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Medicare Advantage Stars

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Background

The Centers for Medicare and Medicaid Services (CMS) rates Medicare Advantage plans and prescription drug plans separately on a scale of one to five stars, with five representing the highest quality. The Star Rating for Medicare Advantage plans is an overall measure of the plan's quality, and is a cumulative indicator of: quality of care, access to care, beneficiary satisfaction, customer service, and responsiveness to member needs. The intent of the program is to tie quality of care to financial reimbursements, whereby rewarding high performing plans and forcing low performing plans to exit the market.

The quality scores for Medicare Advantage plans are based on over 50 distinct individual measures that are derived from four sources:

  • Healthcare Effectiveness Data and Information Set (HEDIS®)
  • Consumer Assessment of Healthcare Providers and Systems (CAHPS®) program
  • Centers for Medicare and Medicaid Services (CMS)
  • Health Outcomes Survey (HOS)
2023 Medicare Advantage Primary Care Incentive Measure Table
Dynamic Measures
Hemoglobin A1c Control for Patients with Diabetes Controlling High Blood Pressure Medication Adherence For Cholesterol (Statins)
Medication Adherence For Diabetes Medication Medication Adherence For Hypertension (RASA) Plan All-Cause Readmissions
Static Measures
Annual Wellness and Initial Preventive Physical Rate Breast Cancer Screening Colorectal Cancer Screening

Eye Exam for Patients with Diabetes

 Follow-Up After Emergency Department Visit For Patients With Multiple Chronic Conditions Medication Therapy Management
Patient Engagement After Inpatient Discharge Osteoporosis Management in Women Who Had a Fracture Screening For Future Fall Risk
Statin Therapy For Patients With Cardiovascular Disease Statin Use in Persons With Diabetes TRC Medication Reconciliation Post Discharge

 

General References & Resources

Masthead Measures Reference Guide

Wellness Rewards for Members

Understanding Formulary Restrictions & Requesting Authorization

Vendor Partners
Last updated on 6/9/2023 2:51:04 PM

 

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Highmark Blue Cross Blue Shield serves the 29 counties of western Pennsylvania and 13 counties of northeastern Pennsylvania. Highmark Blue Shield serves the 21 counties of central Pennsylvania and also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Blue Cross Blue Shield West Virginia serves the state of West Virginia plus Washington County. Highmark Blue Cross Blue Shield Delaware serves the state of Delaware. Highmark Western and Northeastern New York Inc., serves eight counties in Western New York under the trade name Highmark Blue Cross Blue Shield of Western New York and serves 13 counties in Northeastern New York under the trade name Highmark Blue Shield of Northeastern New York. Each of these companies is an independent licensee of the Blue Cross Blue Shield Association. Blue Cross, Blue Shield and the Blue Cross and Blue Shield symbols are registered marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield companies. All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration.