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 2022 measurement year overall star rating is a composite measure constructed from 30 measures for Part C and from 12 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.
|2022 Medicare Advantage Primary Care Incentive Measure Table
|Hemoglobin A1c Control for Patients with Diabetes
||Controlling High Blood Pressure
||Medication Adherence For Cholesterol (Statins)
|Medication Adherence For Diabetes Medication
||Medication Adherence For Hypertension (RASA)
||Plan All-Cause Readmissions
|Annual Wellness and Initial Preventive Physical Rate
||Breast Cancer Screening
||Colorectal Cancer Screening
|Eye Exam for Patients with Diabetes
||Follow-Up After Emergency Department Visit For Patients With Multiple Chronic Conditions
||Medication Therapy Management
|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
Wellness Rewards for Members
Understanding Formulary Restrictions & Requesting Authorization
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Last updated on 1/18/2023 12:08:13 PM