CMS MA Proposed Rule: Star Ratings Updates

Last week, the Centers for Medicare & Medicaid Services (CMS) released a Proposed Rule allowing expanded access to telehealth services for Medicare beneficiaries, streamlining appeals processes for beneficiaries in Dual Eligible Special Needs Plans, helping CMS recover improper payments to plans based on Risk Adjustment Data Validation audits, and continuing to increase the stability and predictability for plans relative to Star Ratings.

CMS’ Star Ratings proposals demonstrate their willingness to evolve the Star Ratings program to eliminate at least some of the longstanding (and frustrating!) volatility and unpredictability within Star Ratings, which should be a welcome change for Medicare Advantage (MA) plans. Key Star Ratings proposals include:

  • Implementing cut point guard rails for non-Consumer Assessment of Healthcare Providers and Systems (CAHPS®) measures to prevent cut points from increasing or decreasing excessively from one year to the next,
  • Enhancing the cut point calculation methodology for non-CAHPS® measures to better eliminate the effect of outliers, and
  • Enhancing adjustments for extreme and uncontrollable circumstances.

CMS also presented proposed measure changes for future Star Ratings calculations:

  • Controlling Blood Pressure will be retired to display for the 2020 and 2021 Star Ratings, with a planned return as a 1x-weighted measure using the new Healthcare Effectiveness Data and Information Set (HEDIS®) 2019 measure specifications beginning with the 2022 ratings. The HEDIS® 2019 changes to this measure are substantive, including updates to reflect new hypertension treatment guidelines from the American College of Cardiology and American Heart Association and significant structural changes (including allowing two outpatient encounters to identify the denominator, allowing the use of telehealth for at least one of the denominator instances, adding an administrative approach to allow Current Procedural Terminology (CPT) Category II code collection, and allowing remote monitoring device readings for the numerator).
  • Plan All-Cause Readmissions will be substantially modified by the National Committee for Quality Assurance (NCQA) for HEDIS® 2020. As a result, this measure will be moved to display for the 2021 and 2022 ratings. HEDIS® 2020 measure changes are expected to include addition of observation stays in the measure, removal of individuals with high frequency admissions from calculations, and expansion of the calculation to include all members older than 18. Small plans may benefit from the proposed changes, as NCQA is also recommending a minimum denominator of 150 in the enhanced calculations.
    • The current MPF Price Accuracy measure will remain the 2020 and 2021 ratings using the current methodology, and the enhanced methodology will be used beginning in the 2022 ratings.  The proposed measure updates capture both the magnitude and frequency of differences between a contract’s Medicare Plan Finder (MPF) advertised prices and the actual pricing at the point of sale.

CMS seeks feedback and input from plans regarding these proposals and will accept comments through December 31, 2018. As we always do, we strongly encourage our clients and other MA plans to provide feedback and alternative proposals to CMS. We’ll provide an update as soon as these proposals are finalized. In the meantime, if you need help with your Star Ratings program or performance, we can help. Please contact me at with questions or for more information.





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Melissa Smith
Melissa Smith

Melissa Smith is Senior Vice President of Stars & Strategy at Gorman Health Group, LLC (GHG). Melissa’s team helps clients improve performance within quality ratings systems such as Star Ratings, improve health outcomes and the member experience, evaluate market dynamics and opportunities, optimize distribution channels, and supports our clients’ strategic planning needs.

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