What do the Medicare Advantage and Part D STAR ratings mean?
“The Medicare Advantage and Part D Star Ratings are important tools in the toolbox for beneficiaries to use as they consider Medicare coverage options,” said CMS Administrator Chiquita Brooks-LaSure. “CMS’s annual ratings deliver meaningful information about the quality of each plan to help people with Medicare make informed health care decisions.”
How do Medicare Advantage and Part D plan costs and benefits change?
Medicare Advantage and Part D plan costs and covered benefits can change from year to year, so Medicare beneficiaries should look at their coverage choices and decide on the options that best meet their health needs.
What percentage of Medicare Advantage plans have 4 or more stars?
Approximately 90 percent of people currently in Medicare Advantage plans that offer prescription drug coverage are enrolled in a plan that earned four or more stars in 2022. The number of plans with a rating of 4 or more stars is higher for 2022 compared to last year.
Are plan providers taking advantage of the star rating system?
Given that the things they are least able to control are patient outcomes, this may not be the desired result. As plan providers become more familiar with how the Star Rating System works, they may be able to unfairly take advantage and manipulate their scores.
How do I increase my star rating for Medicare Advantage?
7 Ways to Improve Your Star RatingEnsure Medication Benefits Are Central to the Consumer Onboarding Experience. ... Develop Targeted Outreach Programs Around Medication Adherence and Preventive Screening. ... Make Every Interaction Count. ... Be Proactive with Consumer Feedback. ... Communicate Consistently and in Different Channels.More items...•
Do Part D plans have star ratings?
CMS rates Medicare Advantage and Part D plans annually, using a scale from one to five, with more stars equating to better performance and quality. A five-star rating is the highest a Medicare Advantage or Part D plan can receive, and half-ratings also exist (1.5, 2.5, 3.5, 4.5).
What Medicare Advantage plan has the highest rating?
What Does a Five Star Medicare Advantage Plan Mean? Medicare Advantage plans are rated from 1 to 5 stars, with five stars being an “excellent” rating. This means a five-star plan has the highest overall score for how well it offers members access to healthcare and a positive customer service experience.
What is CMS Stars program?
Star Ratings are released annually and reflect the experiences of people enrolled in Medicare Advantage and Part D prescription drug plans. The Star Ratings system supports CMS's efforts to empower people to make health care decisions that are best for them.
What is the most popular Medicare Part D plan?
Best-rated Medicare Part D providersRankMedicare Part D providerMedicare star rating for Part D plans1Kaiser Permanente4.92UnitedHealthcare (AARP)3.93BlueCross BlueShield (Anthem)3.94Humana3.83 more rows•Mar 16, 2022
Who sets the standards for Medicare star ratings?
The Centers for Medicare & Medicaid Services (CMS) uses a five-star quality rating system to measure the experiences Medicare beneficiaries have with their health plan and health care system — the Star Rating Program. Health plans are rated on a scale of 1 to 5 stars, with 5 being the highest.
What are the top 3 most popular Medicare supplement plans in 2021?
Three Popular Medicare Supplement PlansBlue Cross Blue Shield. According to Blue Cross Blue Shield (BCBS), Plans F and N are available in most areas. ... AARP United Healthcare. The United Healthcare Medicare Supplement plan is also very popular. ... Humana.
What is the biggest disadvantage of Medicare Advantage?
Medicare Advantage can become expensive if you're sick, due to uncovered copays. Additionally, a plan may offer only a limited network of doctors, which can interfere with a patient's choice. It's not easy to change to another plan. If you decide to switch to a Medigap policy, there often are lifetime penalties.
What are 4 types of Medicare Advantage plans?
Below are the most common types of Medicare Advantage Plans.Health Maintenance Organization (HMO) Plans.Preferred Provider Organization (PPO) Plans.Private Fee-for-Service (PFFS) Plans.Special Needs Plans (SNPs)
What measures are included in star rating?
The overall star rating includes a variety of the more than 100 measures CMS publicly reports, divided into 5 measure groups or categories: Mortality, Safety of Care, Readmission, Patient Experience, and Timely & Effective Care.
What are stars medications?
Star Ratings were created by the Centers for Medicare & Medicaid Services (CMS) to provide quality and performance information to help Medicare beneficiaries choose a plan. Star Ratings range from 1 to 5 (lowest to highest) and reflect the experiences of members regarding the health and drug services they've received.
What is the best Medicare Part D plan for 2022?
The 5 Best Medicare Part D Providers for 2022Best in Ease of Use: Humana.Best in Broad Information: Blue Cross Blue Shield.Best for Simplicity: Aetna.Best in Number of Medications Covered: Cigna.Best in Education: AARP.
Why do Medicare Advantage plans get stars?
Medicare Advantage plans receive a star rating based on performance measures that are intended to help potential enrollees compare plans available in their area as well as encourage plans to compete based on quality. All plans that are part of a single Medicare Advantage contract are combined when calculating the quality rating ...
What is the MLR for Medicare Advantage?
However, plans’ ability to keep these and other payments as profit is not unlimited – Medicare Advantage plans must meet medical loss ratio (MLR) requirements of at least 85 percent, and are required to issue rebates to the federal government if their MLRs fall short of required levels.
What percentage of Medicare Advantage plans will receive bonus payments in 2021?
In 2021, 81 percent of all Medicare Advantage enrollees are in plans that receive a bonus payment from Medicare based on star quality ratings (or because they are new), substantially higher than the share in 2015 (55 percent). Annual bonus payments from the federal government to Medicare Advantage insurers have increased correspondingly, ...
How much is Medicare Advantage rebate in 2021?
Additionally, as more enrollees are in plans that are in bonus status, the average rebate per Medicare Advantage enrollee has more than doubled, rising from $184 per year in 2015 to $446 per year in 2021.
Why are bonus payments increasing?
The rise in bonus payments is due to both an increase in the number of plans receiving bonuses, and an increase in the number of enrollees in these plans. Because unrated plans also receive bonus payments, a total of 85 percent of enrollees are in plans that are eligible to receive quality bonus payments, and 81 percent ...
How much is the average bonus for 2021?
The average bonus per enrollee in an employer plan is $886 in 2021, more than 2.5 times higher than for enrollees in either individual plans ($351) or SNPs ($309). While average bonuses in employer plans have consistently been higher than for other plans, the gap has increased substantially in recent years, driven by a rapid rise in the average bonuses for employer plans. Both the high share of enrollees in group plans that receive bonus payments (98% in 2021), as well as changes to the payment methodology for group plans implemented starting in 2017 contribute to this trend.
What is Medicare Advantage 2021?
Medicare Advantage in 2021: Star Ratings and Bonuses. Medicare Advantage plans receive a star rating based on performance measures that are intended to help potential enrollees compare plans available in their area as well as encourage plans to compete based on quality. All plans that are part of a single Medicare Advantage contract are combined ...
When will CMS require Part D plans?
Starting in plan year 2022, CMS will require Part D plan sponsors to report the pharmacy performance measures that they use to evaluate network pharmacy performance under their network agreements. In instituting this requirement, the agency emphasized the growing magnitude of pharmacy price concessions based on performance measures within the Part D program, and expressed a desire to provide the public with transparency regarding these measures. The agency also said that it believes that “publishing a list of currently used pharmacy performance measures will promote the development of consensus-built standards by the industry that are transparent and equitable across various pharmacy types and patient populations, and support value-based care.” 15
How does the final rule affect Part D?
The final rule makes a significant change to rules governing Part D formulary design. Under the Part D program, CMS permits Part D plans to design their own prescription drug formularies, subject to certain requirements, including limitations on cost-sharing obligations that can be imposed on Part D beneficiaries. Currently, CMS permits Part D plans to place drugs that cost over a specified threshold (for contract year 2021, $670) in a single specialty tier. Plans may charge higher co-insurance—up to 25 or 33 percent, depending on the plan’s deductible—for drugs in this specialty tier. 2 Under the final rule, starting on January 1, 2022, Part D plans may establish a second specialty tier, splitting specialty drugs between a non-preferred specialty tier and a preferred specialty tier, with the preferred tier carrying lower cost-sharing obligations than the non-preferred tier. 3 Plans will have flexibility to allocate Part D drugs across the two specialty tiers, subject to CMS’s existing formulary review and approval process and the specialty tier cost threshold. 4 By allowing plans to apply differential co-insurance obligations to specialty drugs, this dual specialty tier model is designed to give plans flexibility to incentivize beneficiaries to select lower-cost specialty drugs.
How does CMS measure MA?
CMS measures MA and Part D plan quality and performance through a Star Ratings system that annually assigns and publishes a rating for each plan, based on data collected on a number of measures over the course of previous plan years. The Star Ratings system is the primary means through which beneficiaries can compare and select plans, and the basis of quality-based bonus payments awarded to plans by CMS. As a result, the specific Star Ratings measures that the agency evaluates, as well as the methodology through which Star Ratings are calculated, can have major implications for plans and beneficiaries alike.
How is the specialty tier cost determined?
The final rule also codifies updates to the methodologies for calculating of the specialty tier cost threshold and determining whether the drug meets the specialty tier cost threshold. Under the new methodologies, the price of a given drug will be calculated based on ingredient cost for a 30-day supply of the drug (as reported to CMS in prescription drug event records), as opposed to the negotiated price of the drug. CMS will also adjust the specialty tier threshold annually to ensure that the threshold reflects the top one percent of drug prices, rounded up to the nearest $10. 5 This new calculation methodology results in a specialty tier threshold cost of $780 for the 2021 plan year, although the agency has said that—notwithstanding this methodology change—for the current 2021 contract year, it will maintain the specialty tier threshold at $670. 6 CMS intends for these changes to the specialty-tier system to give Part D plans more leverage in negotiating with drug manufacturers for high-cost drugs and, in turn, to reduce out-of-pocket costs for enrollees in exchange for placing certain drugs in the “preferred” specialty tier. 7
What is a Part D suspension?
Part D plans notify the Secretary of Health and Human Services of any imposition of a payment suspension on a pharmacy based on a credible allegation of fraud pursuant to the SUPPORT Act. Plans must report any such payment suspensions via a new secure program integrity portal within CMS’s Health Plan Management System; 19
Does the final rule introduce new star ratings?
While the final rule does not introduce any new Star Ratings quality or performance measures, it codifies updates to CMS’s methodology for the Star Ratings system that were previously instituted through sub-regulatory guidance. CMS’s decision to subject updates to the Star Rating system to formal, notice-and-comment rulemaking is notable in light of the fact that CMS historically has updated Star Ratings measures and methodologies through annually issued call letters and other sub-regulatory guidance, without a formal notice-and-comment rulemaking process as contemplated under the Administrative Procedure Act. By subjecting updates to the Star Ratings system to formal notice and comment, CMS appears to be signaling a recognition of the importance of Star Ratings to stakeholders and of government payments in connection with the MA and Part D programs, and a strengthened commitment to meaningful consideration of stakeholder input in the design of the Star Ratings system.
Is the Part D payment modernization model subject to review?
These changes to the Part D Payment Modernization Model rules, which come in the form of sub-regulatory guidance, are subject to review under the Biden administration’s regulatory freeze. While it is not yet known whether, under the Biden administration, CMS will ultimately choose to implement these changes, such weakening of beneficiary protections would appear to fit squarely within the category of rules that the Biden administration intends to scrutinize and reconsider. It, therefore, remains to be seen whether these changes to the Part D Payment Modernization Model formulary requirements will ultimately take effect, as currently written.
What percentage of Medicare Advantage Star Ratings will be in 2021?
CMS is quadruple-weighting Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures in contract year 2021, which means the surveys will account for 32 percent of the overall Medicare Advantage Star Rating.
What is QBP in Medicare?
MA plans rated four stars and up are eligible for quality bonus payment (QBP) reimbursement. Medicare is slated to distribute nearly $11.6 billion in bonuses — or approximately $450 per member per year — to the highest-quality plans. MA plans that receive value-based reimbursements are required to use the money toward more consumer benefits and thereby have a better product to compete for consumers during the next open enrollment period.
What is a resolve rating?
Resolve ™ for Medicare Advantage Star Ratings, an Adhere™ platform solution, is the ideal tool to help you strategize proactive engagement. It’s the only consumer-centric solution that enables you to optimize scores by addressing 80.5 percent of Medicare Advantage Star Ratings weight relating to medication adherence, quality improvement and consumer experience (e.g., CAHPS).
When a consumer enrolls in your plan, should your plan offer them a detailed onboarding workflow?
When a consumer enrolls in your plan, your plan should offer them a detailed onboarding workflow. Dropping the ball here can cause discontent from the start. Make enrollment an engaging, positive experience that focuses on whole-person health and ensures the consumer has ongoing access to their providers and medication.
How to help clinicians identify social determinants of health?
Incorporate motivational interviewing tactics into your clinical workflow to help your clinicians identify any social determinants of health (SDOH) issues a consumer may have and help connect them with plan benefits or local resources to overcome those barriers. Focus on medication-related measures, which account for 52% of the overall MA Star Rating.
Why are star ratings important?
The Star Rating System appears to be increasing the quality of the plans available and care provided to Medicare Advantage beneficiaries. However, it is not clear that the criteria being evaluated by CMS is necessarily the criteria of most importance to MA beneficiaries, and thus may not be accurately reflecting enrollee preferences. This mismatch of preferences and criteria may be causing more problems than just weakening the effectiveness of the star ratings as an informational tool for patients. Inadequate risk adjustment and consideration of patients’ socioeconomic status may be resulting in ratings which do not accurately reflect the quality of care and service provided, particularly for plans enrolling high proportions of low-income beneficiaries. The corresponding bonus and rebate payment structure may actually be harming the most vulnerable beneficiaries as a result.
What is a 5 star rating?
The 5-star rating system was first implemented by CMS for MA plans in 2008 serving as a tool to inform beneficiaries as to the quality of the various plan options and assist them in the plan selection process. Ratings are set at the MAO contract level—not the plan level—meaning all plans under the same contract receive the same score. Stars are assigned to each contract for each individual measure being evaluated, based on relative performance compared to the other contracts. The overall summary score for each contract is then calculated by averaging the star ratings for each individual measure for a contract.
Why is the Star Rating System unfair?
Many have expressed concern that the Star Rating System—because of how measures are evaluated and rewards are paid —unfairly punishes both low-income enrollees and the plan sponsors primarily serving such enrollees. It is argued that a significant portion of the measures evaluated are influenced by a patient’s socioeconomic conditions, yet very few of the measures are risk-adjusted to neutralize the impact of such differences between patients, thus not allowing for a fair comparison between plans with high versus low enrollment of low-income individuals. This concern has led to calls for either establishing a separate rating system for Special Needs Plans (SNPs) or any MA plan in which enrollees are predominantly low-income, or providing a score adjustment for such plans in order to compensate for those patient differences. [19] The National Quality Forum, in its report released in August 2014, notes the well-documented link between patients’ sociodemographic conditions and health outcomes, and recommends that such factors be included in risk adjustments for performance scores. [20]
How many categories are there in the CMS?
In 2014 and 2015, measures were based on five broad categories, with weights varying based on the category’s level of importance as determined by CMS [3]:
What are the problems with the Star Rating System?
The Star Rating System has had other unintended consequences resulting from poor program structure and misaligned incentives. Some of the biggest problems with the program structure relate to timing. The measurements that will be evaluated each year are determined and announced after both the period from when the measurements are taken and after contract submissions for the following year are due. This leaves plans unaware of what they’re being evaluated on, which makes it difficult to know what they should be doing or to make appropriate changes for the next year resulting in a two-year lag on adjustments by plans and their providers, at best. Another concern is that the retrofitting of the evaluation criteria could allow for CMS to pick winners and losers by selecting criteria that specific companies perform particularly well (or poor) on. Further, the bonus payments are based on the benchmark price and enrollment in the following year from when the measures were taken, which means plans are rewarded for patients they weren’t necessarily covering at the time the reward was earned. Finally, not making the evaluation criteria known ahead of time and delaying the reward is inconsistent with all theories on how to make reward incentive programs effective.
Why are there no thresholds for 4 star rating?
Analysis by CMS has shown that greater improvement is typically achieved for measures which do not have predetermined thresholds than those that do. While this may be because the incentive to improve any further is significantly diminished once the threshold for receiving the bonus payment is achieved, it may also result from underlying differences between measures which have been given thresholds and which have not, as they are not randomly selected. [2]
What is a reward plan?
Rewards are two-part: direct bonus payments to the plan operator and rebates which must be returned to the beneficiary in the form of additional or enhanced benefits , such as reduced premiums or co-payments, expanded coverage, etc.