Good Neighbor Insurance, dev.gninsurance.com, provides Medicare Supplement insurance plans for seniors here in Arizona. We also recommend Health Net’s Medicare Advantage plan at dev.gninsurance.com/medicare-advantage.asp.
The Five-Star Quality Rating System for Medicare Advantage Plans is a system operated by the Centers for Medicare and Medicaid Services (CMS) to provide Medicare members with a clear, easy-to understand measurement system to compare the relative quality of plans they are able to purchase.
The rating system also aims to serve as a cost control mechanism for federal Medicare spending, as there are financial incentives contingent upon a plan’s “Star” rating as established in the Patient Protection and Affordable Care Act of 2010 (PPACA). Under the rating system, contracts which meet the criteria specified by CMS are awarded a ranking of between 1- and 5-Stars for quality ratings ranging from “Poor” (1- Star) to “Excellent” (5-Stars). Since ratings are awarded at the contract level, they apply to all plans offered under that contract.
Why Star Ratings Matter
The most significant benefit plans MA can derive from the system is reserved for those which qualify for an “Excellent” rating. Upon attainment, this quality level empowers plans with the ability to enroll Medicare members outside of the traditional Annual Enrollment Period running from October 15th to December 7th.
Medicare members are allowed to make one special election to a 5-Star plan per year, with no restrictions on the time of year they would have to do so. Other applicable Special Election Periods are still reserved to the member in the event of a change made under the 5-Star provision. Even if a plan hasn’t qualified for an “Excellent” rating – and very few at this point have – there are still incentives for plans to achieve a higher rating, and these incentives can translate into better experiences for plan members.
Under PPACA, and as accelerated in specified counties by a CMS demonstration program, plans with 3-Star ratings (as per the CMS demonstration program) or higher (as per PPACA) are eligible for additional payment bonuses in 2012 and beyond to reinvest into plan quality measures or benefits, giving the recipient the ability to attract more members relative to their competition and increase their rating for the next plan year.
How Star Ratings Are Measured
Medicare Advantage plans are rated based on how well they perform across five different categories, with each category being comprised of measures that account for patient experiences and satisfaction, access to care, processes of care, and outcomes of treatment. The information that is used to evaluate each of the measures in a category is derived from surveys, carrier enrollment statistics, member complaints, and a host of outcome- based metrics.
The five categories that CMS uses to determine the overall rating for Medicare Advantage plans are: Staying Healthy: Screenings, Test & Vaccines, Managing Chronic Conditions, Plan Responsiveness and Care, Member Complaints, and Health Plan Customer Service.
Part D plans are evaluated on four measures: Drug Plan Customer Service, Member Complaints, Member Experience, and Drug Pricing and Patient Safety.