Star Ratings

5-Star Plans Focus on Data Transparency, Digital Adoption, Operations Training, Says AArete

The latest Medicare Part C and Part D Star Ratings data show that it’s getting harder for payers to achieve the bonus payment level of 4 stars or higher, in part due to cut point changes driven by the new Turkey outlier deletion methodology. As CMS continues to alter the way it calculates the Star Ratings, including lowering the weight of Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures for 2026, plans should deploy a top-down, cross-departmental government structure to incentivize quality performance across all functions, according to global management and technology consulting firm AArete.

To learn more about this and other characteristics of a 5-star MA plan, AIS Health, a division of MMIT, spoke with Darren Ghanayem, managing director with the health care payer group at AArete. The firm works with payers across the MA, Medicaid and commercial markets, advising them on everything from systems migrations and provider network strategy to maximizing revenue and optimizing administrative costs. Ghanayem previously served as chief information officer with WellCare Health Plans, prior to its acquisition by Centene Corp., and at Anthem, Inc. (now Elevance Health, Inc.).

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Star Ratings Plummet in 2024 for Stand-Alone Medicare Prescription Drug Plans

Only 2% of Medicare beneficiaries who enrolled in a stand-alone Prescription Drug Plan (PDP) in 2024 will be in contracts with 4 or more stars, compared to 42% in the 2022 plan year and 9% in 2023, according to CMS’s recently released estimates. The average Star Rating for PDPs dropped to 3.11 in 2024 from 3.70 in 2022, with two contracts receiving 1.5 stars.

The distribution change is largely fueled by methodology changes in how many of the Star Ratings are calculated. Known as Tukey outlier deletion, the changes center on removing outlier contract scores when determining the cut points for all non-Consumer Assessment of Healthcare Providers and Systems measures.

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Elevance Shines with Strong 3Q Results Despite Falling Stars

Elevance Health Inc., the parent company of Anthem, enjoyed a strong third quarter, raising its end-of-year earnings guidance and completing a round of stock buybacks. The firm cited a strategic review — which involved layoffs and slashing real estate costs — as a key reason for the results. However, the positive results were dampened by Anthem plans’ middling performance in the newly released 2024 edition of Medicare Advantage Star Ratings, which drew scrutiny from Wall Street.

The strategic review yielded a $697 million boost to the quarter’s balance sheet, with an Elevance press release touting “the write-off of certain information technology assets and contract exit costs, a reduction in staff including the relocation of certain job functions, and the impairment of assets associated with the closure or partial closure of data centers and offices.”

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Despite Top-Level Decline, Star Ratings Suggest Mostly Stable Plan Performance

Only 42% of Medicare Advantage Prescription Drug (MA-PD) contracts that will be offered in 2024 achieved an overall rating of 4 stars or higher, compared with approximately 51% of contracts in 2023, according to the latest Medicare Part C and Part D Star Ratings data. Weighted by enrollment, the average MA-PD Star Rating fell from 4.14 for 2023 to 4.04, with approximately 74% of MA-PD enrollees estimated to be enrolled in contracts that achieved 4 or more stars for 2024, compared with 72% for 2023, CMS reported on Oct. 13.

Those changes were largely expected due to the application of the new Tukey outlier deletion methodology, which was used in determining the cut points for measures not directly related to member experience and largely achieved CMS’s stated goal of infusing more “predictability and stability” into the Star Ratings.

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MA-PD Star Ratings Fall for the Second Consecutive Year

Payer anxieties about lower Star Ratings for the 2024 plan year came to fruition last week with CMS’s release of the annual Part C and Part D quality measurements. The average Medicare Advantage Prescription Drug (MA-PD) contract scored a 4.04, down from 4.14 last year and the lowest average rating since 2017. Just 31 contracts received 5 stars, representing 6.8% of current MA-PD enrollment, vs. 57 contracts serving 21.5% of enrollees last year.

Several methodology changes fueled the ratings decline, which Stars experts have dubbed "TukeyGate," referring to CMS efforts to remove outliers from calculating the cut points for non-Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures. The agency also added two new Part C measures, one for care transitions and another for follow-ups after emergency visits for people with high-risk chronic conditions. A Part C measure on kidney disease monitoring for diabetes patients was removed.

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Despite Top-Level Decline, Tukey-Impacted Star Ratings Suggest Mostly Stable Performance

Only 42% of Medicare Advantage Prescription Drug (MA-PD) contracts that will be offered in 2024 achieved an overall rating of 4 stars or higher, compared with approximately 51% of contracts in 2023, according to the latest Medicare Part C and Part D Star Ratings data. Weighted by enrollment, the average MA-PD Star Rating fell from 4.14 for 2023 to 4.04, with approximately 74% of MA-PD enrollees estimated to be enrolled in contracts that achieved 4 or more stars for 2024, compared with 72% for 2023, CMS reported on Oct. 13.

Those changes were largely expected due to the application of the new Tukey outlier deletion methodology, which was used in determining the cut points for measures not directly related to member experience and largely achieved CMS’s stated goal of infusing more “predictability and stability” into the Star Ratings.

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Only Two Plans Get ‘5 out of 5’ in 2023 NCQA Ratings

Most of the health plans ranked by the National Committee for Quality Assurance received an overall rating of 3.5 stars or higher, according to the NCQA’s 2023 health plan ratings.

Of the rated plans, only two out of the 1,095 plans listed received five stars this year: Kaiser Foundation Health Plan of the Mid-Atlantic States and Independent Health Association, Inc. In the 2022 ratings, six out of 1,048 health plans earned five stars. Commercial health plans had a higher overall rating compared to Medicaid and Medicare health plans.

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CVS, Cigna CEOs Pan Blue Shield of California PBM Deals

The CEOs of CVS Health Corp. and The Cigna Group on Sept. 12 downplayed the potential for PBM market disruption that could result from Blue Shield of California’s recent deal to unbundle its pharmacy benefit contracts. But both executives hedged by emphasizing their PBMs’ flexibility, and Cigna’s boss suggested that its Express Scripts subsidiary has an a la carte PBM menu.

CVS and Cigna leaders also said, during presentations at the Morgan Stanley Health Care Conference, that they are confident that their Medicare Advantage Star Ratings will improve, and they promised further MA growth. Both firms assured investors that their recent, multibillion-dollar provider transactions will lead to future growth. And both firms, which own two of the “Big Three” PBMs, said that biosimilars will be a boon to payers — with CVS promising as much as 80% savings on its forthcoming Humira (adalimumab) biosimilar line.

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ACHP’s MA for Tomorrow Framework Aims to Drive Quality, Level Playing Field

From reforming the Star Ratings program intended to steer consumers to the highest-quality plans to reducing gaming of the current risk adjustment system used to set insurer payments, the Alliance of Community Health Plans (ACHP) is envisioning the future of Medicare Advantage with MA for Tomorrow. While the new framework, released last month, comes at a time when the Star Ratings and other aspects of the MA program are under intense scrutiny, ACHP tells AIS Health, a division of MMIT, that it is the result of a multiyear collaboration with subject matter experts at its provider-aligned, not-for-profit health plans.

ACHP provides recommendations around five key pillars: raising the bar on quality, improving consumer navigation, advancing risk adjustment for care not coding, modernizing network composition and transforming benchmarks. And it says many of the provisions contained in these pillars can be implemented right away. AIS Health spoke with ACHP’s president and CEO, Ceci Connolly, and associate vice president for public policy, Michael Bagel, to learn more about the specific recommendations. (Editor’s note: This interview has been edited for length and clarity.)

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CMS Treats MA Plans to Suspension of Auto-Forward IRE Data in Stars Calculation

In an effort to improve Medicare Advantage and Part D sponsors’ timeliness in processing Parts C and D coverage requests, CMS several years ago launched the Timeliness Monitoring Project (TMP) and began issuing fines to Part D plans with excessively high rates of “auto-forwarding” to the Independent Review Entity (IRE). And while CMS historically deducted one star from the appeals measure-level ratings based on IRE data integrity issues, the TMP also resulted in a scaled reduction intended to reflect the severity of the plan’s failures. Now, CMS is relieving MA organizations of that penalty by suspending the collection of Part C Organization Determinations, Appeals and Grievances (ODAG) universes for non-audited organizations that impacted the appeals measures.

Parts C and D sponsors are required to notify enrollees within specific time frames of their decisions on a coverage determination or redetermination. When plans miss that window, it’s considered an adverse decision, and sponsors are expected to automatically forward the case to the IRE within 24 hours. There are two Part C Star Ratings appeals measures that rely on data submitted to the IRE:

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