On December 14, 2022, CMS released policy and technical changes through a proposed rule for the Contract Year (CY) 2024, to be officially published on December 27, 2022. One notable and significant change includes reducing weight across patient experience measures for the Star Ratings program from 4 to 2. We’ll cover this in more detail, along with 4 other crucial aspects that you’ll want to know about.  

1. Strengthening Quality: Star Ratings Program

What:

CMS has proposed reducing the weight across patient experience/complaints from 4 to 2 for 2026 Stars Ratings, along with several other key proposed measure removals, updates, and additions.  

Why:

While CMS agrees that these measures still play a crucial role in reflecting patient voice and experience of care, CMS wants to align the Stars program with their Quality Strategy—fostering a healthcare system that promotes quality health outcomes, safety, equity, and accessibility.  

What To Do:

Accounting for 58% of the overall 2023 Star Ratings, patient experience would decrease to 41% of the overall 2024 rating for the proposed change in measure weight. The proposed change would refocus plans to prioritize health outcomes, screenings, and preventive care while doing so in a manner that balances patient experience within the journey.

With the refocus on member health outcomes, a good place to start is to ensure members receive annual wellness visits (AWVs) because they’ve been proven to help drive other health actions, including breast cancer or colorectal screenings.  

An analysis of CMS’ 2023 Medicare Advantage and Part D Star Ratings Fact Sheet shows that the national average measure scores for breast cancer and colorectal screenings declined YOY following the COVID-19 PHE. With roughly 70% of Medicare members and 81% of Medicaid members completing an AWV before completing any other high-value activity, AWVs are an untapped resource that can positively impact overall quality scores, risk adjustment, and member satisfaction for plans. 

In addition, getting data-driven insights from members—through mock surveys and other tools—will be critical to prioritize operational and member experience improvements that directly impact plan performance.  

Here is a quick hit summary of the proposed measure removals, updates, and additions:  

Proposed Measure Updates Summary

Proposed Measure Removals Diabetes Care – Kidney Disease Monitoring (Part C)

Medication Reconciliation Post-Discharge (Part C) 
Proposed Measure Updates Colorectal Cancer Screening (Part C) 
– Expand age range to include 45-49,bringing the total age range to 45-75 

Medication Therapy Management (Part D)  
– Expand eligibility criteria to include all 10 core chronic diseases 

Care For Older Adults—Functional Status Assessment (Part C) 
– Proposal to add back to 2026 Star Ratings 

Medication Adherence for Diabetes, Hypertension, & Cholesterol (Part D) 
– Implement risk adjustment based on SDS 
Proposed Measure Additions Kidney Health Evaluation for Patients with Diabetes (Part C) 

Concurrent Use Opioids & Benzos (COB) (Part D) 

Polypharmacy Use of Multiple Anticholinergic Medications in Older Adults (Poly-ACH) (Part D) 

Polypharmacy Use of Multiple Central Nervous System Active Medications in Older Adults (Poly-CNS) (Part D) 

More details on these proposed measure updates can be found on pages 518 – 539 of the proposed rule

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2. Advancing Health Equity: Digital Health Literacy & HEI

Addressing digital health literacy—the superdeterminant of health.

What:

CMS proposes that MA organizations develop and maintain procedures to identify and offer digital health education to enrollees with low digital health literacy to assist with accessing any medically necessary covered telehealth benefits. 

Why:

Telehealth has always been critical, yet there is an assumption that everyone has access. For populations experiencing health disparities, additional barriers, such as reduced digital literacy, continue to worsen care gaps.  

What To Do:

80% of low-income households that qualify for reduced-rate broadband access don’t realize it.  

The good news is that Icario’s Digital Bridge Program is designed to promote digital access by connecting members to devices, broadband access, digital support, and education services. By providing information to members on the availability of free or low-cost devices, broadband internet service, hotspots, and the education and technical support they need to use these tools to close gaps in care, plans can help address this major social determinant of health. Additionally, connecting members to digital resources helps combat loneliness and promote connection. 

Further Reading: Beginning in 2024, D-SNP HRAs will require screening for food, house, and transportation as part of the 2023 Final Rule. See how one plan increased their HRA completions by 2x+.  

HEI incentive structure addresses health disparities.

What:

To advance health equity, CMS has put forward efforts in the Stars program through the Health Equity Index (HEI) incentive structure that rewards plans for specific measure-level scores for members with specific social risk factors (SRFs), such as receiving a low-income subsidy (LIS), being dually eligible, or having a disability.  

Why:

While not deemed a Star measure, the HEI reward incentive structure would be geared to specifically address health disparities within care of an MA plan’s membership. The proposed rule suggests the HEI reward structure begins for 2027 Star Ratings, leveraging data from measurement years 2024 and 2025. 

For certain current Star Ratings measures, it may be more difficult for most plans to achieve the same level of care for groups that experience social determinants of health (SDoH), including lack of transportation, lower health literacy, communication challenges, and housing instability.  

The proposed rule aims to eliminate health disparities in plan performance by SRFs, consistent with CMS efforts to advance health equity. 

What To Do:

Table 5 is a high-level summary of the steps CMS is proposing to take to calculate the HEI. 

Table 5: Steps To Calculate The HEI

Steps
High-Level Description of Steps to Calculate the HEI
Step 1
Measure-level scores for each measure included in the HEI are calculated for each contract using data from the two most recent measurement years based on enrollees with the specified SRFs using a modeling approach that accounts for year.
Step 2
Measures that are case-mix adjusted in the Star Ratings would employ all standard case-mix adjustors except for adjusters that are the same as the SRFs included in the HEI, are strongly correlated with the included SRFs, or are conceptually similar to the included SRFs.
Step 3
A contract would need to meet the reliability and minimum denominator criteria for at least half of the measures included in the HEI based on data from the two most recent measurement years and have at least 500 enrollees at the contract level in the most recent measurement year to have the HEI calculated.
Step 4
For each measure using all contract-level scores calculated in Step 1/Step 2 that have at least 0.7 reliability and meet the minimum denominator criteria, points would be assigned as follows: 1 point to those contracts that score in the top third of all contracts, 0 points to those that score in the middle third of all contracts, and 1 negative point to those that score in the bottom third of all contracts.
Step 5
For each contract, the HEI would be calculated as the weighted average of the points assigned in Step 4 using the Star Ratings measure weights and including only measures for which the contract met all inclusion criteria.

The full breakdown of HEI proposals, calculations, and reward structure can be found on pages 549 – 566. 

3. Expanding Coverage: Language Accessibility 

What:

The proposed rule suggests plans must provide ongoing materials in all languages spoken by 5% or more of their served population by delivering fully translated materials or offering an equivalent experience in a different manner. It suggests once a plan learns of an enrollee’s preferred language, whether through an individual request, health risk assessment (HRA), or an additional member touchpoint, the plan must provide required materials in that identified language as long as the enrollee: 1) remains with the plan, or 2) requests another language.  

Why:

CMS noticed two things:  

  1. Across dually eligible members, MA plan materials are not captured in a full suite of languages as compared to Medicaid managed care organizations (MCOs) 
  1. MA members have had to file separate requests to obtain materials in their preferred language

What To Do:

Numerous studies have tried to figure out why members leave health plans. One key reason that pops up regularly is dissatisfaction with the communication members receive from their plan. 

Personalizing healthcare is a proven way to boost Star Ratings and keep members engaged with your health plan. But more importantly, personalized outreach that leverages the right language can be one of the most effective ways to break down Social Determinants of Health (SDoH) barriers and move members who need it the most to take the right health actions. Furthermore, CMS also emphasizes the opportunity to reward members for updating their language preferences, as it promotes improved health and the efficient use of healthcare resources. 

Additionally, CMS is calling for this proposed rule to expand towards individualized care plans (ICPs) for Special Needs Plans (SNPs), showing their focus on breaking down language barriers in the healthcare experience.  

4. Cash Equivalent Clarification: Rewards & Incentives  

What:

CMS is looking to learn how MA plans interpret and implement the current R&I programs guidance and whether stakeholders believe further framework and definition around cash equivalents is needed. 

Why:

CMS is requesting continued feedback on rewards and incentives (R&I) “cash equivalent” rules in the MA program.  

Previously, the Office of Inspector General (OIG) had put forth in a December 2020 rule that “gift cards offered by large retailers or online vendors that sell a wide variety of items (e.g., big-box stores) could easily be diverted…we would consider such gift cards to be cash equivalents.” However, Icario believes that recent prohibitions on larger retailers such as Walmart and Target (and potentially others similar such as Dollar General, CVS, Home Depot, etc.) is in direct conflict with CMS’ strategic plan to address health equity. In addition, restricting access to a network of retailers disadvantages MA members without steady transportation, limited accessibility or mobility, or those that may be low income and reliant upon these rewards to help purchase necessities. 

What To Do:

To comply with the current rules while still providing members with easy access to benefits, including OTC medication, nutrition, hearing, fitness, and vision, plans are offering flexible benefits care cards to their members. These cards allow MA plans to tailor restrictions to meet specific program goals while offering members benefits and incentives via a retail network covering more than 62,000 locations—including those hardest to reach in most rural areas.  

A benefits care card ensures that plans comply with CMS guidelines while promoting improved member satisfaction by delivering a variety of plan benefits and compliant rewards on a single, easy-to-use card. The capability enables plans to encourage and incentivize healthy behaviors among members by offering them rewards that match the plan’s specific goals, including closing gaps in care.

5. Proposed Star Calculation Changes 

In addition to the previous 4 proposed rules, here is a quick hit of the proposed Stars calculation changes: 

  1. Removal of bi-directional guardrails caps, which restricts upward, and downward movement of a measure’s cut points compared to the prior year when determining measure-specific thresholds for CAHPS measures.  
    1. This significantly reduces the predictability of cut points and allows for better alignment to keep pace with industry-driven movements. Previously, guardrails in place ensured non-CAHPS measure’s cut points did not increase or decrease more than 5% from one year to the next. 
  1. Tukey Outlier deletion was instated. Prior modeling from CMS shows outliers are more common in the lower end leading to 1- or 2-star thresholds often being bumped higher. 
    1. Lower Star Ratings would reduce bonus payments, rebates, and supplemental benefits offered to beneficiaries. For plans serving the most vulnerable, lower bonuses and rebate dollars could make it even harder to address disparities. At the high end of the spectrum, this may also raise the 4- and 5-Star cut points. 
  1. Modifying the Improvement Measure to only apply for 5-star plans may drag down performance for others.  
    1. If this protection is removed, the improvement measures can once again drag down the ratings of plans with lower Star Ratings. 
  1. Proposal for removal of Star Ratings measures when a measure steward other than CMS (such as NCQA or PQA) retires the measure.  
    1. This proposal will allow CMS to respond more quickly to measure removals by external measure stewards to ensure that measures included in Star Ratings are clinically meaningful, reliable, and up to date. 
    2. For example, when a measure steward such as NCQA retires a measure, they go through a process that includes extensive review by their various measurement panels. In addition, they solicit public comment regarding proposed measure retirements, so health plans, purchasers, consumers, and other stakeholders can weigh in on the relevance and scientific soundness of any changes to the HEDIS measurement set. 
  1. Remove the 60 percent rule that is part of the adjustment for extreme and uncontrollable circumstances, as the Tukey outlier deletion to alleviate the impact of any extreme outliers. 

The proposed rules highlight CMS’ focus on its strategic pillars: advancing health equity, expanding coverage, and improving health outcomes. Looking ahead into next year, comments are due on the above details, among others, by February 13, 2023. Sign up for CMS News Alerts, as Icario will issue a summary of the 2024 Advanced Notice that will drop in early 2023.