Five-Star Quality Rating System for Medicare Advantage Plans

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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.

Medicare Advantage Plan Star Ratings Overview[edit]

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.[1]

Medicare Advantage (MA) Plan Domains[edit]

  1. Screenings, tests and vaccines
  2. Managing chronic conditions
  3. Plan responsiveness and care
  4. Members complaints, problems getting services, and choosing to leave the plan
  5. Customer service

PDP Domains[edit]

  1. Member experience with drug plan
  2. Drug pricing and patient safety
  3. Customer service
  4. Member complaints, problems getting services, and choosing to leave the plan

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.[1]

Ratings are given between 1 and 5 stars:

StarsRating
*****Excellent
****Above Average
***Average
**Below Average
*Poor

How Can Medicare Beneficiaries Use Star Ratings?[edit]

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.[1]

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.[1]

The plan results screen shows the plan name as well as other key information in an easy to read, comparative format:[1]

  1. Estimated annual drug cost
  2. Monthly premium
  3. Health benefits overview*
  4. OOPs (Copay/Deductible)
  5. Drug coverage (includes restrictions relevant to medications entered)
  6. Overall star rating

Increasing Importance of Star Ratings[edit]

Beginning in 2012, Medicare Advantage plans will receive bonus payments based on their quality ratings.[2]
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.[2]
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.

Bonus Payments Tied to Star Ratings[edit]

Overview of Payment Calculations[2][3][edit]

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.[2]

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%.[2]


A summary of bonus payments for 2012 is included in the table below:[2][3]

Plan RatingBonus (Health reform law)Bonus (CMS demonstration)
5 star1.5%5%
4 to 4.5 star1.5%4%
3.5 starNone3.5%
3 starNone3%
2 and 2.5 starNoneNone
1 starNoneNone
Unrated (plans that are too new, or have too few enrollees)1.5%3%
Benchmark bonus is applied to...New benchmarkBlended benchmark
Double bonuses?YesYes


A summary of rebates for 2014 is included in the table below:[2]

Plan RatingRebate
4.5 or 5 stars70%
3.5 or 4 stars65%
Less than 3.5 stars50%
Unrated65%


The health reform law increases the bonus payments made through 2014 for plans with high ratings.[2]

Plan Rating2012 Bonus Payment2013 Bonus Payment2014 Bonus Payment
4 or more stars1.5%3.0%5.0%
Unrated1.5%2.5%3.5%

Payments under the Health Reform Law[2][3][edit]

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:

  1. Lower than average Medicare fee-for-service costs
  2. Medicare Advantage penetration rate of 25% or more
  3. Designated urban floor benchmark in 2004

In 2012, there will be 210 counties that qualify for bonus payments.[3]

Payments under the CMS Demonstration[2][3][edit]

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.

About CMS and Plan Benchmarks[edit]

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:[2]

Sample Bonus Payment in 2012[edit]

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.

What Plans Are Measured On[edit]

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.[4]

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.[4]

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.[4]

Measure TypeDescriptionWeight
Outcome measuresfocus on improvement to a beneficiary’s health as a result of the care that is provided3
Intermediate outcome measuresconcentrate on ways to help beneficiaries move closer to achieving a true outcome3
Patient experience measuresrepresent beneficiaries’ perspectives about the care they receive1.5
Access measuresreflect processes or structures that may create barriers to receiving needed health care1.5
Process measurescapture a method by which health care is provided1

2012 MA Plan measures[edit]

[4]

MeasureLabelWeightDomain
Breast cancer screeningBreast cancer screening1Domain 1: Staying healthy - screenings, tests and vaccines
Colorectal cancer screeningColorectal cancer screening1Domain 1: Staying healthy - screenings, tests and vaccines
Cardiovascular Care – Cholesterol ScreeningCholesterol screening for patients with heart disease1Domain 1: Staying healthy - screenings, tests and vaccines
Glaucoma testingGlaucoma testing1Domain 1: Staying healthy - screenings, tests and vaccines
Annual flu vaccineAnnual flu vaccine1Domain 1: Staying healthy - screenings, tests and vaccines
Pneumonia vaccinePneumonia vaccine1Domain 1: Staying healthy - screenings, tests and vaccines
Improving or maintaining physical healthImproving or maintaining physical health3Domain 1: Staying healthy - screenings, tests and vaccines
Improving or maintaining mental healthImproving or maintaining mental health3Domain 1: Staying healthy - screenings, tests and vaccines
Monitoring physical abilityMonitoring physical ability1Domain 1: Staying healthy - screenings, tests and vaccines
Access to primary care doctor visitsAt least one primary care doctor visit in the last year1.5Domain 1: Staying healthy - screenings, tests and vaccines
Adult BMI assessmentChecking to see if members are at a healthy weight1Domain 1: Staying healthy - screenings, tests and vaccines
Care for older adults – medication reviewYearly review of all medications and supplements being taken (for Special Needs Plans only)1Domain 2: Managing Chronic Conditions
Care for older adults – functional status assessmentYearly assessment of how well plan members are able to do activities of daily living (for Special Needs Plans only)1Domain 2: Managing Chronic Conditions
Care for older adults – Pain screeningYearly pain screening or pain management plan (for Special Needs Plans only)1Domain 2: Managing Chronic Conditions
Osteoporosis management in women who had a fractureOsteoporosis management1Domain 2: Managing Chronic Conditions
Diabetes care – eye examEye exam to check for damage from diabetes1Domain 2: Managing Chronic Conditions
Diabetes care – kidney disease monitoringKidney function testing for members with diabetes1Domain 2: Managing Chronic Conditions
Diabetes care – blood sugar controlledPlan members with diabetes whose blood sugar is under control3Domain 2: Managing Chronic Conditions
Diabetes care – cholesterol controlledPlan members with diabetes whose cholesterol is under control3Domain 2: Managing Chronic Conditions
Controlling blood pressureControlling blood pressure3Domain 2: Managing Chronic Conditions
Rheumatoid arthritis managementRheumatoid arthritis management1Domain 2: Managing Chronic Conditions
Improving bladder controlImproving bladder control1Domain 2: Managing Chronic Conditions
Reducing the risk of fallingReducing the risk of falling1Domain 2: Managing Chronic Conditions
Plan all-cause readmissionsReadmission to a hospital within 30 days of being discharged1Domain 2: Managing Chronic Conditions
Getting needed careEase of getting needed care and seeing specialists1.5Domain 3: Ratings of Plan Responsiveness and Care
Getting appointments and care quicklyGetting appointments and care quickly1.5Domain 3: Ratings of Plan Responsiveness and Care
Customer serviceCustomer service1.5Domain 3: Ratings of Plan Responsiveness and Care
Overall rating of health care qualityOverall rating of health care quality1.5Responsiveness and Care
Overall rating of planOverall rating of health plan1.5Domain 3: Ratings of Plan Responsiveness and Care
Complaints about the health planComplaints about the health plan1.5Domain 4: Member Complaints, Problems Getting Services, and Choosing to Leave the Plan
Beneficiary access and performance problemsProblems Medicare found in members’ access to services and in the plan’s performance1.5Domain 4: Member Complaints, Problems Getting Services, and Choosing to Leave the Plan
Members choosing to leave the planMembers choosing to leave the plan1.5Domain 4: Member Complaints, Problems Getting Services, and Choosing to Leave the Plan
Plan makes timely decision about appealsHealth plan makes timeline decision about appeals1.5Domain 5: Health Plan Customer Service
Reviewing appeals decisionsFairness of health plan’s denials to member appeals, based on an independent reviewer1.5Domain 5: Health Plan Customer Service
Call center – foreign language interpreter and TTY/TDD availabilityAvailability of TTY/TDD services and foreign language interpretation when members call the health plan1.5Domain 5: Health Plan Customer Service

2012 PDP Plan Ratings[4][edit]

|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

MeasureLabelWeightDomain
Call center – pharmacy hold timeTime on hold when pharmacist calls plan1.5Domain 1: Drug Plan Customer Service
Call center – foreign language interpreter and TTY/TDD availabilityAvailability of TTY/TDD services and foreign language interpretation when members call the drug plan1.5Domain 1: Drug Plan Customer Service
Appeals auto-forwardDrug plan makes timely decisions about appeals1.5Domain 1: Drug Plan Customer Service
Appeals upheldFairness of drug plan’s denials to member appeals, based on an independent reviewer1.5Domain 1: Drug Plan Customer Service
Enrollment timelinessPlan handles new enrollment requests within 7 days1Domain 1: Drug Plan Customer Service
Complaints about the drug planComplaints about the drug plan1.5Domain 2: Member Complaints, Problems Getting Services, and Choosing to Leave the Plan
Beneficiary access and performance problemsProblems Medicare found in member’s access to services and in the plan’s performance1.5Domain 2: Member Complaints, Problems Getting Services, and Choosing to Leave the Plan
Members choosing to leave the planMembers choosing to leave the plan1.5Domain 2: Member Complaints, Problems Getting Services, and Choosing to Leave the Plan
Getting information from drug planDrug plan provides clear information or help when members need it1.5Domain 3: Member Experience with Drug Plan
Rating of drug planMembers’ overall rating of drug plan1.5Domain 3: Member Experience with Drug Plan
Getting needed prescription drugsMembers’ ability to get prescriptions filled easily when using the plan1.5Domain 3: Member Experience with Drug Plan
MPF compositePlan provides accurate price information for Medicare’s Plan Finder website and keeps drug prices stable1Domain 4: Drug Pricing and Patient Safety
High risk medicationPlan members 65 and older who received prescriptions for certain drugs with a high risk of side effects, when there may be safer drug choices3Domain 4: Drug Pricing and Patient Safety
Part D medication adherence for hypertensionTaking blood pressure medication (ACEI or ARB) as directed3Domain 4: Drug Pricing and Patient Safety
Part D medication adherence for cholesterolTaking cholesterol medication (statins) as directed3Domain 4: Drug Pricing and Patient Safety

Changes to Ratings and Measures for 2013[edit]

On April 2, 2012, CMS issued the final Call Letter to all MA/MAPDP plans, outlining revisions to the Plan Ratings program for 2013.[5]

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.[5]

New Measures[edit]

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:

  1. Whether the doctor had medical records and other information about the enrollee’s care
  2. Whether there was follow-up with the patient to provide test results
  3. How quickly the enrollee received test results
  4. Whether the doctor spoke to the enrollee about prescription medications
  5. Whether the enrollee received help managing care
  6. Whether the personal doctor is informed and up-to-date about specialist care

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.

Changes to Methodology of Current Measures[edit]

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.

Measures Being Removed[edit]

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.

New Measures for the Display Page[edit]

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.[5]

The following measures are under consideration to be added to the display page, and will be finalized by fall 2012:[5]

Existing Plan Rating Measures

Measures in Development being moved to the 2013 Display Page

Proposed Changes for 2014 Plan Ratings[edit]

Proposed New Measures[5][edit]

References[edit]

External links[edit]