The Medicare Five Star Quality Rating System

The Five Star Quality Rating System for Medicare Advantage Plans is run by the Centers for Medicare & Medicaid Services and was put in place as part of an effort to help educate consumers on quality and make quality data more transparent. The stars consist of 33 measures hailing from five rating systems.

• HEIDIS: Healthcare Effectiveness Data and Information Set, which has been an evaluation used for all health insurance plans for years. This measures encounter data.

• CAHPS: Consumer Assessment of Health-care Provider Systems.

•Medicare Reviews. (Centers for Medicare & Medicaid Services).

• HOS: Healthcare Outcomes Survey.

• IRE: Independent Review Entity.

These systems rate Medicare Advantage plans according to five domains: staying healthy via preventive services such as screenings and vaccines; managing chronic conditions; ratings of plan responsiveness and care; complaints, appeals and voluntary disenrollment; and telephone customer service.

Each of the 33 measures contributes equally to the Star Summary Score.

Data to support these star ratings comes from surveys, empirical observation, administrative (claims) data and medical records.

Based on criteria provided in technical specs outlined by CMS, rates and scores are calculated and stars are awarded on a contract level.

CMS Stars ratings are published annually and are available for viewing by all Medicare members prior to open enrollment.

They are required to be listed with each new enrollment kit for 2011 and 2012. One of the new changes in health care reform is that payment to each of the Medicare Advantage plans is based on the star rating.

According to the Congressional Budget Office, payment reforms for Medicare Advantage plans based on Stars scores are projected to save billions in federal health care spending.

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