The CMS 2019 Final Rate Notice: Star Ratings changes

Medicare Advantage plans are still digesting the 2019 Medicare Advantage and Part D Rate Announcement and Call Letter, released last week by the Centers for Medicare & Medicaid Services (CMS). Here, Cotiviti’s Ashley McNairy, product director for Cotiviti’s Government Quality Solutions, breaks down the key changes to the Star Ratings program on the docket for 2019 and the potential impact on health plan processes and bottom lines.


What new Star Ratings measures is CMS adding for 2019? 

CMS is adding the Statin Therapy for Patients with Cardiovascular Disease (SPC) measure to the Part C domain and the Statin Use in Persons with Diabetes (SUPD) measure to the Part D domain. Statin Therapy for Patients with Cardiovascular Disease is a HEDIS® measure developed by the National Committee for Quality Assurance (NCQA), while Statin Use in Persons with Diabetes is a Pharmacy Quality Alliance (PQA) measure. Therefore, plans may already be tracking their performance. Plans that track Part D measures through Cotiviti have been able to track their performance for this measure beginning this year (for calendar year 2017). 


What existing measures is CMS modifying? 

CMS is making these modifications to Part C and D measures: 

  • For the Medication Adherence for Hypertension and Diabetes measures (Part D), CMS will expand its data sources for identifying the end-stage renal disease (ESRD) exclusion. It plans to include ICD-10-CM codes found in both Part A and B claims, and the RxHCCs codes from the Risk Adjustment Processing System (RAPS).
  • For all three Medication Adherence measures (Part D), CMS is implementing a simpler approach to counting the discharge date in the Proportion of Days Covered adjustment.
  • For the Members Choosing to Leave the Plan measure (Parts C and D), CMS plans to expand the exclusions to include the plan benefit package service area reductions.

CMS also considered removing the Reducing the Risk of Falling measure (Part C). Based on feedback that removal could create the appearance that fall prevention is not important, however, it has decided to leave the measure in place and continue to include it in the Part C Health Plan Quality Improvement measure calculations. 


Another change to note is that CMS is including five new measures within the overall improvement measure: Improving Bladder Control, Medication Reconciliation Post-Discharge, Getting Appointments and Care Quickly, Customer Service, and Care Coordination. This could have a large impact on this very important five-weighted measure.


Is CMS dropping any measures? 

Yes. CMS is removing the Beneficiary Access and Performance Problems (BAPP) measure in both Part C and Part D. Although the agency received mixed responses—advocacy groups opposed removal while health plans supported removal—CMS will proceed to retire the current BAPP measure. A revised BAPP measure, including only Compliance Activity Module data (the CAM score will be the only deduction), will hit the display page for 2019. There is no official word yet on whether the original measure will be re-added in future years. 


Several parts of the United States were hit by severe natural disasters in 2017. Did that affect the Final Notice? 

Specifically noting the hurricanes that severely damaged Texas, Florida, and Puerto Rico, as well as wildfires in California, CMS is making a few more changes to the cut point and Reward Factor calculations due to the exclusion of plans impacted by these disasters in 2017. This could have a great impact on other plans if the cut points turn out to be dramatically different by excluding these plans.


In the past, CMS has automatically reduced a plan’s measure rating to one star if it determined that the measure data are “incomplete, biased, or erroneous.” However, it’s now implementing a new system called “scaled reductions.” Explain what this means, and how it will impact MA plans. 

The scaled reduction approach is good news for plans and impacts the four appeals measures. Rather than a one-size-fits-all approach that automatically reduces a plan to one star when CMS finds the data to be incomplete, biased, or erroneous, the plan’s Star Rating will be reduced one star at a time based on the degree of data accuracy. This means a plan with more missing Independent Review Entity (IRE) data will see a greater reduction than a plan with a lower degree of missing data. CMS plans to provide Medicare Advantage organizations with a preview of the data before the Star Ratings are finalized.


Remind us: when do Star Ratings get published?

CMS will publish the Star Ratings for each Medicare Advantage organization on October 11, 2018, based on the 2017 calendar year data, along with final technical notes for the 2019 Star Ratings.



HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).


Ashley McNairy
Ashley McNairy is an experienced senior product director supporting Cotiviti's Risk Adjustment, Quality and Stars, and Consumer Engagement solutions. Her primary responsibility is the successful delivery of our solutions, ensuring they address the most pressing challenges for HEDIS, Star Ratings, member engagement, and retrieval initiatives. Driven by her passion to see improvements in healthcare quality, Ashley takes pride in working with clients to improve their quality initiatives and enable better care for their members.

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