Plan Preview 2 is now over. MA plans should have spent a great deal of time validating what the Centers for Medicare and Medicaid Services (CMS) published privately in early August and September. Final measure scores and ratings for all contracts will be out in public sometime around October 10.
Recent Star history
Star ratings have been a whirlwind the past few years. Due to the COVID pandemic, some or all of the Star methodology was suspended or materially changed. This led to a surge in Star scores through 2022. With the 2023 Star Year, rules began being put back in place. Thus, Star ratings came down from the stratosphere. The 2024 Star Year was especially tough. Even with the recalculation that occurred due to the Tukey lawsuit, results were still materially below historic rates.
Plan Preview learnings
We will have to wait until October to see what happens for Star Year 2025, but Plan Preview gave us a few indicators about what we can expect.
About two-thirds of measures saw cut points go up across most or all of the cut points in each measure. We see this as a result of two things.
- There was Tukey latency for some measures and cut points. What do we mean? The Tukey outlier requirement was implemented for Star Year 2024. This removed high and low outlier performance for many measures. As a result, it was harder to achieve higher results as cut points inflated. High performing plans were especially impacted. CMS sought to implement this in one fell swoop in 2024, but was stopped by the federal courts. CMS had to recalculate Star Year 2024 results and honor guard rail requirements in the existing rule, which generally caps most movement of cut points by 5% up or down. In some measures then, there was remaining Tukey impact that needed to be built into the 2025 cut points. This was regardless of whether plan performance improved or not. So in some cases, we saw 2025 cut points move largely for Tukey’s remaining impact. Will we continue to see major changes in cut points due to Tukey? Two points here. First, there appears to be some remaining Tukey latency out there, but future changes due to Tukey alone should continue to decrease. Second, we also expect that Medicare utilization will continue to rebound, which will mean continued cut point inflation due to better achievement in many measures.
- Plan achievement on a number of measures appears to be increasing from Star Year 2024 to Star Year 2025. We see this as a post-pandemic bump or recovery. In Measure Year 2022 (Star Year 2024), people were not yet fully back on their healthcare journey. But in Measure Year 2023 (Star Year 2025), people began again to take seriously their need to seek out care from their primary care physicians and get routine tests. Thus, measure values/scores naturally would rise from Star Year 2024 to Star Year 2025. When values increase, cut points often do as well.
We estimate that, like with cut points, about two-thirds of measures will see measure values/scores increase. Of the remainder, most will stay about equal to Star Year 2024, with a handful of measures dropping. This appears to be across all measure types – clinical, survey, and operational. But when a plan’s measure values/scores go up, it may or may not translate into a higher Star score. That depends on how much the plan or contract may have improved against the total pool of plans or contracts. As such, we predict that average scores for measures will increase in just a majority of measures, not two-thirds. While measure values/scores went up in the others, many plans likely did not keep up with progress of the overall pool and average scores for about a third of measures could go down. The rest will remain about the same.
What might happen in Star Year 2026?
We do expect some additional Tukey impacts – some from historic latency remaining and perhaps some new Tukey impact from new outliers. Utilization will continue to recover so we expect many cut points and measure values/scores of plans to increase. Plans likely will struggle on the new kidney measure, the conversion of colorectal cancer to an electronic measure, and with the two returning HOS measures on improving and maintaining physical health and mental health. With the drop of member experience measures from 4x to 2x weights, some plans will see lower overall scores.
More Plan Preview learnings
From Plan Preview we also learned a few more things:
- Medication Adherence continues to be a big struggle for plans and they are being hurt by the fact that these measures are 3x-weighted. While there was some positive news here, changes were not what they were in other clinical measures. Of note here is that two new drug measures come online as of Measure Year 2025. Plans need to build a battle plan here.
- Plans should pay attention to all three of the final Categorical Adjustment Index (CAI) factors – Part C, Part D, and Overall. CMS does make mistakes on flagging members appropriately throughout the year as well as in CAI calculations. Mistakes in the penetration of dual eligibles (DE), low income subsidy (LIS) eligibles, and disabled eligibles can impact CAI calculations. Active monitoring of member flags and proactive calculations of the CAI throughout the year is very important. In some cases, the CAI makes the difference in achieving a higher overall score.
- Improvement is taking on much more importance. First, both measures are 5x and each counts toward the overall score. Second, with member experience measures dropping from 4x to 2x, the relative importance of clinical, drug, and improvement increases a great deal. Moving measures that help your improvement score means results in two ways – the better measure score achievement (hopefully nicely weighted) and getting a higher improvement score.
- The Reward Factor often also helps plans achieve higher ratings. As contracts improve in performance (driving their mean up) and lessen the volatility of performance (lowering the variance), a reward factor kicks in. This is another way that plans get to 4 Star as they progressively improve their performance. Along with an improvement strategy, look at these details to see where you stand.
- Now, we only have one more year (Star Year 2026) of the Reward Factor and that should scare many plans. Right now, roughly about 0.3 of the 0.4 (75%) of the Reward Factor is being paid out nationally. But current estimates suggest that the Reward Factor’s replacement – the Health Equity Index – will initially only pay out 0.1 of the 0.4 possible. This will hurt many higher performing plans unless they drive the HEI. Some won’t be eligible or might only be eligible for 0.2. But others meet the critical thresholds for LIS/DE as examples. The Measure Years for the HEI in SY 2027 are 2024 and 2025. So one year is already banked. Paying acute attention to HEI in 2025 is critical. As you remediate care gaps for the population, create appropriate interventions for the HEI population as well.
- Last on our agenda of learnings is that appeals during Plan Preview do work. It is important to track throughout the year and report any anomalies to CMS quickly. Plan Preview 1 is your time to appeal any issues derived from previous reports throughout the year as well as report any new findings. If you do not do it in Plan Preview 1, you will likely lose your chance. Winning appeals on one or more measures could be the difference between a lower or higher score. CMS does make mistakes and plans can find them during the plan preview period and before. Plans are reticent to file these appeals with a regulator, but be bold as it could mean a higher score. But the more you have behind you in terms of data and time, the more likely you convince CMS the data is wrong.
Conclusion
In conclusion, plans need to make Plan Preview a year-round process. Create an action plan to thoroughly review all the data that goes into the Star ratings throughout the year – two weeks of Plan Preview time is just not enough! Create a Plan Preview calendar that has responsible parties and data review throughout the year and proactively report and document issues you see with data.
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