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The Centers for Medicare and Medicaid Services (CMS) is working with Medicare Advantage Plans, like Florida Blue, by using a Star rating program that helps us better care for and serve our Medicare Advantage and Medicare Part D plan members. The Medicare Star rating program measures how well plans perform based on a cross section of quality metrics including clinical, pharmacy, member satisfaction with their plan (as well as their provider), health outcomes, and plan operations.
Click on the links below for details.
- Quality Metrics Categories and How They are Measured
Quality metrics categories
Medicare Advantage health plans are rated on how well they perform in the following five categories. The 50+ quality metrics are divided into the following categories:
- Category 1: Staying healthy. Evaluates how often members receive screening tests, vaccines, checkups, and other preventive services to help them stay healthy.
- Category 2: Managing chronic (long-term) conditions. Evaluates how effectively health plans help members manage certain conditions, and receive recommended tests and treatments, with a focus on diabetes and medication management.
- Category 3: Member satisfaction. Evaluates the member experience with their health plan and how they feel about the quality of care they receive from the health plan and their providers.
- Category 4: Customer service. Evaluates how responsive and helpful the plan’s customer service is and the accuracy of information given to members.
- Category 5: Pharmacy services. Evaluates customer service, member complaints, the member experience, drug safety and the accuracy of pricing.
A Plan’s star ratings are ranked 1- 5 in each category, then used to determine the plan‘s overall score:
- ***** Excellent performance (Green Stars)
- **** Above average performance (Maroon Stars)
- *** Average performance (Orange Stars)
- ** Below average performance (Purple Stars)
- * Poor performance (Red Star)
How are the categories measured?
The star rating measures each Medicare Advantage plan’s performance in 50+ measures consisting of:
- Clinical quality standards (Green)
- Member satisfaction (Blue)
- Health plan administrative performance (Red)
- Compliance with CMS operational standards (Orange)
The data sources used to create the star ratings include:
- Clinical quality standards
- Health Effectiveness Data and Information Set (HEDIS®)
- Pharmacy Data (Prescription Drug Event (PDE))
- Health Outcomes Survey (HOS)
- Member satisfaction
- Consumer Assessment of Healthcare Providers and Systems ( CAHPS®)
- Member Complaint Tracking
- Grievance and Appeals
- Administrative performance and compliance standards
- CMS Audits
- Pharmacy (Part D) Data Integrity
- Call Center Performance
- What Florida Blue is Doing to Maintain or Improve Star Ratings
Our main goal is to help our members maintain and improve their health outcomes and effectively manage long-term conditions. We are working to maintain and improve our star ratings in a number of ways including:
- Use a dedicated team focused on improving our star ratings for the measures that have not achieved the highest possible scores. We continually evaluate the star ratings and the individual measures that comprise them.
- Work with Care Management, Healthcare Quality, and our network providers to help our members stay healthy by evaluating how often members receive screenings, vaccines, checkups, and other preventive services. Offer incentives to providers where they are rewarded for their performance based on a number of Quality (HEDIS/Star) measures.
- How You (the provider) Can Help Improve Star Ratings
It’s more important than ever that we work with you to achieve 4+ Star ratings. Doing so not only means we are achieving positive performance and member’ health outcomes, it also means lower costs and enhanced benefits for members.
To get to where we need to be requires focused attention on mastering all the right HEDIS®, pharmacy, and CAHPS® experience measures. We will continue to work with our Florida Blue providers, our BlueMedicareSM members, network pharmacies, and related vendors to ensure that evidence-based care is provided as assessed through star ratings measures.
We count on you and appreciate your willingness to collaborate with us to share information, collect medical records, and engage your patients in obtaining preventive screenings and managing their chronic conditions. In return, we want to be able to provide you with clinical resources, financial incentives, and practice-based support to help us improve health outcomes and achieve 4+ Star ratings.
Opportunities for you (the provider) to help us achieve our targeted and health outcomes include:
- Increase the number of BlueMedicare members/patients who receive timely preventive tests and screenings (e.g., wellness visits, breast cancer screening, colorectal screening, flu vaccine, BMI assessment)
- Improve management of chronic conditions:
- Track hemoglobin A1c (HbA1c) tests for diabetic members and adjust therapy as needed to achieve a HbA1c of less than 9.
- Ensure your patients with diabetes receive their retinal eye exams. Have you received and reviewed the results and documented this in your records?
- Perform annual nephropathy screenings to identify potential kidney complications by doing a urine analysis, urine micro albumin test, or having your patient on an ACE Inhibitor or ARB.
- Optimize the anti-hypertensive medications in your patients with hypertension. If their BP is elevated, continue to treat and monitor until it comes down to the normal range.
- Ensure positive health care experiences and outcomes for BlueMedicare patients:
- Ensure that members discharged from the hospital are scheduled to see a Primary Care Physician (PCP) within 7-10 days of discharge to prevent possible readmissions.
- Transitions from care settings should be closely monitored and coordinated through the PCP practices to ensure the best health outcomes.
- Does your access model support patients needing urgent care during and after-hours? Are members getting care coordination services from their providers (i.e., follow-up appointments, tests, referrals to specialists)?
- Safeguard satisfaction levels for BlueMedicare patients:
- Refer all member complaints about Florida Blue directly to the health plan for timely resolution.
- Make customer service the highest priority within your practice setting.
- Address members’ mental and physical health during the office visit.
- Ensure BlueMedicare patients know the importance of taking their medications to maximize the benefits of their treatment:
- Assist members with their medication adherence goals to support the treatment of diabetes, hypertension, and cholesterol control.
- Help to identify barriers to adherence.
- Encourage members with multiple conditions and medications to participate in our Pharmacist-led program for Medication Therapy Management (MTM). If a pharmacist contacts you about recommendations as a result of a MTM review, please review the suggested recommendations.
- Ensure members that are discharged from the hospital or skilled facilities have their current medications reconciled against their discharge medications within 30 days of discharge.
- CMS Surveys Used to Measure Members’ Experiences
CMS develops and administers many different patient experience surveys. Surveys ask patients about their experiences with, and ratings of, their health care providers and plans, including hospitals, doctors, drug plans, and others.
The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey is a mandated regulatory survey sent to a select number of Medicare members annually. CAHPS results are an integral part of the CMS Star ratings. CAHPS collects information on consumers’ experiences with their health plan, personal doctor, specialists, and health care in general and is used for CMS Star ratings. It has become the national standard for measuring and reporting on consumers’ experiences with their health plans.
The Medicare Health Outcomes Survey (HOS), utilized for CMS Star ratings, is a patient-reported outcomes measure used in Medicare managed care. According to CMS, the goal of the HOS program is to gather valid and reliable clinically meaningful data that have many uses, such as targeting quality improvement activities and resources; monitoring health plan performance and rewarding top-performing health plans; helping the Medicare-covered make informed health care choices; and advancing the science of functional health outcomes.
- Provider Quality Incentive Programs
Florida Blue offers a Provider Quality Bonus Program to our BlueMedicare HMO network Primary Care Physicians (PCPs) who care for our Medicare Advantage members. Our bonus program is tied to initiatives to support our Medicare Stars improvement program. PCPs may have the opportunity to earn:
- A monthly bonus for closing gaps on specified measures and/or
- An annual bonus for reaching a specified Stars quality rating.
PCP’s with a designated number of our Medicare Advantage members in their care on December 31 of the measurement year are eligible for the annual bonus. Those who care for a minimum of one member are eligible for the monthly bonus.
Find More Information
For additional details about our Medicare Provider Quality Bonus Program (e.g., eligibility, specified measures, weights, payment scale and schedule, and more) please log into Availity and visit the Florida Blue Passport web portal. If you do not have an account with Availity and would like to establish one, visit Availity.com to register.
Communications and Resources
- HEDIS Documentation and Coding Guide, November 2017
- Stars Reference Guide, October 2017
- HEDIS Stars Quick Cue Sheet, January 2017
- Bulletins and FAQs
- Ensuring BlueMedicare Patients' Colorectal Cancer Screening Care Gaps are Closed, November 2017
- Attn: Providers w/BlueMedicare Patients Who Have a Diabetic Retinopathy Screening Care Gap, November 2017
- Colorectal Cancer Screening Kits for BlueMedicare Members, October 2017
- Cologuard No Authorization Required Bulletin, October 2017
- Cologuard FAQs, October 2017
- Enrollment & Benefits Care Reminders in Availity, September 2017
- Colorectal Cancer Screening Kits for BlueMedicare Members, July 2017
- Attestation Name Change, July 2017
- Convenient Bone Density Screening Options for BlueMedicare Patients, April 2017
- Cologuard Screening Now Covered for BlueMedicare Patients, February 2017
- BlueMedicare Member Outreach to Completion of Health Care Services by Year-End, November 2016
- Attn: Medicare Advantage HMO Primary Care Physicians and PPO Physicians, Outreach to Help Patients Improve Health, October 2016
- BlueMedicare Member Rewards Program, September 2016
- BlueMedicare-covered Patients to Receive Colorectal Cancer Screening Kits, September 2016
- BlueMedicare Members Encouraged to have Colorectal and Breast Screening Exams, August 2016
- What Are CMS Stars Measures? August 2016
- Med Adv Coding for First Med and Annual Wellness Visits Bulletin, July 2016
- BlueMedicare Annual Wellness Visit Outreach, June 2016
- HEDIS 2017 Medicare Stars Quick Cue Sheet, June 2016
- Addressing Sensitive Topics with BlueMedicare-covered Patients, March 2016
- Attention PCPs: Comprehensive Quality & Risk Program for Florida Blue Medicare Advantage and/or Qualified Health Plan Patients, December 2016
- Member Communications
- Healthy Blue Rewards Member Reward Program (mailed September 2016)
- HEDIS Stars Measures Tip Sheets
- Body Mass Index: Adult BMI Assessment, January 2017
- Breast Cancer Screening, December 2016
- Cardiovascular Disease: Statin Use in Patients with Cardiovascular Disease (SPC), March 2017
- Care of Older Adults (COA), December 2017
- Colorectal Cancer Screening (COL), May 2017
- Comprehensive Diabetes Care, July 2016
- Controlling Blood Pressure, January 2017
- COPD: Pharmacotherapy Management of COPD Exacerbation, February 2017
- Diabetes Care Retinal Exam (DRE), October 2017
- Diabetes-Statin Use in Persons with Diabetes (SUPD) PQA Measure, March 2017
- Medication Reconciliation Post-Discharge, January 2017
- Osteoporosis Management in Women (OMW), October 2016
- Rheumatoid Arthritis (ART): Disease-Modifying Anti-Rheumatic Drug Therapy, March 2017
- Transitions of Care (TRC), November 2017
- Provider Quality Incentive Programs