepines and certain barbiturates in the measure calculation.
Because of the extensive changes in specifications, the current 4-star threshold for 2013 does not apply; star ratings will be based on statistical analysis and relative ranking of plan scores.
Medicare Plan Finder composite (Part D) Limiting the comparison between Prescription Drug Event (PDE) prices and Plan Finder prices to 1st 2nd and 3rd quarter PDEs; this is due to the fact that Plan Finder prices are locked on medicare.gov at the end of the 3rd quarter
The price stability portion of the composite measure will move to the CMS display page.
Diabetes Treatment Measure (Part D) CMS will include direct renin inhibitors in accordance with the updated PQA specifications. The updated measure will be defined as: the percentage of Medicare Part D beneficiaries who were dispensed a medication for diabetes and a medication for hypertension who were receiving an angiotensin converting enzyme inhibitor (ACEI), angiotensin reception blocker (ARB), or direct rennin inhibitor medication which are recommended for people with diabetes.
Adherence measures (Part D) Reexamining appropriate measures for adjusting the Proportion of Days covered to account for inpatient stays where medication fills would not be captured by PDE data.
Plan makes timeline decision about appeals (Part C) Include dismissed appeals in the calculation. The measure will now be defined as percent of appeal timely processed by the contract, compared to all the contract’s appeals decided by the IRE (includes: upheld, overturned, partially overturned, and dismissed appeals). The measure will include all Standard Coverage, Standard Claim, and Expedited appeals (including dismissals) received by the IRE. CY2011 data will be used for the 2013 plan ratings. Withdrawn cases will be excluded from the measure.
Call center – Foreign Language Interpreter and TTY/TDD (Part C and D) This measure will be collected from all SNPs in 2012 (previously excluded).
The calculation of the measure will also change; successful contact with an interpreter will be defined as establishing contact with a translator and starting or completing survey questions. Interpreters must be able to communicate responses to the call surveyor in the caller’s non-English language about the plan sponsor’s Medicare benefits. Successful contact with a TTY/TDD service is defined as establishing contact with a TTY/TDD operator who can answer questions about the plan’s Medicare Part C or Part D benefit. Accuracy of answers and time to completion are not included in this metric.
Note: The previously established 4-star threshold will change for 2013 ratings.
Enrollment timeliness (Part C and D) The measure will be expanded to include MA-only contracts (previously only included PDPs or MA-PDs). The data timeframe for the measure will be 1/1/12 through May or June 2012 (depending on availability of June data in time for 2013 ratings).
Beneficiary access and performance problems (Part C and D) Replaces the effectiveness score with the percentage of elements passed out of all elements audited. CMS is exploring a minimum threshold of 5 elements in order for inclusion in the final score, and they will also adjust the CAP reporting period from the current 14 months, to the 12 months from January to December of a year.
Pneumonia Vaccine (Part C) Moving to a display page measure, due to the long recall time.
Access to Primary Care Doctor Visits Moving to the display page, due to little variation across contracts.
Display measures (viewable on cms.gov) are not part of plan ratings; they are either measures that have been transitioned from the plan ratings, or new measures that are being tested before inclusion in the plan ratings.
The following measures are under consideration to be added to the display page, and will be finalized by fall 2012 :
Existing Plan Rating Measures
Measures in Development being moved to the 2013 Display Page