The Centers for Medicare & Medicaid Services (CMS) assigns Medicare Advantage plans with a quality rating on an annual basis using a five-star rating system.
Star ratings give Medicare beneficiaries a standardized way to compare Medicare health plans on overall quality and service - and determine the highest quality plans in their area.
Each Medicare Advantage plan is assigned an overall rating from one to five stars, based on the plan's performance in more than 50 specific areas across five general categories.
- Category 1: Staying healthy
Evaluates how often members receive screening tests, vaccines, checkups and other preventive services to help them stay healthy. - Category 2: Managing chronic conditions
Evaluates how effectively health plans help members manage long-term conditions. - Category 3: Member satisfaction
Evaluates member satisfaction with their health plan and how they feel about the quality of care they receive from the health plan and providers. - Category 4: Customer service
Evaluates how responsive and helpful the plan's customer service is and the accuracy of information given to members. - Category 5: Pharmacy benefits
Evaluates medication pricing, patient safety and member experience.
The ratings, updated annually, are based on ongoing monitoring and analysis to represent:
***** Excellent performance
**** Above average performance
*** Average performance
** Below average performance
* Poor performance
Star ratings reflect the performance of each Medicare Advantage plan in 53 individual measures consisting of:
- Clinical quality standards
- Member satisfaction surveys
- Health plan administrative performance
Compliance with CMS operational standards
The data sources used to create the star ratings include:
- Clinical quality standards and member satisfaction surveys:
- Health Outcomes Survey (HOS)
- Health Effectiveness Data and Information Set (HEDIS®)
- Consumer Assessment of Healthcare Providers and Systems (CAHPS®)
Administrative performance and compliance standards:
- CMS audits
- Part D data integrity
- Grievance and appeals
- Call center performance
- Member complaint tracking
We remain focused on achieving the highest possible scores in order to improve the health of our members, attract new members to our high-quality plans and continue offering competitive reimbursement to our providers.
We continually evaluate our overall ratings and the individual measures that comprise them. This may result in increased focus on quality program initiatives, such as HEDIS measures and risk adjustment reviews.
Reports are issued regularly that identify Medicare Advantage members who may have a gap in medical care or diagnosis reporting. Reports are distributed to the member's primary provider to support and promote preventive screenings, chronic disease management and coding compliance. Providers should use the reports to contact their patients and schedule them for appointments to close their gaps as soon as possible.
Please review the Gap closure instructions to learn about closing gaps. We have contracted with Novillus to distribute member gap reports to providers. You may be contacted by Novillus staff to verify contact information.
Our Medicare Quality Incentive Program is designed to reward providers who ensure that identified medical care or diagnosis gaps for Medicare Advantage patients are addressed and closed prior to the end of each year.
We have contracted with Signify Health LLC to complete in-home health assessments for selected Medicare Advantage members. This program enhances our ability to capture risk adjustment data and identify or close gaps in care for our members. This is not a substitute for care provided to our members by physicians and other health care professionals, and there is no cost to the member to participate in the evaluation. During the evaluation, the Signify Health provider conducts a comprehensive update of the member's medical record including:
- Reviewing all current medications
- Documenting all existing and past medical conditions
- Providing additional tests (e.g., diagnostic laboratory tests), if appropriate
- Referring members for case management and/or disease management, if appropriate
Documenting current treatment plans and educating the member about the importance of adhering to the prescribed treatment plan
Upon completion of the evaluation, we receive a detailed report which will be shared with the provider that the member designates as his or her primary provider.
Each year we send our Medicare Advantage members a Passport to Health that includes a list of preventive screenings available to them at no cost through their Medicare plan. We encourage them to bring this checklist to their providers as a tool to discuss their overall health and how to live a healthy lifestyle.
Learn more about Medicare preventive services
We encourage all of our providers to provide five-star level services to our members. You help impact our star ratings by:
- Submitting claims and documenting all services thoroughly and accurately. Learn more about claims and payment and review our Risk Adjustment coding and documentation tips (PDF).
- Ensuring your patients receive appropriate screening tests and preventive services. We encourage our members to have an annual wellness visit each year. This directly impacts our star ratings for Category 1.
- Helping your patients manage their chronic conditions, such as high blood pressure, arthritis and diabetes. Our care management program can provide additional support for patients with complex needs. This is reflected in our star ratings for Category 2.
- Avoiding high risk medications for your elderly patients. We will notify providers who have patients on high risk medications and encourage the use of alternatives wherever possible.
- Meeting the requirements for Medicare Advantage providers, including advance directives and access and availability standards. Review the Medicare Advantage Plans section of our Administrative Manual for more information.
- Understanding the impact that you and your office staff have on member satisfaction with their health care experience, which is reflected in the CAHPS and HOS surveys. Use our provider checklist (PDF) for member surveys to promote a positive experience for members. This impacts our star ratings for Category 3.