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Star Ratings: Measuring Quality

The Centers for Medicare & Medicaid Services (CMS) Star Rating System measures the overall quality of Medicare Advantage (MA) HMO, PPO, and Part D plans. Plans are rated on a scale of one to five stars, with five representing the highest quality.

The system encompasses: 

· Quality of care

· Access to care

· Consumer satisfaction

· Customer service

· Responsiveness to member needs

 

Quality scores are based on more than 50 distinct measures that are derived from four sources:

·  Healthcare Effectiveness Data and Information Set (HEDIS®)

·  Centers for Medicare & Medicaid Services

·  Consumer Assessment of Healthcare Providers and Systems (CAHPS®) program

·  Health Outcomes Survey (HOS)

 

Learn more about the benefits and achieving excellence.

 

Measures You Can Affect

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Includes breast cancer screening, colorectal cancer screening, flu vaccine, BMI assessment, and osteoporosis management.

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Includes diabetes care (eye exam, monitoring kidney disease, controlling blood sugar), rheumatoid arthritis management, controlling blood pressure, and managing readmissions.

MedicaidManagedBehavioralHealth

Includes, diabetes, hypertension, and cholesterol medication adherence, and medication reconciliation post-discharge.

AuthorizationsURCriteria

Improving and maintaining physical and mental health, including monitoring physical activity, improving bladder control, and fall management.

AuthorizationsURCriteria

Obtaining needed care and appointments promptly; care coordination, e.g. patient records/reports needed for patient care and prompt test results.