Understanding Star Ratings

The Centers for Medicare & Medicaid Services (CMS) developed the Medicare Star Ratings program to help consumers compare Medicare Advantage (MA) health plans based on quality of care. The program includes a set of quality performance ratings developed by the National Committee for Quality Assurance (NCQA) and CMS for all MA health plans. CMS rates the relative quality of service delivered by health plans and care delivered by providers based on a five-star rating scale, where five stars indicate the highest score.

How are Medicare Star Ratings determined?

There are approximately 40 measures in the Star Rating framework that evaluate clinical care, member experience, and operational efficiencies. Star Ratings are determined using different data sets including, but not limited to, the following:

• Health Effectiveness Data and Information Set (HEDIS^®) collects primarily clinical outcomes and data. This HEDIS^® data best reflects clinical care delivered by the provider and staff.
• Prescription Drug Event data collected by health plans to provide insight for prescription drug-related measures.
• The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey is sent to a random sample of members every spring to measure their experience with care delivered and the health plan. This data focuses on the member’s accessibility to quality care.
• The Health Outcomes Survey (HOS) is sent to a random sample of members every summer to measure self-reported health status and the quality of their health. A follow-up survey is sent to these same members two years later to measure changes in health outcomes.
• Operations data from health plans is used to assess the quality of customer service and other services health plans are providing to their members.

Medicare Star Ratings: What is your role as a provider?

By providing high-quality care to patients in a timely manner, providers play a critical role in the Star Ratings program. There are different opportunities for providers to engage with patients to deliver high quality and timely care while helping patients manage their health.

Areas of opportunity to align provider practices with Medicare Star Ratings:

• Promote timely and appropriate screenings, tests and treatment
• Provide education to staff for proper documentation of care and health status
• Strengthen patient and provider relationships through open communication regarding health care needs and quality of care
• Collaborative development of chronic condition care plan
• Follow-up with patients regarding medications
• Assess timeliness of care and work with office staff to optimize scheduling

These practices promote patient safety, preventive medicine, early disease detection and chronic disease management. Please reference HEDIS measure tip sheets for more information.

Healthcare Effectiveness Data Information Set. HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).