Medicare Advantage Stars

Background:
The Centers for Medicare and Medicaid Services (CMS) rates Medicare Advantage plans and prescription drug plans separately on a scale of one to five stars, with five representing the highest quality. The Star Rating for Medicare Advantage plans is an overall measure of the plan's quality, and is a cumulative indicator of: Quality of care, Access to care, Beneficiary satisfaction, Customer Service, and Responsiveness to member needs. The intent of the program is to tie quality of care to financial reimbursements, whereby rewarding high performing plans and forcing low performing plans to exit the market.

The quality scores for Medicare Advantage plans are based on over 50 distinct individual measures that are derived from four sources:

  • Healthcare Effectiveness Data and Information Set (HEDIS®)
  • Consumer Assessment of Healthcare Providers and Systems (CAHPS®) program
  • Centers for Medicare and Medicaid Service (CMS)
  • Health Outcomes Survey (HOS)

Scope: Medicare Advantage Plans (MA-PD, MA only, PDP)
Scoring: The 2015 overall star rating is a composite measure constructed from 36 measures for Part C and from 15 measures for Part D.
Payout: Up to 5% Performance Bonus for Medicare Advantage Plans earning 4-5 stars 

Plans earning 5 stars receive a special icon on CMS's website and are eligible for year-round open enrollment. Plans earning < 3 stars in successive years receive a not-so-special icon on CMS's website and have restrictions on new membership. Health Plan Rates are posted on www.medicare.gov.

2019 Medicare Advantage Primary Care Incentive Measure Table
AWV: Annual Wellness and Initial Preventive Physical Exam Adult BMI Assessment Breast Cancer Screening
Colorectal Cancer Screening Diabetes Care: Retinal Eye Exam Diabetes Care: HbA1c Control
Diabetes Care: Nephropathy Fall Risk Assessment Controlling High Blood Pressure
Medication Adherence: Cholesterol (Statins) Medication Adherence: Diabetes Medication Medication Adherence: Hypertension (RASA)
Medication Therapy Management Medication Reconciliation Post Discharge Osteoporosis Management in Women who had a Fracture
Readmissions: All-Cause Rheumatoid Arthritis: DMARD Therapy Statin Therapy: Cardiovascular Disease
Statin Use: Diabetes

 

General References & Resources

HEDIS Measures Reference Guide

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Last updated on 6/13/2019

 

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