An Introduction to the Centers for Medicare & Medicaid Services Star Ratings Program
What is the Medicare star ratings program?
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 and performance. The program includes a set of quality performance ratings developed by the National Committee for Quality Assurance 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 CMS star ratings determined?
The ratings include specific clinical, member perception and operational measures. There are approximately 40 measures in the star rating framework.
To best capture a range of quality metrics, 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 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) is an annual survey 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 every summer to a random sample of members to measure self-reported health status and the quality of their health care. A follow-up survey is sent to these same members two years later to measure changes in health perception.
- Operations data from health plans is used to assess the quality of customer service and other services health plans are providing to their members.
CMS 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 help ensure high quality and timely care while helping patients manage their health.
Areas of opportunity to align provider practices with the CMS star ratings program:
- Promote timely and appropriate screenings, tests and treatment
- Provide education to staff members for proper documentation of care delivered
- 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, which is especially beneficial for this population.
Star ratings help members enhance relationships with providers and health plans by ensuring accessibility to care, enhanced quality of care and optimal customer service.
Contact the Customer Service Center number on the back of the members Medicare Advantage insurance card.
Healthcare Effectiveness Data Information Set. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).