Insurers concerned over how CMS will calculate Medicare Advantage star ratings in next 2 years

The Trump administration’s effort to lower the administrative burden on providers may have an inadvertent effect on calculating star ratings for Medicare Advantage (MA) plans, insurers say.

Insurers and advocacy groups wrote to the Centers for Medicare & Medicaid Services (CMS) on an interim final rule that outlined changes to MA plans due to the pandemic. Several insurer groups and individual payers were concerned about how CMS plans to calculate the star ratings for the 2021 and 2022 plan years, which affect reimbursement for plans.

CMS decided to pause the ongoing data collection surveys used to calculate the 2021 star ratings, including the Consumer Assessment of Healthcare Providers and Systems and the Healthcare Effectiveness Data and Information Set.

The decision was to lessen the administrative burden for providers overwhelmed with the COVID-19 pandemic. CMS will use the scores from the 2020 star ratings to apply to the 2021 year.

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However, insurance lobbying group America’s Health Insurance Plans (AHIP) was concerned that the consumer assessment survey measures will carry a greater weight for the 2021 star ratings compared to this year.

“We believe it would be unfair and inappropriate to allow the weighting for these measures to increase as scheduled, given that plans are unable to demonstrate they have improved performance on the measures,” the comments said.

AHIP was concerned some plans could see a reduction in their overall star ratings, but there wouldn’t be new data to support that change. The calculation could be costly for some MA plans.

Blue Cross and Blue Shield of North Carolina wants to ensure plans could get proper credit for any performance improvement. It noted that single-state health plans like theirs could be harmed by carrying forward 2020 star ratings into 2021 and 2022.

“The change rewards plans that have engaged in selectivity in service areas and penalizes plans that have endeavored to serve large swaths of the geography and population across a state,” the comments said.

The insurer gave an example of a plan that falls short of a 4.0 star rating in 2020 by a narrow margin and not being able to hit that 4.0 rating in 2021 and beyond.

CMS should also test an alternative method for calculating and awarding the quality bonus payment to improve beneficiaries’ access to home care, major insurer Anthem said in comments.

“This pandemic has only increased the importance of programs supported by rebate dollars, such as expanded telehealth benefits, meals and social isolation programs, critical to beneficiaries during the [public health emergency],” Anthem said.

Only a plan with a star rating of 4.0 can quality for a bonus payment.

Anthem, however, wants CMS to allow a plan with a 3.5 rating to qualify for such bonus payments.

“Such a demonstration would improve program stability and expand beneficiaries’ access to benefits that address the Social Determinants of Health,” the comments said.

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Providers and pharmacies also had concerns with the telehealth flexibility created under the interim regulations.

CMS temporarily waived restrictions on using telehealth, which has lead to an explosion of use during the pandemic.

Now, CVS Health implored CMS in comments that the agency should make the changes permanent.

“It will continue to promote good public health and limit exposure between patients,” the pharmacy chain said.

Hospital system Providence St. Joseph Health also praised CMS’ decision to allow hospitals to bill an originating site fee for telehealth services, which “gives some reimbursement for hospital-incurred costs,” the system said in comments.