Quality departments within Medicare Advantage (MA) plans are poring over the newly released 2024 MA and Part D Advance Notice to determine how Star Ratings measures, weights, and cut points will change—and now must figure out the best strategy for addressing these updates. Here’s a quick summary of what’s on the horizon for the 2025 Star Ratings, which are based on the 2023 calendar year (CY 2023), as well as proposed changes for the 2026 Star Ratings (based on CY 2024).
Confirmed 2025 Star Ratings (CY 2023) changes
Here are the most significant changes the Centers for Medicare & Medicaid Services (CMS) has confirmed for the 2025 Star Ratings:
- The Plan All-Cause Readmissions (PCR) measure will increase in weight from 1x to 3x.
- The Breast Cancer Screening (BCS) measure will be moved from an administrative measure to an electronic clinical data systems (ECDS)-only measure, mirroring the change to the BCS HEDIS® measure.
- Previously optional exclusions for Controlling Blood Pressure (CBP), Colorectal Cancer Screening (COL), and Kidney Health Evaluation for Patients with Diabetes (KED) will now be required exclusions.
- Several changes to the frailty and advanced illness exclusion value sets will impact multiple measures.
- CMS plans to implement a web-based mode for CAHPS® surveys and wording clarifications in the 2024 CAHPS survey.
Proposed 2026 Star Ratings (CY 2024) changes
In the Contract Year 2024 Policy and Technical Changes to the Medicare Advantage Program document released in December 2022, CMS proposed to reduce the weight of patient experience/complaints and access measures from 4x to 2x for the 2026 Star Ratings. This would reverse the previous increase that was implemented for the 2023 Star Ratings, which led to these measures comprising 58% of a plan’s overall rating.
In announcing this change, the agency stated:
We still believe these measures focus on critical aspects of care such as care coordination and access to care from the perspective of enrollees, but taking into consideration additional stakeholder feedback we have received and the effect of the policy on the 2023 Star Ratings, we have reconsidered our position from the June 2020 final rule and now believe these measures currently receive an undue weight in the Star Ratings program.
Here are additional significant changes CMS proposes for the 2026 Star Ratings:
- The following measures would be moved from the display page to the Part D measure set:
- Concurrent Use of Opioids and Benzodiazepines (COB)
- Polypharmacy Use of Multiple Anticholinergic Medications in Older Adults (Poly-ACH)
- Polypharmacy Use of Multiple Central Nervous System Active Medications in Older Adults (Poly-CNS)
- The following measure and indicator would be added to the Part C measure set:
- Kidney Health Evaluation for Patients with Diabetes (KED)
- Care for Older Adults (COA) – Functional Status Assessment and Medication Review
- The National Committee for Quality Assurance (NCQA) is proposing non-substantial changes to the following HEDIS measures, which would be applied to Star Ratings as well:
- Breast Cancer Screening (BCS)
- Kidney Health Evaluation for Patients with Diabetes (KHE)
Recap of confirmed 2024 Star Ratings (CY 2022) changes
Here are a few quick reminders about confirmed changes to the 2024 Star Ratings, which will be publicly released in October 2023 following the plan preview in September.
- The Tukey outlier will be used for non-CAHPS measures to determine cut points.
- Controlling Blood Pressure (CBP) will increase in weight from 1x to 3x.
- The following measures will be added to the Part C program:
- Transitions of Care (TRC)
- Follow-up after Emergency Department Visit for Patients with Multiple Chronic Conditions (FMC)
- Medication Reconciliation Post Discharge (MRP) will be counted twice: once as a standalone measure using the Transitions of Care (TRC) numerator and also as part of the TRC measure average rating
- The Comprehensive Diabetes Care (CDC) – Medical Attention for Nephropathy indicator will be retired following its previous retirement from the HEDIS program
- Plan All-Cause Readmission (PCR) will return to the Part C program from the display page with a weight of 1x.
- While NCQA changed the Colorectal Cancer Screening (COL) measure to include members aged 45-75, the Star Ratings will continue reporting 50–75 through the 2024–2025 Star Ratings, then adjust to full age band.
- The RxHCC codes for identifying end stage renal disease (ESRD) in the Medication Adherence for Diabetes, Hypertension and Cholesterol (MAH) and Statin Use in Persons with Diabetes (SUPD) measures have been removed.
A “Universal Foundation” for quality measures
As the number of quality measure sets continues to grow, CMS is proposing what the agency calls a “Universal Foundation” of a core set of quality measures to be aligned across federal programs. This includes both several measures that are already part of the Star Ratings program as well as others not yet included. CMS explained:
Having this “Universal Foundation” will support efforts to ensure high quality care for the more than 150 million Americans covered by our programs and serve as an alignment standard for rest of the health care system. The “Universal Foundation” will 1) focus provider attention, 2) reduce provider burden, 3) allow for consistent stratification of measures to identify disparities in care, 4) accelerate the transition to interoperable, digital quality measures, and 5) allow for cross-comparisons across quality and value-based care programs, to better understand what drives quality and equity improvement and what does not.
The preliminary adult universal foundation measures that CMS proposes span several domains, including:
- Wellness and prevention
- Chronic conditions
- Behavioral health
- Seamless care coordination
- Person-centered care
When compliance changes like these are implemented, Cotiviti’s Star Intelligence solution is ready to help your organization track, model, and predict how they impact your Star Ratings with our configurability and flexibility. In fact, amid a widespread decline in Star Ratings across the industry, nearly 65% of Cotiviti’s Quality and Stars clients that were eligible to receive a 2023 Star Rating earned four stars or higher.
Watch our recent webinar and learn how Star Intelligence enables health plans to:
- Access a one-stop shop for HEDIS and Stars management
- Get a clear view of progress with trending and benchmarking dashboards
- Leverage analytics that offer measure prediction, EOY predictions, trends, and opportunities for growth
- Get reliable insights through predictive cut points built into advanced analytics
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
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