evekhm/cms_iom_500 huggingface dataset:
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were used as the threshold for qualifying for the HEI reward, this goal would not be met. Larger contracts might be able to meet a minimum number threshold even though they serve a relatively small number of enrollees with the specified SRFs compared to their total enrollment. This would make it easier for these contracts to do well among these enrollees. Additionally, based on current data, few contracts that do not meet the percentage of enrollees with the specified SRFs threshold serve a large number of LIS/DE/disabled enrollees. In simulations using data from the 2021 Star Ratings data, we see that, on average, 15 percent of enrollees are LIS/ DE/disabled in MA and cost contracts that do not meet the minimum percentage of LIS/DE/disabled enrollees to be eligible for the HEI reward; 5 percent of enrollees are LIS/DE/disabled in PDP contracts that do not meet the minimum percentage of LIS/DE/ disabled enrollees to be eligible for the HEI reward. Thus, most contracts that do not meet the percentage of enrollees with the specified SRFs threshold would also not meet a threshold based on a number of enrollees with the specified SRFs. Additionally, we note that contracts that serve a low percentage of LIS/DE/disabled enrollees tend to perform well in Star Ratings. Contracts are not penalized for not meeting the percentage of enrollees with the specified SRFs threshold. As the HEI reward only has an upside, we expect that these contracts will continue to perform well even if they do not qualify for the HEI reward. Contracts will still have the HEI score calculated and will be able to see how they perform on the HEI even if they do not meet the enrollment thresholds. 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. Comment: Some commenters stated it would be more challenging for employer group contracts to meet the proposed enrollment thresholds because this population is less likely to be LIS/DE or disabled, and that the HEI reward could undermine advances in health equity in these plans. A commenter recommended this could be addressed by using a total enrollment threshold rather than a percentage enrollment threshold. Another commenter suggested that enrollment in employer group plans be excluded from the determination of whether a contract meets the percentage enrollment
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health equity in these plans. A commenter recommended this could be addressed by using a total enrollment threshold rather than a percentage enrollment threshold. Another commenter suggested that enrollment in employer group plans be excluded from the determination of whether a contract meets the percentage enrollment thresholds. Response: CMS believes that since enrollees in employer group plans contribute to contracts performance scores, these enrollees also should contribute to the contracts enrollees with the specified SRFs percentage. While employer group plans on average enroll a smaller percentage of LIS/DE/ disabled enrollees than other plans, most contracts are a mix of different plan types, and contracts that include employer group plans may still meet the percentage enrollment thresholds we proposed and are finalizing for the HEI. In addition, contracts that serve a low percentage of LIS/DE/disabled enrollees tend to perform well in Star Ratings since they are serving a less vulnerable population. Contracts are not penalized for not meeting the percentage enrollment threshold. As the HEI reward only has an upside, we expect that these contracts will continue to perform well even if they do not qualify for the HEI reward. The HEI reward is structured so as to support our goals to avoid rewarding contracts that do not serve many enrollees with specified SRFs, making it easier for them to do well. For that reason, we are finalizing the HEI reward methodology such that contracts with employer groups plans will be treated like all other contracts. VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00171 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222290 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations 167We approximated the percentage of LIS/DE individuals enrolled in non-DSNP MA plans based on the number of LIS enrollees per PBP, as listed in the 2022 Low Income Subsidy Enrollment by Plan report: https://www.cms.gov/research- statistics-data-and-systemsstatistics-trends-and- reportsmcradvpartdenroldatalis-enrollment/2022- low-income-subsidy-enrollment-plan. Comment: Some
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statistics-data-and-systemsstatistics-trends-and- reportsmcradvpartdenroldatalis-enrollment/2022- low-income-subsidy-enrollment-plan. Comment: Some commenters raised various concerns around some contracts possibly having more difficulty meeting the percentage of enrollees with the specified SRFs threshold to qualify for the HEI reward, including contracts in states that require sponsors to establish separate contracts that only include dual eligible special needs plans (D SNPs). These commenters raised concerns that other MA organizations may be less likely to meet the threshold of enrollees with specified SRFs to qualify for an HEI reward. Response: There is currently a limited number of states that require MA organizations to have separate DSNP- only contracts under  422.107(e), and the provisions of  422.107(e) only apply when specific minimum conditions are met, including a requirement that DSNPs in the state have exclusively aligned enrollment with an affiliated Medicaid managed care organization and a requirement that DSNPs use certain materials that integrate Medicare and Medicaid content. Further, even in states that require MA organizations to have separate DSNP-only contracts, dually eligible individuals may still enroll in other MA organization contracts, and such contracts may still meet the minimum threshold of enrollees with SRFs (which includes not only LIS/DE individuals but also those with disability status). Based on our simulations, other contracts would meet the minimum percentage to qualify for an HEI reward in these States. We estimate that approximately 3 million LIS/DE individuals were enrolled in non-DSNP MA plans in 2022.167 Comment: A commenter raised a concern that the percentage of enrollees with the specified SRFs thresholds would make it difficult for plans to receive an HEI reward, as the percentage of members with SRFs falls under the national median for the majority of contracts. Response: Contracts may still qualify for half of the HEI reward if they have at least one-half the median and up to but not including the median percentage of enrollees with the specified SRFs. CMS believes one-half the median enrollment is a relatively low bar for a minimum enrollment threshold. In simulations using data from the 2021 Star Ratings, only 17 percent of MA and cost contracts and 11 percent of PDPs did not meet the one-half the median threshold.
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the median enrollment is a relatively low bar for a minimum enrollment threshold. In simulations using data from the 2021 Star Ratings, only 17 percent of MA and cost contracts and 11 percent of PDPs did not meet the one-half the median threshold. Comment: A couple of commenters recommended using one-half the median percentage of enrollees with the specified SRFs as the threshold to be eligible for the full HEI reward rather than the tiered threshold that uses both one-half the median and the median percentage of enrollees with the specified SRFs. Response: CMS believes the tiered threshold structure is more appropriate because it allows for a greater maximum HEI reward among contracts that have larger proportions of enrollees with the specified SRFs and smaller rewards for contracts with smaller proportions of enrollees with the specified SRFs. Comment: A commenter raised a concern that DSNP look-alikes may benefit more from the HEI reward because these plans are permitted to crosswalk members from these plans to other standard plans. Response: In order to qualify for the HEI reward, contracts must not only meet the minimum percentage of enrollees with the specified SRFs thresholds but also meet the minimum performance threshold. CMS adopted contracting limitations for DSNP look- alike plans at  422.514(d), which provides that starting with Contract Year 2023, CMS will not renew a contract for a MA planother than a SNPthat has actual enrollment in the January of the prior contract year of 80 percent or more of enrollees who are entitled to Medicaid, unless the MA plan has been active for less than one year and has enrollment of 200 or fewer individuals at the time of such determination. DSNP look-alikes have the opportunity to transition enrollees under  422.514(e). The number of D SNP look-alike plans is relatively small compared to the overall number of MA plans. For Contract Year 2022, there were 47 DSNP look-alike plans and for Contract Year 2023, there are 15 DSNP look-alike plans. While DSNP look- alikes do have the opportunity to transition membership under  422.514(e), we do not have reason to expect that DSNP look-alikes would benefit more from the HEI reward than other MA plans that transition membership using crosswalk authority at
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to transition membership under  422.514(e), we do not have reason to expect that DSNP look-alikes would benefit more from the HEI reward than other MA plans that transition membership using crosswalk authority at  422.530(b) or crosswalk exception authority at  422.530(c). Comment: A commenter recommended using regional or service area medians instead of national medians for the percentage enrollment thresholds. The commenter also recommended CMS conduct an assessment based on service areas to determine whether all contracts would have the ability to enroll a sufficient number of individuals in the target SRF groups. Response: We believe our proposed minimum percentage enrollment threshold of one-half the median percentage of contract-level enrollees with SRFs to qualify for the HEI reward is a relatively low bar and is intended to accommodate areas and circumstances that may make it more difficult to enroll individuals with the specified SRFs. Comment: A commenter stated the HEI reward would disqualify smaller contracts because of the percentage enrollment thresholds and that this would discourage the enrollment of beneficiaries with SRFs in smaller tailored plans that best meet their needs, such CSNPs. Response: The minimum enrollment thresholds are one of the ways in which we have designed the HEI reward to avoid rewarding large contracts over small contracts. If a total number, rather than a percentage, of enrollees were used as the threshold, this would disadvantage small contracts. In simulations using data from the 2021 Star Ratings, there were small contracts that met both tiers of the percentage enrollee thresholds, including contracts with fewer than 1,000 enrollees. The median contract size for contracts meeting the median percentage enrollee threshold in our simulations is 12,000 enrollees for MA and cost contracts and 14,000 for PDP contracts, the median contract size for contracts meeting the one-half median percentage enrollee threshold is 23,000 enrollees for MA and cost contracts and 26,000 for PDP contracts, and the median contract size for contracts with less than one-half the median is 20,000 enrollees for MA and cost contracts and 64,000 for PDP contracts. Setting the minimum enrollment percentage threshold at one- half the contract-level median is a relatively low bar. Additionally, we proposed and are finalizing using two years of data to calculate the HEI reward to allow smaller contracts to be reliably
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Setting the minimum enrollment percentage threshold at one- half the contract-level median is a relatively low bar. Additionally, we proposed and are finalizing using two years of data to calculate the HEI reward to allow smaller contracts to be reliably evaluated. Using two years of data increases the sample size when calculating the measure-level scores among the subset of enrollees with the specified SRFs and makes it more likely that smaller contracts can meet the criteria for a measure to be included in the calculation of the HEI score as described at  422.166(f)(3)(iv) and 423.186(f)(3)(iv). Comment: A commenter recommended that CMS not exclude contracts with less than 500 enrollees VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00172 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222291 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations from the HEI reward as proposed at  422.166(f)(vi) and 423.186(f)(vi). Response: In general, contracts with less than 500 enrollees are too small to have Star Ratings calculated because the data are not reliable. In general, the measure-level data for these contracts do not meet a reliability of 0.7. Contracts with less than 500 enrollees also often do not meet measure-level minimum denominator requirements. These issues are further exacerbated with the HEI since the HEI requires the calculation of measure-level scores for a subset of the contracts enrollees with the specified SRFs and, thus, these very small contracts do not meet the criteria in  422.166(f)(3)(iv) and 423.186(f)(3)(iv). 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
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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
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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
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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
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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