Medicare Advantage (MA) plans always have an eye towards improving their Star Rating. The Centers for Medicare and Medicaid Services (CMS) has a 1-to-5 star scale used to rate plans based on quality measures such as plan responsiveness and care, managing members’ chronic conditions, members completing health screenings, member complaints and even when members choose to leave the plan.

One Star represents a poor performing plan, while 3 Stars is for an average plan and 5 Stars for an excellent plan. Consumers use the Star ratings to compare plans while shopping for their MA coverage.

CMS makes changes in weighing quality measures

Recently, CMS made some changes to their ratings system that will have a far-reaching effect on the MA market. CMS is implementing changes to how it weighs these quality measures and how it awards submeasure ratings, making it more difficult for plans to remain in the 3-Star “average” group and pushing more plans to the lower or higher ratings tiers. These changes put more emphasis on the member experience, which can be more subjective.

The Diabetes Care Eye Exam Rating submeasure is one that plans can focus on to improve their overall Star Rating. This measure looks at the percentage of members with a diabetes diagnosis who received an eye exam in the past year. Plans receive between 1 and 5 Stars based on their success rate. For example, plans who have a 78% success rate or higher on this measure would earn 5 Stars that would count towards their overall Star Rating.

The CMS change has had immediate effects. The difference between 5-Star and 1-Star performing plans is shrinking. This compression means that “average” plans are being squeezed out. Since 2018, the number of 3-Star plans has steadily declined.

Increased value in Star ratings raise the bar for member plans

The new focus on member experience will have a big impact on Star ratings. Currently, 32% of the quality measures that determine Star ratings are related to member experience and access. By 2023, that number will rise to 57%¹.  And not all of the new measures fall on providers for delivering on member experience. Plans that provide digital self-service tools, such as an online provider locator and appointment scheduler, will have a distinct advantage.

Having a high Star rating gives plans a huge advantage when it comes to gaining market share. Members compare plan ratings and naturally gravitate towards plans that score higher. Five-Star plans also receive a built-in advantage as they’re able to market their plan all year round, unlike plans who are restricted to marketing during open enrollment only.

Learn more about how your Medicare Advantage plan can improve your diabetic eye exam Star rating and enhance your member experience. Download our whitepaper here or visit eyemed.com to speak with a sales representative.

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1 - Carlton S., Neher K., Repasky C.; “New Stars ratings for Medicare Advantage prioritize customer experiences”; (Oct 2020); McKinsey & Company.