Stars Basics

Question 1

When does CMS publish the final Stars Results?

Answer 1

Each year, CMS publishes the final Star results around October each year

Question 2

How many total Stars measures are there for Medicare Advantage plans?

Answer 2

It varies each year, but CMS can rate MA plans in up to 40 unique Star measures each year.

Question 3

How many total Star measures are there for Prescription Drug Plans (PDPs)

Answer 3

It varies each year, but CMS can rate PDP plans in up to 12 measures (Part D only).

Question 4

An easy way to explain the way CMS measures health plans for Stars Ratings is around the two “H”’s. What do those 2 H’s stand for?

Answer 4

Health and Happiness. About 50% of the measures relate to “health” (clinical measures and health outcomes) and the other 50% around “happiness” (member experience and operations)

Question 5

All Star measures are not weighted the same. What is the lowest weighting and give examples of the types of measures that are weighted at that level?

Answer 5

1x is the lowest weighting CMS assigns a Star measure. These go to measures that are considered “process” measures - like whether members completed the “process” of getting a vaccine, test or screening (like their mammography, diabetes eye exam) or operational process measures like whether we posted our drug prices accurately on our website (Medicare Plan Finder Drug Accuracy)

Question 6

What is the highest weighted measures (hint: there are two of them) and what is their weighting)?

Answer 6

Part C Quality Improvement and Part D Quality Improvement which are each weighted 5x.

Question 7

How does CMS determine the score for the two Quality Improvement measures?

Answer 7

For the Part C and Part D Quality Improvement measures, CMS looks at how each plan does across all of the Part C and D measures, respectively. Are plans getting better year over year across those measures (in which case plans would get 4 or 5 stars), staying about the same (in which case plans would get 3 stars) or generally getting worse year over year (in which case plans would get 1 or 2 stars)

Question 8

Give examples of 3X weighted measures

Answer 8

Medication Adherence for Choleterol Meds, Medication Adherence for High Blood Pressure Meds, Medication Adherence for Diabetes Meds, Hospital Readmission, Controlling Blood Pressure, Controlling Blood Sugar (Members with Diabetes)

Question 9

Give examples of 2x Weighted measures

Answer 9

The CAHPS measures and Operational measures are mostly 2x (previously were 4x weighted)

Question 10

For the CAHPS measures, how many members does CMS survey for each of our H contracts to provide a Star Rating?

Answer 10

Several hundred (usually between 400-800 members). This is true even for plans that have over 1M members! So the several hundred members that CMS selects for Star Ratings makes a huge impact to our overall results. That’s why EVERY member interaction is so important and for us to have as many promoters (and minimize detractors) as possible.

Question 11

Which Agencies does CMS rely upon to create and update the HEDIS and CAHPS measures (one agency) and then the Pharmacy measures (the 2nd agency)?

Answer 11

National Committee for Quality Assurance (NCQA) creates the HEDIS and CAHPS measures; and PQA (Pharmacy Quality Alliance) creates the Rx measures. So if we want changes to those measures, we work through those Agencies directly.

Question 12

Who is the federal Agency that oversees the Stars Program and published the annual Ratings?

Answer 12

CMS (the Centers for Medicare and Medicaid Services)

Question 13

CMS created a new way to incentivize MA plans to help members with social risk factors starting with 2027 Star Ratings. What is that new “reward” program called?

Answer 13

Health Equity Index (HEI) Reward

Question 14

What is the first “gate” that MA plans have to go through to even be eligible for the Health Equity Index Reward?

Answer 14

To even be eligible for the HEI reward, plans have to have a high enough percentage of members with social risk factors to be eligible for the reward. It starts around 21 or 22% (it can vary each year but is in the low 20s). If an H contract doesn’t have enough members with social risk factors, they will NOT be eligible to get this “boost” in Star score

Question 15

What is the 2nd “gate” the MA plans have to go through to determine how BIG their Health Equity Index Reward will be?

Answer 15

Once a plan is eligible for the HEI Reward, the amount of the reward (or “bonus”) will range from 0 to 0.4 depending on how will plans do with performance in the Star measures for members with social risk factors. The better plans do in managing health and experience for members with social risk factors, the higher the reward (maxing out at a 0.4 bonus reward on top of the final base Star score).

Question 16

What 3 types of members does CMS define as having social risk factors (SRFs) for purposes of calculating the Health Equity Index Reward

Answer 16

For now, members that are Low Income Subsidy, Disabled, or are Duals (members eligible for both Medicare and Medicaid) are considered SRF members. In the future, CMS may expand the definition to included other groups of members who have challenges with social determinants of health.

Question 17

How many H contracts does Aetna have that receive a Star Rating from CMS?

Answer 17

We are projecting around 41 plans (or H contracts) will get a star rating in 2026.

Question 18

What are our two biggest H contracts and what percentage of members is in each of those two contracts relative to our total number of members?

Answer 18

Our National Individual (IVL) PPO H5521 which has around 25% of our total MA membership and our National Group PPO H5522 which has around 33% of our total MA membership.

Question 19

For the Overall Star Rating, what interval does CMS set as the final Star Rating….Full stars (e.g. 2 stars, 3 stars, 4 stars, 4 stars); or Half-stars (e.g. 3.5 stars, 4 stars, 4.5 stars, 5 stars).

Answer 19

Half-Stars.

Question 20

How does CMS round to determine the final Star Rating?

Answer 20

CMS rounds based on the quarter point (e.g. 3.75 rounds up to 4 stars, 4.25 rounds up to 4.5 stars, etc.)

Question 21

What happens if an H contracts falls below 3 stars for 3 consecutive years?

Answer 21

CMS can put the plan under sanction to freeze marketing and enrollment until it’s satisfied with the corrective action plan put in place to improve performance; or CMS can move to terminate the plans all together in which case those members who have to join another plan with another company.

Question 22

There are 3 medication adherence measures for seniors with Diabetes, Cholesterol, and Hypertension (High Blood Pressure). To be considered “compliant” for purposes of Star Ratings, what percentage of the time does CMS expect the member to take their medications during the course of the year?

Answer 22

85%. This is called PDC (proportion of days covered). So, for example, if a member is prescribed a Statin on Jan 1 and is on that medication for the entire calendar year (365 days), then the member to fill their meds at least 311 days (>85%) for Aetna to get “credit” for that member as being compliant with their medications.

Question 23

For the Hospital Readmission measure, CMS is looking to see if a member is readmitted to the hospital after the initial discharge from the hospital. If they are re-admitted (e.g. for an infection, or complications, etc.) within a certain # of days of their initial discharge, CMS considers that a non-compliant member which hurts our Star score for that measure. How many days after initial discharge is CMS looking for that readmission?

Answer 23

30 days. If a member is readmitted within 30 day of their initial discharge, it hurts our Star score. After 30 days, it is considered a new hospital admission (and the clock “resets”).

Question 24

Financially, what benefit is there to MA plans to get higher Star Ratings?

Answer 24

CMS provides bonus dollars to MA plans for higher Star ratings that they can then use to put back to make benefits more competitive for their members. So higher Star Ratings really goes back to help members with improved benefits! And helps health plans because more competitive benefits = higher potential for growth and improved member satisfaction.

Question 25

What’s an easy “back of napkin” estimate for how much more an average health plan gets per member in Stars bonus dollars from CMS if they can achieve 4-stars versus 3.5 stars?

Answer 25

The average health plan would get $300-$400 a year more per member per year for a 4-star plan versus a 3.5 star plan! So for a 100,000 member plan, this means $30-$40M more in bonus payments in a calendar year for achieving 4 stars versus 3.5 stars (or losing that if you think of it in the inverse). For a 1M member plan, that would be $300-$400M!

Question 26

What is the highest Star Rating that benefits MA plans from a Stars bonus/rebate perspective?

Answer 26

4.5 Stars. Most people believe it’s 5-stars. While 5-stars is the highest maximum possible score, there is no additional Stars bonus/rebate benefit past the 4.5 star level. 5-star plans receive the advantage of year-round marketing and enrollment (not just limited to the Annual and Open Enrollment Periods as most MA plans are allowed).

Question 27

What does “HEDIS Hybrid” mean?

Answer 27

Also know as “medical chart chases.” Some of the HEDIS measures are scored based on a sample of our members that are selected for audit. So for example, rather than have plans submit proof that ALL members with a diagnosis of hypertension have their blood pressure under control, NCQA selects a sample of members with hypertension (e.g. 411) and then Aetna has to go out to the provider offices to collect the documentation (e.g. a medical chart that shows that the members blood pressure is under control). If we can find a compliant record, then we get positive “credit” for the Star score. The “hybrid” means that we can establish compliance through an electronic medical record OR the medical chart obtained through the chart chase process.

Question 28

What do the Call Center Monitoring Measures test?

Answer 28

They test our ability to help members with hearing impairment connect with the 711 Relay service; as well as members who speak foreign languages connect with a foreign language interpreter. CMS hires secret shoppers to conduct calls to health plans during business hours and see how we perform. A plan that can connect to the service and answer a basic introductory Q within a designated time limit passes the test/.

Question 29

Approximately how many MA plans across the industry get a Star Rating?

Answer 29

Over 400. Aetna represents about 10% of the H contracts that get Star Ratings.

Question 30

Who are the “Top 6” largest MA organizations that we often get compared against for Star Ratings?

Answer 30

United, Humana, Cigna, Elevance, and Centene. Aetna is currently the 3rd largest by membership in the country

Question 31

Traditionally, health plans have taken a “one size fits” all approach when engaging members. But members are people with distinct personalities, characteristics and communication preferences. What is the concept called for how we engage members taking into account these different attributes and communicate with our members more effectively?

Answer 31

Precision Engagement. Our member experience team is building this model into our communication approach so we can increase our member engagement rates and satisfaction.