Across the Medicare Advantage (MA) Risk Adjustment (RA) healthcare world, we often hear about “Star Ratings.”  With the October MA Star Ratings being released by the Centers for Medicare and Medicaid Services (CMS) a common question is: What are the CMS Star Ratings?

CMS publishes the Medicare Part C and Part D Star Ratings each year to measure the quality of health and drug services received by beneficiaries enrolled in Medicare Advantage (MA) and Prescription Drug Plans ( PDPs, PD or Part D plans) with a set of measures. The measures are associated with “Star Ratings” that  also reflect the experiences of beneficiaries and assist beneficiaries in finding the most appropriate MA plan for them. The Medicare Advantage Organization (MAO) offer the MA plan(s) and then their performance is measured or scored using a star rating. In addition, the star ratings help potential enrollees (beneficiaries) compare plans available in their area as well as encourage plans to compete based on quality. Due to the Public Health Emergency (PME), CMS did make a few changes, for example, delaying the implementation of the guardrails for one year, which enables the cut point changes by more that 5% if national performed declined. In addition, CMS expanded the hold harmless provisions for improvement measures due to the undermining effects of COVID-19.

CMS has published some great charts and graphics regarding the 2022 MA star ratings and these are available at: 2022 Star Ratings Fact Sheet (cms.gov)

There are thirty-three (33) measures for Part C and fifteen (15) for Part D MA. Each measure/category is given a score to calculate the one to five stars, with the scoring being five for the highest and one the lowest. The measures cover five main categories, CMS assigns one overall star score for their performance in these categories. The five MA Star Rating categories are:

  • Staying healthy: screening tests and vaccines: Includes whether members received various screening tests, vaccines, and other check-ups to help them stay healthy.
  • Managing chronic (long-term) conditions: Includes how often members with certain conditions received recommended tests and treatments to help manage their condition.
  • Member experience with the health plan: Includes member ratings of the plan.
  • Member complaints and changes in the health plan’s performance: Includes how often Medicare found problems with the plan and how often members had problems with the plan. Includes how much the plan’s performance has improved (if at all) over time.
  • Health plan customer service: Includes how well the plan handles member appeals

Here is a list of the first fifteen specific measures for Part C:

  • C01 Breast Cancer Screening
  • C02 Colorectal Cancer Screening
  • C03 Annual Flu Vaccine
  • C04 Improving or Maintaining Physical Health
  • C05 Improving or Maintaining Mental Health
  • C06 Monitoring Physical Activity
  • C07 Adult BMI Assessment
  • C08 Special Needs Plan (SNP) Care Management
  • C09 Care for Older Adults – Medication Review
  • C10 Care for Older Adults – Functional Status Assessment
  • C11 Care for Older Adults – Pain Assessment
  • C12 Osteoporosis Management in Women who had a Fracture
  • C13 Diabetes Care – Eye Exam
  • C14 Diabetes Care – Kidney Disease Monitoring
  • C15 Diabetes Care – Blood Sugar Controlled

Yes, there is a monetary bonus payment associated with the star ratings, thus MAO (plans) and their providers work very closely to address and meet the measures. The CMS 2022 report indicates that Plans that scored 4 Stars or higher are eligible for a 5% Quality Bonus Payment or QBP. In addition, Quality Bonus Payments can result in higher rebates that allow the MAOs to provide additional supplemental benefits and lower premiums. Comparing the per member (enrollee) MA plan bonus, it was $184 in 2015 and in 2021, it was $446 per member. Then there is the health plans who fail to perform and they are penalized or risk contract termination for consistently low ratings.

Since 2012, the overall MA star rating/score have increased, from 3.18 in 2012 to 4.06 in 2018 on average. Scoring in determined by county and thus can vary by MAO depending on the specific county performance and data. CMS reported that 90% of beneficiaries in Medicare Advantage Part D (MA-PD) are enrolled in plans receiving four or five stars for 2022, the agency’s top scores for quality. The average Star Rating across MA-PD contracts for 2022 rose to 4.37, up from 4.06 in 2021 and 4.16 in 2020. Member (customer) experience represents a large portion of the overall star, at 20.6% in 2022.

The growth of Medicare Advantage, Part C enrollment has been significant, with a 1.3% growth in 2009, to 16.7 % in 2018. Data shows that ninety percent (90%) of the MA membership is enrolled in a 4.0+ related health plan. Most advise “Senior” beneficiaries to take a look at the Star Ratings before signing up for a plan and/or to continue with a plan.

Having an accurate and strong data abstraction and collection process as well as technology system for analytics will help with your MA star rating tracking and monitoring. The Health Information Professional can really fit into this data analytics role so don’t be afraid to step up.

Reimbursement Management Consultants (RMC) can provide assistance with medical coding support, auditing, education, compliance consulting, and HCC/risk adjustment services. RMC is a woman-owned, US-based and operated company which specializes in a variety of medical coding and auditing services. Contact us here.

Written by Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA Approved ICD-10-CM/PCS Trainer