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 needsThe 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 2021 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.

The information in the tables below is viewable by logging in to NaviNet® and accessing the Resource Center that way.

2021 Medicare Advantage Primary Care Incentive Measure Table
Dynamic Measures
Comprehensive Diabetes Care: HbA1c Control (<=9%) Controlling High Blood Pressure Medication Adherence For Cholesterol (Statins)
Medication Adherence For Diabetes Medication Medication Adherence For Hypertension (RASA) Plan All-Cause Readmissions
Static Measures
Annual Wellness and Initial Preventive Physical Rate Breast Cancer Screening Colorectal Cancer Screening
Comprehensive Diabetes Care: Eye Exam (Retinal) Performed Comprehensive Diabetes Care: Medical Attention For Nephropathy Follow-Up After Emergency Department Visit For Patients With Multiple Chronic Conditions
Improving Bladder Control Medication Therapy Management Monitoring For Physical Activity
Patient Engagement After Inpatient Discharge Osteoporosis Management in Women Who Had a Fracture Screening For Future Fall Risk
Statin Therapy For Patients With Cardiovascular Disease Statin Use in Persons With Diabetes TRC Medication Reconciliation Post Discharge

 

General References & Resources

Masthead Measures Reference Guide

Member Rewards

Understanding Formulary Restrictions & Requesting Authorization

Vendor Partners

  • Matrix
  • Home Access
  • AdHereHealth
Last updated on 5/5/2021

 

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