CMS Star Rating of CVS Health and Centene, lead the federal government to hit the insurers with lower quality scores for the health-insurance plans they sell to seniors.
The scores are a big deal for health insurers, because plans that score 4 stars or higher receive bonus payments from the federal government that they can use to edge out competition by funding new health-plan benefits to attract more customers.
The federal government paid $10 billion in bonus payments in 2022, according to the Kaiser Family Foundation. Plus, consumers can see the scores while shopping for insurance plans.
CMS Star Rating System Measure…?
For Medicare plans providing health coverage, such as Medicare Advantage or Medicare Cost plans, each plan is given an overall summary rating based on how it performs across five main categories:
- Chronic conditions management
- Member experience
- Member complaints
- Customer service
BHM Healthcare Solutions offers services to health plans and providers increasing the timeliness and accuracy of claims medical necessity review leading to a less stressful member patient experience.
Click for the brief: Key Takeaways from the 2023 Final Star Ratings
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The Centers for Medicare & Medicaid Services (CMS) publishes the Medicare Advantage (Medicare Part C) and Medicare Part D Star Ratings each year to measure the quality of health and drug services received by consumers enrolled in Medicare Advantage (MA) and Prescription Drug Plans (PDPs or Part D plans).
The Star Ratings system helps Medicare consumers compare the quality of Medicare health and drug plans being offered so they are empowered to make the best health care decisions for them. An important component of this effort is to provide Medicare consumers and their caregivers with meaningful information about quality alongside information about benefits and costs to assist them in being informed and active health care consumers.
Expansion Applications Use Star Ratings
CMS’ new Past Performance criteria prohibits applicants from entering into new contracts and from service area expansions if any contract held by the organization has below a 3-Star Part C Summary, Part D Summary, or overall rating during each of the last two ratings cycles. This new rule takes effect in spring 2023 for New Contract and Service Area Expansion Applications, effective January 1, 2024. The provisions are applied at the Legal Entity level, rather than the Contract or Parent Org level.
For the 2023 Star Ratings, the only adjustments for the impact of the COVID-19 public health emergency (PHE) are the measure-level adjustments for three Healthcare Effectiveness Data and Information Set (HEDIS) measures derived from the 2021 Health Outcomes Survey (HOS).
The 2022 Star Ratings included measure-level adjustments for other (non-HOS) measures under the extreme and uncontrollable circumstances rules as a result of the COVID-19 PHE. For example, for most measures, if a measure-level Star Rating was lower for the 2022 Star Ratings relative to the prior year, the measure-level Star Rating (and numeric score) reverted to the rating (and numeric score) from the 2021 Star Ratings.
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