2023-07115.pdf

Comment: A commenter was concerned that measures with lower minimum denominator requirements would invalidate the HEI results. Response: The HEI reward methodology includes several steps to ensure the measure data used are reliable. A measure is only included for the HEI for a contract if the measure has a reliability of at least 0.7 when calculated for the subset of enrollees with SRFs in the contract with the specified SRF(s), and the contract meets the measure denominator requirement when the measure is calculated for only the enrollees with the specified SRF(s). In addition, if at least 25 percent of contracts are unable to meet these criteria, the measure will be excluded from the HEI. Comment: Some commenters requested more information about the HEI reward methodology and that CMS share data and simulations prior to implementing the HEI reward. A handful of commenters suggested including the HEI on the Star Ratings display page with the detailed methodology. A few commenters requested that the implementation of the HEI reward methodology be delayed to allow contracts more time to prepare. A commenter also requested that CMS provide data on DSNPs or other SNP types with a high proportion of LIS/DE or disabled individuals to demonstrate the effect of the HEI reward among these contracts compared to contracts with lower proportions of LIS/DE or disabled members. A commenter requested the expected measure-level performance thresholds for each of the thirds. Response: To prepare health plans for implementation of the HEI reward, CMS will calculate the HEI reward beginning with the 2024 Star Ratings and will share the results in confidential contract-level reports in HPMS. Contracts will have these data for 3 years prior to the HEI being implemented as part of the 2027 Star Ratings. Each sponsoring organization will be able to see its contract-level percentage of enrollees with the specified SRFs; whether each measure included in the HEI met the reliability and denominator criteria to be included in the HEI; whether contract performance was in the upper, middle, or lower third of performance for each measure included in the HEI; the HEI value; and the HEI reward for contracts that qualify. The performance thresholds for each of the thirds at the measure level will be dependent on the distributions of measure data for the measurement years of data being used to calculate the HEI reward for each Star Ratings year. This information will also be available in the HPMS reports. We will share the percentage of enrollees with the specified SRFs thresholds, including for Puerto Rico contracts. CMS will also share summary-level results by type of contract for informational purposes. CMS does not intend to display these results as display measures. Since the HEI is not a measure, we believe that sharing the information through HPMS will allow us to provide contracts with more detailed information about the HEI for their quality improvement efforts. Sections 422.164(c)(3) and (d)(2) and 423.184(c)(3) and (d)(2) require only new measures and measures with substantive specifications changes to be on the display page for two years prior being in the Star Ratings. Historically, we have not displayed methodological changes on the display page since it would be confusing to the public to have two sets of ratings, one on Medicare Plan Finder on www.medicare.gov and an alternative rating on cms.gov. In simulations using data from the 2021 Star Ratings, the percent of enrollees who have the specified SRFs for the HEI (that is LIS/DE/disability status) is 15 percent for MA and cost contracts and 5 percent for PDPs that do not meet the enrollment threshold to be eligible for a reward (that is, one-half of the contract-level enrollment median); 28 percent for MA and cost contracts and 10 percent for PDPs that meet one- half of the contract-level median up to but not including the median; and 61 percent for MA and cost contracts and 37 percent for PDPs that meet the median enrollment threshold. The percent of enrollees who are LIS/DE/ disabled is 42 percent for MA and cost contracts and 13 percent for PDP contracts that received an HEI reward (that is, met an enrollment threshold to be eligible for a reward and received an HEI score of greater than zero). Comment: A commenter requested more time so that regional plans would not be penalized for not having the minimum enrollment amount yet. Response: In simulations using data from the 2021 Star Ratings, many regional plans met the minimum percentage enrollment thresholds. No plans will be penalized by the HEI reward if they do not have enough enrollees to qualify for the reward since it is an upside only reward. Comment: Some commenters suggested the HEI should be a measure rather than a reward. Response: CMS believes including the HEI as a reward in place of the current reward factor will better incentivize MA, cost plan, and PDP contracts to perform well among enrollees with specified SRFs than if the HEI were included as a Star Ratings measure. The HEI reward is upside only and is focused on those contracts serving a disproportionate percentage of enrollees in underserved populations in order to incentivize high quality care for these populations. If the HEI was a measure, contracts could have their overall and summary ratings negatively impacted if they did not do well serving these enrollees because they would earn low measure-level Star Ratings on an HEI measure, which could bring down their overall and summary ratings. Additionally, contracts that serve a small percentage of enrollees with the specified SRFs may do well on a measure because they serve relatively few of these beneficiaries, making it easier for them to do well. Adding the HEI as a reward rather than a measure also allows for the methodology to include a performance threshold below which contracts will not be eligible for the HEI reward, which will incentivize improved performance by contracts for their enrollees with the specified SRFs and help reduce disparities. Comment: A commenter recommended that the HEI reward replace the CAI rather than the current reward factor. Another commenter stated that eliminating the reward factor and replacing it with the HEI reward while retaining the CAI would create a duplication in ratings and that plans may be penalized by having both the CAI and the HEI. Response: The HEI reward serves a different purpose than the CAI. The CAI is a data-driven approach to account for within-contract disparities in performance associated with SRFs in Star Ratings measures that are not already adjusted according to the measure specifications developed by measure stewards. As we stated in the April 2018 rule, the CAI accounts for VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00173 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222292 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations within-contract disparities and adjusts for those disparities in order to allow fair comparisons among contracts; it also addresses the sensitivity of the Star Ratings to the composition of the enrollees in a contract. The CAI is designed to improve the accuracy of performance measurement, while not masking true differences in performance between contracts; in contrast, the HEI reward is designed to create incentives to reduce disparities in care. The HEI, therefore, will not replace the CAI but rather will assist plan sponsors in better identifying and then addressing disparities in care provided to members with a particular SRF, with the ultimate goal of reaching equity in the level and quality of care provided to enrollees with SRFs. Neither the CAI nor the HEI reward penalize plans. The CAI adjusts for the within-contract differences in performance to create a level playing field across contracts, and the HEI reward is an upside only reward. Comment: A commenter stated continued support for the CAI and stated that they assume the CAI will continue to be implemented. Response: CMS appreciates the continued support for the CAI and, as stated in the proposed rule, CMS will continue to implement the CAI. Comment: A couple of commenters raised concerns that replacing the current reward factor with the HEI reward would dilute the effectiveness of the current quality incentive structure or not achieve CMSs goal of driving quality improvement and minimizing unintended consequences. A commenter stated that replacing the current reward factor with the HEI reward would risk undermining market competition and disincentivizing quality improvement investments. Response: CMS believes there is still an incentive within the current Star Ratings methodology for sponsoring organizations to invest in quality improvement. Any such investments will be reflected in high measure-level Star Ratings and higher improvement measure stars. Further, contracts can still do well on the Star Ratings and achieve the highest rating of 5 stars without receiving either the current reward factor or the HEI reward. CMSs goal is to continue to evolve the Star Ratings methodology over time to ensure that the methodology encourages continued improved plan performance across beneficiaries. Comment: One commenter stated that Star Ratings for high-performing contracts with a disproportionately high share of enrollees with SRFs could be adversely impacted with the addition of the HEI and removal of the reward factor. Another commenter stated that DSNP-only contracts are more adversely impacted by the removal of the reward factor. Another commenter requested that CMS study the impact of removing the reward factor on contracts with high LIS/DE/disabled enrollment. Response: In our simulations, we have not found that DSNP-only contracts or contracts that include DSNPs along with other MA plans will be more adversely impacted by the removal of the reward factor. In the 2023 Star Ratings, the reward factor was lower on average for both DSNP-only contracts and contracts offering any DSNPs compared to contracts without DSNPs. When the reward factor is removed in our simulations, 17 percent of contracts with any DSNPs have a decrease in overall Star Ratings versus 22 percent of all other contracts. This indicates that contracts with DSNPs are less impacted than other contracts by the removal of the reward factor. Comment: A commenter stated most plans at the 5-star level earn 5 stars due to the addition of the reward factor and that removal of the reward factor will result in many plans losing their 5-star rating. Response: While it is true that the reward factor bumps up some 4.5 star contracts to 5 stars, the replacement of the current reward factor with the HEI reward will provide contracts with additional opportunities for an upside reward. This means there are still opportunities for contracts to increase their Star Rating from 4.5 to 5 stars. Additionally, we note that there is nothing that would prevent a contract from still earning 5 stars even if it did not earn an HEI reward. Comment: A few commenters suggested alternatives to using the original reason for Medicare entitlement to identify enrollees who have a disability and are therefore included in the HEI as having a SRF. A commenter suggested using diagnoses in claims data. A commenter noted a need to expand the identification of enrollees with a disability beyond the original reason for entitlement and recommended CMS only allow the physician who is treating the patient to make the determination that the patient has become disabled after Medicare enrollment. A commenter recommended additional ways to identify enrollees with a disability in future years, including the HEDIS Advanced Illness and Frailty Exclusions and enrollee self- reported disability in Health Risk Assessments. The commenter also recommended CMS include additional fields to enrollment forms to collect information on disability. A commenter suggested CMS could explore using the disability definition under the Americans with Disabilities Act. Another commenter supported the proposed definition of disability and recommended limiting to this definition for consistency. Response: CMS appreciates these comments, and we will continue to evaluate how we could expand the ways we identify individuals who have a disability for purposes of calculating and applying the HEI reward and CAI. Any changes would need to be proposed through notice-and-comment rulemaking. Comment: A commenter suggested CMS compare disability eligibility data with the Medicare Current Beneficiary Survey (MCBS) to assess the gap in measuring disability under the current definition included in the HEI reward, which identifies individuals with a disability based on original reason for entitlement. Response: While looking at data from the MCBS would show some of the gap in our identification of enrollees with a disability using the original reason for entitlement compared to those enrollees who developed a disability after enrolling in Medicare, we would not be able to use data from the MCBS for the HEI reward. In order to include data on functional limitations in the HEI reward, we would need national data at the beneficiary level, which the MCBS does not provide. Comment: A few commenters stated that there were many changes proposed to the Star Ratings and recommended more incremental change. A commenter requested that CMS consider distributing the implementation of the proposed changes to the Star Ratings over the next three years. Response: As discussed in section I.B.1. of this final rule, not all of the proposed changes to the Star Ratings regulations in the December 2022 proposed rule are being finalized at this time. Also, as proposed and finalized, the HEI reward will be implemented beginning with the 2027 Star Ratings, whereas most of the other Star Ratings changes finalized in this rule will be implemented beginning with the 2026 Star Ratings. Comment: Some commenters raised concerns about the possibility that some plans may more heavily market to dually eligible enrollees in order to have them enroll in non-DSNP products, so that such plans may meet the threshold of having enough members to be eligible for the HEI reward, or that the HEI reward would discourage enrollment in DSNPs and Chronic Condition SNPs. Another commenter stated the HEI VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00174 Fmt 4701 Sfmt 4700