Quality Measures and the Role of CBOs: 

Part 2: STAR Ratings 

Tim McNeill, RN, MPH 
Agenda 

1. Star Ratings Overview 

2. Target Population 

3. How to Analyze Star Rating Data 

4. How to Apply Star Rating Data 
What Are STAR Measures? 

3 

• The CMS administers the Star Ratings program to 

provide beneficiaries with an objective measure to 

compare plans 

• Health Plan Star Ratings are publicly available 

• The Star Ratings program provides incentives to health 

plans to improve the quality of services rendered to 

beneficiaries 
Who are covered under the Star 

Ratings? 

4 

• The CMS administers the Star Rating program for 

Medicare Advantage plans 

• The CMS defines Medicare Advantage plans as the 

following: 

– A Type of Medicare health plan offered by a private 

company that contracts with Medicare to provide all Part A 

and Part B benefits. 
Types of Medicare Advantage Plans 

5 

• There are four (4) types of Medicare Advantage Plans 

– Health Maintenance Organization (HMO) Plans 

– Preferred Provider Organization (PPO) Plans 

– Private Fee-for Services (PFFS) Plans 

– Special Needs Plans (SNPs) 
Health Maintenance Org Plan 

6 

• As a member in a HMO plan, a beneficiary is limited to 

the doctors, providers, and hospitals that are in the 

HMO network. 

• Generally, beneficiaries can only receive care from an 

out-of-network provider in the case of an emergency. 
Preferred Provider Org (PPO) Plan 

7 

• With a PPO, the beneficiary has the option of 

seeing doctors, providers, and hospitals in the 

plan network for a reduced cost 

• If the beneficiary chooses to go out of network, 

they can choose this option for a higher cost 

• Key difference is that the plan provides greater 

flexibility to go to providers that aren’t part of 

the plan’s network
Private Fee-for-Service (PFFS) Plans 

8 

• Medicare Advantage plan that is offered by a 

private insurance company 

• The plan determines the amount they will pay 

doctors and providers and how much the 

beneficiary must pay when they get care 
Special Needs Plan (SNP) 

9 

• A type of Medicare Advantage Plan that is limited to 

people with specific diseases or characteristics particular

to a target population. 

• Types of SNPs 

– Chronic Condition SNP (C-SNP) 

– Institutional SNP (I-SNP) 

– Dual Eligible SNP (D-SNP) 
What population is eligible for MA 

Plan enrollment 

10

• People 65 or older 

• People under 65 with certain disabilities 

• MA Plan population identifiers 

– Low-Income Subsidy (LIS) 

– Dual Eligible (DE) 
Population Enrolled in a MA Plan 

11
What is the Purpose of Star 

Ratings? 

12

• Provides an Objective measure for a consumer to 

compare health plans, as it relates to quality 

• Provides an incentive for health plans to improve on 

defined quality measures to improve outcomes for 

enrolled beneficiaries 

• Allows a mechanism for plans that meet high quality 

measures to achieve financial rewards for 

performance. 
Why are MA Plans concerned about 

Low Star ratings 

13

• Beginning in 2016, MA Plans that achieve less than a 

three-star rating for three consecutive years will be 

issued a notice of non-renewal of the contract for the 

following year (Termination). 
Why are MA Plans concerned about 

Star ratings (cont.) 

14

• Plans with a five-star rating have the advantage of year 

round enrollment. Plans with less than a five-star 

rating are limited to the open-enrollment period 

– Non-5-Star Plan 

• Open Enrollment Period 

• October 15 – December 7 

– 5-Star Plan 

• Open Enrollment 

• 5-star special enrollment period 
5-Star special enrollment period 

15

• An eligible beneficiary can switch to a 5-Star MA plan 

(one time) from December 8 – November 30 

– Tremendous Advantage 

– Allows a Plan to begin becoming the dominant plan in a 

defined market 

• 5-Star plans essentially have open enrollment year long 

while other plans are limited to the open enrollment 

period of Oct – Dec. 
Star Rating Calculations 

16

• MA Star Ratings are calculated based on data from five 

sources: 

– HEDIS 

– CAHPS (Consumer Assessment of Healthcare Providers and 

Systems) 

– HOS (Health Outcomes Survey) 

– CSM administrative data support measures such as call center 

performance, volume of complaints, and beneficiary 

disenrollment 

– Part D measures 
Public Release of Star Ratings 

17

• Star Ratings are released each October, before the 

open enrollment period. 

• Star Ratings can be found on the Medicare Advantage

Plan compare website 

• https://www.medicare.gov/find-aplan/questions/home.aspx# 
MA Plan Compare Website 

18
Star Rating Domains 

• MA Plans are given a summary Star Rating based 

on their performance in one of five domains 

– Use of Screenings, tests, and vaccines 

– Management of chronic conditions 

– Member experience (CAHPS) 

– Member complaints 

– Customer service/appeals 
2016 Part C & D Star Rating 

Measures (Select) 

Measure Data Source Weight

Care for Older Adults – Medication HEDIS

Review

Care for Older Adults – Functional Status HEDIS

Assessment

Reducing the Risk of Falling HEDIS/HOS

Plan All-Cause Readmissions HEDIS

Care Coordination CAHPS

Medication Adherence for Diabetes PDP plan 

Medications reporting

Medication Therapy Mgmt completion PDP Reporting

rate for Comprehensive Medication 

Reviews

1

1

1

3

1.5

3

1
Socioeconomic Factors impact 

on Stars 

• The CMS has authorized an external analysis of the 

impact of socioeconomic factors on quality measures 

• Study is the result of MA Plan complaints that 

socioeconomic factors negatively impact their ability 

to improve quality measures 

• Target population 

– LIS: Low-Income Subsidy 

– DE: Dual Eligibles 
Socioeconomic study outcomes 

• Preliminary data has been mixed 

• Some factors show worse outcomes for LIS/DE 

populations 

• Some factors actually show that LIS/DE populations 

had better outcomes than the general population 

• Additional studies will be done 
Domain: Staying Healthy: 

Screenings, Test, and Vaccines 

• C01 - Breast Cancer Screening. 

• C02 - Colorectal Cancer Screening. 

• C03 - Annual Flu Vaccine. 

• C04 - Improving or Maintaining Physical 

Health. 

• C05 - Improving or Maintaining Mental 

Health. 

• C06 - Monitoring Physical Activity. 

• C07 - Adult BMI Assessment. 
Managing Chronic (Long Term) 

Conditions 

• C08 - SNP Care Management. 

• C09 - Care for Older Adults – Medication Review. 

• C10 - Care for Older Adults – Functional Status Assessment. 

• C11 - Care for Older Adults – Pain Screening. 

• C12 - Osteoporosis Management in Women who had a Fracture. 

• C13 - Diabetes Care – Eye Exam. 

• C14 - Diabetes Care – Kidney Disease Monitoring. 

• C15 - Diabetes Care – Blood Sugar Controlled. 

• C16 - Controlling Blood Pressure. 

• C17 - Rheumatoid Arthritis Management. 

• C18 - Reducing the Risk of Falling. 

• C19 - Plan All-Cause Readmissions. 
Member Experience with Health 

Plan 

• C20 - Getting Needed Care. 

• C21 - Getting Appointments and Care 

Quickly. 

• C22 - Customer Service. 

• C23 - Rating of Health Care Quality. 

• C24 - Rating of Health Plan. 

• C25 - Care Coordination. 
Drug Safety and Accuracy of Drug 

Pricing 

• D10 - MPF Price Accuracy. 

• D11 - High Risk Medication. 

• D12 - Medication Adherence for Diabetes Medications. 

• D13 - Medication Adherence for Hypertension (RAS 

Antagonists). 

• D14 - Medication Adherence for Cholesterol (Statins). 

• D15 - MTM Program Completion Rate for CMR. 
Analysis of Star Ratings 

• Average Star Ratings are available for each category 

• A comparison of a health plan in your area by average star 

rating provides tangible market data 
All-Cause Readmissions 

28

• 30-day readmission 

• Numerator Description 

– At least one acute readmission for any diagnosis within 30 days of 

the Index Discharge Date minus planned readmissions 

– “What are examples of planned readmissions?”

• Denominator Description 

– Acute inpatient discharges for commercial members 18 to 64 years 

of age and Medicare members 18 years of age and older as of the 

Index Discharge Date who had one or more discharges on or 

between January 1 and December 1 of the measurement year 
Average Star Rating 

29
Sample Analysis: All-Cause 

Readmissions 

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• Average Star Rating 

– 2012 

• 3.3 

– 2013 

• 3.0 

– 2014 

• 3.5 

– 2015 

• 3.0 
Data on Star Ratings 

31

• CMS provides data on Plan Star Ratings 

• Access the Following website 

• https://www.cms.gov/Medicare/Prescription-DrugCoverage/PrescriptionDrugCovGenIn/PerformanceData.

html 
All-Cause Readmissions (continued) 

32
33
34
Data Review Tips 

35

• Low Performing Plans 

• Individual Star Ratings by category for select plans 

• Data provided in a CSV file that will convert to a Excel file 

– Sort the file based on the desired measure you want to address 

– Sort the category from lowest to largest in the select category 

to provide a list of those plans with the worst performance 

– Remember that plans that consistently score a 3 or worse for 

three consecutive years will be issued a notice of non-renewal 
Value Proposition (Part 1) 

36

• Identify the risk that your potential customer has (financial and 

quality). 

• Determine the penetration of the customer in the market. 

• Determine the types of beneficiaries served by the customer and 

list all of the challenges faced by this target population. 

• Assess how your service addresses the customer’s risk.

• Determine the level of access that you have to the target 

population. (Can you effectively reach their target population)? 
Value Proposition (Part 2) 

37

• Determine if there is a subset of the population served by the 

customer, that you could have the most impact in serving (e.g. If 

contracting with a Medicaid Managed Care plan that serves 

pregnant women and duals, you will want to segment your 

services to the Dual-eligible Medicaid beneficiaries). 
Value Proposition (Part 3) 

38

• Document how your program will complete the following: 

– Reach the target population 

– Provide services to the target population 

– Document the effectiveness of your program for the individual 

and the population served 

– Track the Return on Investment (ROI) obtained by buying 

your services 

– Provide continuous quality improvement 

– Deliver regular data to the customer to show the impact of 

your program at the individual an aggregate level 
MCO Contracting Checklist 

39

• Do you know how the MA plan fared on the Medical Loss Ratio

requirement for the prior year? 

• Do you know what the MA plan spent on hospital readmission 

activities last year? 

• Do you know what the competitor MA plan spent on hospital 

readmission activities last year? 

• Do you know how the MA plan performed on their HEDIS and 

STAR Ratings performance card? 
MCO Contracting Checklist (cont.) 

40

• Does the MA plan currently have beneficiaries that admit to the 

hospital where your program provides services? 

• Does the MA plan have bundled payment contracts or valuebased payment arrangements with the hospital where your 

program operates? 

• Is our data collection process HIPAA compliant? 
Questions 

• Tim McNeill, RN, MPH 

• ACL/AoA Consultant 

– Phone: (202) 344-5465

– E-mail: tmcneill@me.com