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CMS Star Ratings: Navigating changes in 2021 and the coming years


CMS Star Ratings: Navigating changes in 2021 and the coming years

As many health plans know, achieving a higher Star Rating will soon be more challenging. The Centers for Medicare & Medicaid Services (CMS) is changing the makeup of the rating system, with two changes to patient experience weighting set to take place in 2021 and 2023, respectively. For 2021 Star Ratings, CMS has increased the relative weighting of patient experience measures from 1.5 to 2. And for 2023 Star Ratings, CMS will increase the weight of patient experience measures from 2 to 4. How will these CMS Star Rating changes affect health plans, and how can they best prepare for them?

In the past, health plans could see a 4-star rating that only focused on HEDIS® and Part D adherence. But by 2023, member experience will make up 57% of the total Star Rating. To ensure a solid rating in adherence with these new changes, health plans will now be tasked with creating a strategy to tackle these new measures, collaborating with all who are involved in their Star Ratings program. As such, they need to assemble a success team made up of the right people, identify strengths and weaknesses in the member experience, and create objectives that translate into corporate goals.

Once a strong team is assembled, health plans should reexamine the patient experience by starting with the member journey and consider members’ experience in interacting with the plan.
The health plan member journey
Figure 1: Sample member journey.

Take a look as we line up each step of the member journey—and how health plans can optimize it to improve the member experience.


Enrollment is a significant first step for members—and it’s up to health plans to be clear about benefits from the beginning. Members should be able to understand and navigate new plans with ease. After all, when members don’t know or understand their benefits, they’re less likely to seek care. Plans should empower members to get a grasp of every benefit on their plan and how to use it. For example, when members are aware of how to access prior authorization, they can know up front what is necessary for treatment, rather than getting an emotional surprise after the fact.

Understanding plan details should extend to sales agents and brokers as well, ensuring that they know which plan is ideal for each member. Any changes made should be communicated quickly and coherently. And in keeping with updates due to COVID-19, anything related to premiums, deductibles, and benefits should be accessible to members right away.


As the saying goes, “you never get a second chance to make a first impression.” Onboarding is the first impression that a member has with their new health plan, and they should be able to navigate it effortlessly. Consider how to concisely educate members on what benefits are available to them and what kind of value they can attain. Whether the onboarding experience is with an associate or through an online portal, the member experience should be seamless and easily navigable.

As part of the process, make sure that each member completes a health risk assessment to help with the construction of their member profile. The profile gives health plans an idea of the best way to contact each member, information for constructing personalized communications, and the member’s preferred level of engagement. It’s worth investing in technology to improve this experience using incentives to help engage members on their care. The more engaged they are, the more the health plan can educate members on how they can use their plan to their benefit.

Keeping COVID-19 in mind, communications surrounding the global pandemic are crucial. Members may be more isolated and less social, avoiding preventative care, and concerned about their own wellbeing as well as that of their friends and family. Consider what members are going through and personalize communications to reflect their concerns and support them throughout this time.

Accessing care

During the phase of accessing care, members need continuous engagement. The thing to keep in mind is to prioritize needs, not gaps. For example, a need might be transportation, rather than the gap, in getting a doctor’s appointment. For this member, an in-home assessment might be better to address their need and close the gap with a telehealth appointment. For a reminder of their preferences, revisit their original member profile and reduce duplicative tasks. Focus areas should include: optimizing telehealth options, performing member outreach, and collaborating with providers.

Telehealth options

Providing telehealth outreach is key for members, old and new. Even existing members might need a reminder that summarizes what telehealth options exist, how they work, and what they cost. And health plans should consider all items that can be addressed via telehealth visits, such as:

  • Prescription refills
  • Ordering future screenings
  • Assessments that can be done via telehealth
  • Medical recommendations post discharge
  • Pain screenings
  • Depression screenings

Health plans should urge members to remember their annual wellness exams and in-home assessments. And while reaching all members may be unrealistic, be sure to target members with a high return for both quality and risk.

Member outreach

Member outreach is crucial to improving Star Ratings, especially as CMS makes the shift to prioritizing the patient experience. For instance, medication adherence will continue to be a large part of Star Ratings—18 of the 45 measures (40%) are related to medication behavior. Health plans should examine medication adherence among members and consider interviewing them to understand barriers.

Another way to get into the mindset of the member is through CAHPS® (Consumer Assessment of Healthcare Providers and Systems) measures. Health plans should start proxy CAHPS measures immediately and consider new options for conducting surveys. For examples, 70% of seniors are now online, allowing surveys to be conducted digitally rather than via mail. For those who can’t be reached online, surveys could simply be two or three questions conducted via phone call, offering gift cards or free merchandise for participation. Ensure that results are distributed throughout staff and providers, so that all are involved in improving metrics and have actionable insights to guide focus.

Provider collaboration

If planning to incentivize providers, consider working with groups that are more willing to engage and place an emphasis on concrete member experience measures over process measures. Provide monthly scorecards so provider groups know how they’re performing in specific measures. Consider what training is needed for them to ensure a positive members experience, and train them consistently to cover any staff turnover within offices. Remind providers that member experience is felt more often in the waiting area or with the provider, and the different CAHPS questions that they should consider. For example, one specific question asks members if they saw their provider within 15 minutes of the appointment time; another example is a section on “care coordination,” which asks if their provider had their medical history, the timing of results from lab tests, and the quality of care from specialists.

Contacting the plan

Members should have a seamless experience when contacting their health plan. Make sure to understand every touchpoint that the member has with the heath plan and ask how it can be improved. Consider how to thread daily interactions together to streamline communications and set up personalized models of experience tailored to different member groups.

One example is a concierge call center. Educating staff on the importance of these phone calls is crucial, as they can have a direct effect on the impact of different appeals or complaints that come through. But for each form of communication, try to find the middle ground between contacting the member too much and not enough.


Despite your best efforts, sometimes members will disenroll from your plan. In the event that this happens, make sure to get as much intel as possible behind their reason for leaving. Ask:

  • Was it a change in healthcare needs?
  • Was it cost-related?
  • Did they require a higher or lower benefit range?

This information can help identify larger issues and adapt to fit member expectations.

As health plans build their comprehensive Star Ratings strategy, they should consider this entire member experience. As ratings shift to focus more on patient experience, keeping members satisfied, engaged, and aware of the nuances and benefits included in each plan will become key. Consider how to keep up with these expectations, and to sustain member wellbeing throughout their experience with the plan.

Keep up with changes to Star Ratings criteria

Curious about the other Star Ratings changes that are currently in the works? Download our calendar to see what health plans can anticipate.

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

About the Author

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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