量子资源网 Insights | 量子资源网 Weekly Roundup

Filter by topic:

Receive timely expert insights on topics you care about.

496 Results found.

CMS releases draft benefit and payment parameters for 2026 Marketplace

Our second In Focus article reviews the recently proposed Notice of Benefit and Payment Parameters (NBPP) for 2026. The Centers for Medicare & Medicaid Services (CMS) , released October 10, 2024, describes the policy and payment changes that will affect the Affordable Care Act (ACA) markets in 2026. Public comments must be submitted to CMS by November 12, 2024. Key highlights from the proposed rule follow.

Broker Oversight and Monitoring

CMS proposes to increase oversight and accountability for brokers and agents that write policies through HealthCare.gov. In response to the earlier this year of fraudulent actors reassigning broker designations and switching consumer enrollments without their permission or knowledge, CMS has already implemented several , including the of 850 Healthcare.gov agents and brokers. CMS intends to build on these actions through the following interventions:

Clarify that lead agents, typically an agency owner or executive, are subject to the same rules as individual brokers, agents, and web-brokers and that enforcement action can be taken against the lead agents if they explicitly or implicitly condone misconduct or fraud
Broaden CMS鈥檚 authority to suspend broker and agent system access, inclusive of instances of suspected misconduct that affects eligibility determinations, operations, applicants, or systems
Update the model consent form to include documentation of the broker reviewing and confirming the accuracy of submitted application information with the consumer.

Marketplace User Fees

CMS proposes to increase the user fee collected to pay for administration of HealthCare.gov as follows:

Between 1.8 percent and 2.5 percent in 2026 for federally facilitated marketplaces (FFM) states, up from 1.5 percent of monthly premiums in 2025
Between 1.4 percent and 2 percent in 2026 for state-based marketplaces on the federal platform (SBM-FPs), up from 1.2 percent in 2025

The proposed changes are due, in part, to uncertainty caused by the future of the enhanced premium tax credits that are set to expire at the end of 2025. The enhanced premium tax credits are the driving force behind the in nationwide marketplace enrollment to more than 21 million people in 2020 from 11.4 million in 2020. If not extended, or if it takes past March 2025 for Congress to act, CMS has indicated the user fees will increase in 2026 to 2.5 percent for FFM states and 2% for SBM-FPs to accommodate expected enrollment declines. Notably, after several years of significant decreases, CMS is proposing to increase the user fees above 2025 levels regardless of the outcome of the enhanced premium tax credits.

Plan Limits for Non-Standard Plans

CMS proposes to clarify rules limiting the number of non-standardized plans an issuer can offer through HealthCare.gov (two or less in 2025). The limit is applied per product network type (e.g., HMO, PPO), per metal level, per service area, per inclusion of adult/pediatric dental and/or vision benefits (with additional exceptions, starting in payment year (PY) 2025, for plans with specific design features that would substantially benefit consumers and meet other requirements). To maximize the number of non-standardized plans offered on HealthCare.gov, an issuer could offer up to 16 plans per metal level and network type in a given service area by creating every combination of adult dental, pediatric dental, and adult vision (or even more, if plans meet the exception requirements).

Though CMS does not limit the number of standardized plan options an issuer offers on HealthCare.gov, they propose reinstating a meaningful difference standard to prevent consumer confusion and unnecessary plan proliferation. The proposed standard is similar to the removed standard from 2019; for plans in the same metal level, product type, and service area, a reasonable consumer needs to be able to identify at least one material difference in benefit coverage, provider networks, and/or formulary.

New Premium Payment Threshold Options for Issuers

CMS proposes new options for issuers to avoid triggering late payment grace periods for consumers who make most but not all of their premium payment to minimize termination of coverage for consumers who owe a small amount. The options include:

The current option of a 鈥渞easonable鈥� percentage of net premium. CMS proposes codifying 95 percent as the minimum threshold.
New proposals of as low as 99 percent of gross premium and a fixed-dollar threshold of $5 or less.

CMS is also considering limiting issuers to offering just one payment threshold option鈥攅ither fixed-dollar or percent of premium鈥攖o avoid consumer confusion.

Increased Transparency for State-Based Marketplaces

CMS proposes new initiatives to promote transparency into state-based marketplace (SBM) program operations. These initiatives include:

Publishing State Marketplace Annual Report Tool (SMART) submissions, which are used to monitor SBM compliance with select eligibility and enrollment, program integrity, and financial reporting requirements. SBMs must annually participate in independent programmatic and financial audits as part of SMART. CMS proposes to make the 2023 SMART submissions public in spring 2025.
Expanding the disclosure of SBM information to include data collected but not currently published, including details on SBM eligibility, enrollment, and plan certification policies as well as Navigator program spending, call center metrics, and website traffic data.

SBMs already are required to publish programmatic and financial audit summaries and generally publish robust data and information on their program operations through public reports and meetings; however, this information is neither centrally located nor consistently published across all SBMs.

Key Considerations

The proposed 2026 NBPP would build on previous actions that CMS has taken to address fraudulent broker and agent activity and to shore up financial sustainability of Healthcare.gov operations in light of uncertainty about the enhanced premium tax credits. It also seeks to make clear how plan variations adding dental or vision benefits factor into HealthCare.gov plan limits and gives issuers new premium payment threshold options. Lastly, it proposes new transparency requirements for SBMs. Interested stakeholders, including SBMs and issuers, should monitor how these proposed changes will affect consumers, operational processes, product strategy, and financial sustainability.

Connect With Us

The 量子资源网, Inc., team has the depth, experience, and subject matter expertise to assist with tailored analysis and the modeling capabilities to assess the policy impacts to consumers, marketplaces, and issuers. If you have questions or want to discuss the proposed rule, contact our featured experts below.

For additional information on elements of the proposed NBPP not discussed here, Wakely Consulting鈥檚聽white paper, , highlights the proposed changes to the Risk Adjustment program, Medical Loss Ratio, and the Actuarial Value Calculator, among other changes.聽

Medicaid unwinding: enrollment shifts and Q2 2024 managed care insights

Read Blog

This week, our In Focus section addresses the significant change in national and state-specific Medicaid enrollment as a result of the Medicaid unwinding process. First, we highlight notable enrollment changes in the post-unwinding months. Next, we provide an update on second quarter (Q2) 2024 monthly capitated, risk-based Medicaid managed care enrollment. The experiences of the unwinding and the impact and current enrollment landscape are directly affecting strategic and programmatic decisions across all states, Medicaid managed care plans, and their partners and stakeholders.

Background

As explained in previous鈥�In Focus鈥痑rticles (article #1,鈥�article #2鈥痑苍诲鈥�article #3), federal COVID-19 relief laws allowed states to receive higher federal funding for Medicaid as long as they did not terminate Medicaid coverage for anyone enrolled in Medicaid during the public health emergency. One result of the continuous coverage policy was sustained growth in Medicaid enrollment. More than 21 million additional individuals were continuously enrolled in Medicaid for up to three years between February 2020 and March 2023. In December 2022, Congress ended the Medicaid continuous coverage policy after March 31, 2023. States were鈥�allowed鈥痶o begin processing redeterminations as early as February 2023 and start disenrolling ineligible individuals as early as April 2023.

The Centers for Medicare & Medicaid Services (CMS) offered states a series of flexibilities intended to facilitate the unwinding process, which reduced some administrative burden and improved continuity of coverage for Medicaid enrollees. Most states adopted at least one of the flexibilities, with many using multiple options. Nonetheless, variations in timing and implementation of the flexibilities have affected their effectiveness.

California, for example, received federal approval for flexibilities in its automatic redetermination process early on but implemented enhanced automation months into its unwinding process. This increased automation cut the number of disenrollments in half. Another key challenge during the unwinding was contacting enrollees about the redetermination process, and several of the federal flexibilities involved increased coordination with Medicaid managed care organizations (MCOs).

Key Takeaways

States lost an average of 15 percent of their peak COVID-era Medicaid enrollment between March 2023 and June 2024. Several effective practices could be adopted to address those individuals and families who remain eligible but not enrolled and to minimize procedural disenrollments in the future. Below is a snapshot of data and early insights 量子资源网, Inc. (量子资源网), experts identified through their work with Medicaid stakeholders and analysis of Medicaid enrollment and eligibility data.

Some states are several months beyond their anticipated unwinding period. Still, more than half of states continue to see small net reductions in their Medicaid populations (see Table 1).

Table 1. Enrollment Changes during and after Unwinding, September 2024

Despite the ongoing enrollment reductions, net Medicaid enrollment generally remains above pre-pandemic levels and is likely to remain so. This enrollment change has been boosted by several states鈥擨daho, Utah, Nebraska, Oklahoma, Missouri, South Dakota, and North Carolina鈥攚hich expanded their Medicaid programs immediately before or during the COVID-19 pandemic.
Following the official end of the Medicaid unwinding period, the acuity of the Medicaid population increased significantly. Early actuarial assessments, including those conducted by 量子资源网 actuaries, indicate that the average Medicaid population is older and sicker than before the unwinding started. Consequently, Medicaid populations may be more complex and expensive to manage鈥攑rompting states and managed care plans to reassess their capitation rates for current and future years. The 24th鈥痑nnual Medicaid Budget Survey conducted by The Kaiser Family Foundation (KFF) and 量子资源网 (量子资源网), in collaboration with the National Association of Medicaid Directors (NAMD), also provides key take-aways on provider rates and managed care, among other issues in the As Pandemic-Era Policies End, Medicaid Programs Focus on Enrollee Access and Reducing Health Disparities Amid Future Uncertainties: Results from an Annual Medicaid Budget Survey for State Fiscal Years 2024 and 2025.

Medicaid Managed Care Enrollment Update 鈥� Q2 2024

Today, 量子资源网 Information Services (量子资源网IS) posted a quarterly update for Medicaid managed care enrollment. We collected and analyzed monthly Medicaid enrollment data from the second quarter (Q2) of 2024 (April鈭扟une) in capitated, risk-based managed care in 29 states. These data allow for the timely analysis of enrollment trends across states and MCOs as well as state and plan-specific analyses of managed care enrollment following the official end of the Medicaid unwinding period.1

The 29 states highlighted in this review have released monthly Medicaid managed care enrollment data via a public website or in response to 量子资源网鈥檚 public records request. This report reflects the most recent data posted or obtained. 量子资源网 has made the following observations related to the enrollment data (see Table 2):

As of June 2024, Medicaid managed care enrollment across the 29 states tracked in this report was 62.7 million, down by 10.2 million (14 percent) year over year.
In our review, all but one state, Mississippi, saw decreases in enrollment in June 2024 because of Medicaid redeterminations.
The 22 expansion states included in the review鈥擜rizona, California, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maryland, Michigan, Minnesota, Missouri, Nevada, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, Virginia, Washington, and West Virginia鈥攈ave seen net Medicaid managed care enrollment decrease by 6.2 million (11.1 percent) in the past year, to 50.1 million members at the end of Q2 2024.
The seven states that had not expanded Medicaid as of June 2024鈥擣lorida, Georgia, Mississippi, South Carolina, Tennessee, Texas, and Wisconsin鈥攈ave seen Medicaid managed care enrollment decrease 24 percent to 12.6 million members at the end of Q2 2024.

Table 2. Monthly MCO Enrollment by State, April鈭扟une 2024

Note: In Table 2 above, 鈥�+/- m/m鈥� refers to the enrollment change from the previous month. 鈥�% y/y鈥� refers to the percentage change in enrollment from the same month in the previous year.

It is important to note the limitations of the data presented. First, not all states report the data at the same time during the month. Some of these figures reflect beginning of the month totals, whereas others reflect an end of the month snapshot. Second, in some cases the data are comprehensive in that they cover all state-sponsored health programs that offer managed care options; in other cases, the data reflect only a subset of the broader managed Medicaid population. This limitation complicates comparison of the data described above with figures reported by publicly traded Medicaid MCOs. Hence, the data in Table 1 should be viewed as a sampling of enrollment trends across these states rather than a comprehensive comparison, which cannot be established based solely on publicly available monthly enrollment data.

Connect with Us

More detailed information on the Medicaid managed care landscape is available with a subscription to 量子资源网IS, which collects and aggregates Medicaid enrollment data, health plan financials, and additional actionable information about eligibility expansions, demonstration and waiver initiatives, as well as population- and service-specific information, such as Medicare and Medicaid dually eligible beneficiaries, ABD populations, long-term services and supports, and patient-centered medical homes. 量子资源网IS also includes a comprehensive public documents library containing Medicaid requests for proposals and responses, model contracts, scoring sheets, and protests.

For additional analysis of the Medicaid unwinding initiative and 量子资源网IS鈥檚 enrollment data and subscription service, contact our featured experts below.

24th annual Kaiser Family Foundation state Medicaid budget survey released聽

Read Blog

The 24^th annual Medicaid Budget Survey conducted by The Kaiser Family Foundation (KFF) and 量子资源网 (量子资源网), in collaboration with the National Association of Medicaid Directors (NAMD), was released on October 23, 2024 in the report As Pandemic-Era Policies End, Medicaid Programs Focus on Enrollee Access and Reducing Health Disparities Amid Future Uncertainties: Results from an Annual Medicaid Budget Survey for State Fiscal Years 2024 and 2025.

At the end of state fiscal year (FY) 2024 and heading into FY 2025, states were wrapping up the unwinding of the pandemic-related continuous enrollment provision, focusing on an array of other priorities, and facing uncertainty about the stability of state revenues. States were also looking ahead to federal and state elections in November and the potential implications of those elections for Medicaid enrollees, states, and providers. As states have emerged from the now-expired COVID-19 Public Health Emergency, which profoundly affected Medicaid enrollment and spending, many are focused on using Medicaid to address long-standing health disparities (often exacerbated by the pandemic), improve access to behavioral health services and long-term services and supports (LTSS), address enrollee social determinants of health, and implement broader delivery system and value-based initiatives. The report includes key take-aways on provider rates and managed care, benefits and prescription drugs, and social determinants of health and reducing health disparities.

The report was prepared by Kathleen Gifford, Aimee Lashbrook, and Caprice Knapp from 量子资源网; and by , , , , from the Kaiser Family Foundation. The survey was conducted in collaboration with NAMD.

The release of 2025 Medicare Advantage Star ratings and improving future rating cycle performance

Read Blog

This week, our In Focus section reviews the release of the and pivots to the actions that Medicare Advantage Organizations (MAOs) could take to improve performance in future rating cycles.

Background

Newly MA Star Ratings information is based on the 2025 Star Ratings published on the Medicare Plan Finder on October 10, 2024. Star Ratings are largely based on the quality of care, member satisfaction, and retention.

The Centers for Medicare & Medicaid Services (CMS) increased many measure-level cut points from the 2024 Star Ratings, requiring MAOs to achieve higher performance on these measures to receive a four or higher Star Rating. An earlier In Focus reviewed a white paper published by Wakely, an 量子资源网 Company, which provides an in-depth analysis of CMS鈥檚 latest policy and methodology changes that affect an MAO鈥檚 overall quality performance and Star Rating.

Topline Results

Significant attention is being given to the notable overall industry decline in Star Ratings. Specifically, only seven Medicare Advantage (MA) plans received an overall 5-Star Rating in 2025, compared with 38 in 2024. Only 40 percent of MA prescription drug plans achieved a score of four or five Stars versus 43 percent in 2024.

Key Considerations for Star Ratings, and What to Do 量子资源网 Them

The ratings significantly influence the financial and operational effectiveness of each MAO, directly affecting plan reimbursement and ability to enhance benefits. The 2025 Star Ratings will impact 2026 MA quality bonus payments. Health plans that earn four or more Stars are eligible for quality bonus payments and greater rebate percentage the following year. Plans may reinvest payments to make plan products more attractive to beneficiaries and emphasize a higher rating in their marketing efforts.

In the wake of CMS鈥檚 release of Star Ratings, an intense focus has shifted to each MAO鈥檚 specific overall Star Rating. Given the clear implications for population health and health plan sustainability, companies will need to quickly pivot to address opportunities for performance improvement. Key steps to optimize Star Ratings include:

Grow Foundational Knowledge 鈥� MAOs need to build broad organizational understanding of the domains and measures, the weights, the levers that can affect individual measures and domains, and the rating cycle.
Assess the Current Landscape 鈥� Organizations will benefit from having executive sponsorship, a governance structure, and overall leadership for each domain and measure. They should develop the ability to report on measures, and set interim goals. Assessments also need to ensure the network and bonus structure are aligned with Stars.
Develop a Roadmap 鈥揂 calendar of events is critical for supporting performance improvement. This should include a preoperational and operational strategy as well as a year-over-year workplan to track, assess, and identify systems, technology, processes and people with a process for evaluation. Formulate a hiring and investment plan, if needed.
Prepare for Reporting and Oversight 鈥� Develop a reporting and oversight structure, including a cadence of reporting and structure for review, process, and timing of reports by measure/domain leads. Ensure dashboards are updated annually to include new measures and weights and that a process is in place for managing display measures.

What to Watch

The MA landscape is highly dynamic, with some companies leading in market share, while others are leaders on quality ratings. As companies adapt to regulatory changes and strive for higher quality ratings, we can anticipate further shifts in the coming years. This will be exacerbated by shifts we are forecasting based upon the Health Equity Index and upcoming changes in Star weights. Strategies and actions MAOs implement in 2024 and 2025 will affect their 2026 Star Ratings.

Connect with Us

量子资源网 experts have conducted in-depth analysis on all contracts, domains, and measures that roll into the Star Ratings. For further analysis of the 2025 trends and plan-specific impacts, contact our featured experts below.

Explore The 量子资源网 Stars Accelerator Solution for additional insights into programmatic strategies, best practices for design of meaningful solutions to implement, and approaches to measure the effectiveness of these solutions.

What to watch for in Medicare Advantage policy this fall

Read Blog

This week’s In Focus section previews key public policy issues affecting Medicare Advantage (MA) and Medicare Part D that could potentially be addressed under regulations issued by the Centers for Medicare & Medicaid Services (CMS) later this fall. CMS鈥檚 highly anticipated regulations鈥攚hich include annual programmatic, policy, and technical updates to the MA and Part D programs for the coming plan year鈥攁re under review at the Office of Management and Budget and are expected to be released in the coming weeks ahead.

In addition to the proposed rule, healthcare organizations are closely tracking CMS regulations that are expected to be released later this year, which would impact MA plan payment rates as well as proposed regulations intended to streamline the prior authorization process for prescription drug coverage under Medicare. This annual regulatory policymaking process is getting under way as the Medicare Open Enrollment period begins October 15, 2024, during which Medicare beneficiaries will compare Medicare health plan and drug coverage options and select the coverage that best meets their health care needs. (See Table 1 for key 2024 MA dates.)

As the last major Medicare policy regulations from the Biden Administration, healthcare entities can expect a continued focus on regulatory policies and requirements that strengthen program oversight and enhance beneficiary protections, while also seeking to maintain stability in Medicare benefits offerings and plan choices.

Following are some of the key issues to watch for as CMS鈥檚 annual regulatory process begins this fall.

Health Equity

Ensuring health equity is a foundational element of CMS鈥檚 strategic plan and the agency seeks to advance health equity goals and improvements across all of its programs, including Medicare Advantage. Beginning next year, MA plans will be required to conduct an annual review and analysis of utilization management (UM) policies and procedures from a health equity perspective. By requiring public reporting and identifying any impacts on underserved populations, this requirement is designed to ensure MA plans鈥� UM policies and procedures ensure access to medically necessary care, especially for vulnerable, low-income populations, such as beneficiaries who receive the Part D low-income subsidy and those who are dually eligible for Medicare and Medicaid.

In addition, CMS has finalized rules to collect health equity data, including race and ethnicity data, and adopted changes to the MA quality measurement program that will provide incentives for MA plans to improve care for underserved and vulnerable populations, including beneficiaries with high social risk factors.

Stakeholders should expect CMS to continue building and strengthening policies to advance health equity goals while exploring new initiatives to reduce disparities and close gaps in care for vulnerable populations.

Consumer Protection and Oversight

Earlier this year, CMS launched a high-profile effort to increase transparency in Medicare Advantage, including the release of a request for information (RFI) to solicit public input on ways to improve data collection and enhance oversight over all aspects of the MA program. More details are available in the . In addition to seeking comments on improving overall MA data collection and public reporting, the CMS RFI on MA data collection solicited specific recommendations to improve data collection and accountability for MA plans鈥� provider networks and prior authorization process.

While the formal comment period closed in May 2024, responses to the CMS RFI on MA data collection can inform and shape future regulatory policy direction, as CMS continues to examine ways to improve transparency and oversight over MA plans.

Quality and Star Ratings

CMS will soon release the Medicare Advantage Star Ratings, which measure the quality of MA plans based on a range of quality and performance metrics. The Star Rating system provides beneficiaries with crucial information to compare plans and select the coverage option that best meets their needs. High-performing plans receive bonuses鈥攚hich provides incentives for plans to continue to improve quality of care for beneficiaries and patient outcomes. Last year, MA plans received $11.8 billion in bonus payments, and 74 percent of MA beneficiaries were enrolled in plans that achieved a rating of four or more stars. For more information,

On the regulatory front, CMS recently adopted significant changes to Star Ratings that continue to have far-reaching impacts on MA plans鈥� quality performance, which, in turn, will continue to shape and inform their quality improvement strategies. Among the notable regulatory changes CMS has adopted is the new Health Equity Index, which rewards MA plans that provide high quality care to beneficiaries with social risk factors, including low-income beneficiaries and those dually eligible for Medicare and Medicaid. Though this policy change takes effect in 2027, MA plans can take steps now to prepare and enhance their capabilities to improve quality of care for beneficiaries with social risk factors, including using targeted care coordination programs.

As policymakers and stakeholders continue to monitor the impact of recently finalized changes to MA Star Ratings, CMS will continue exploring improvements to the MA Star Ratings system that further raise the bar on quality and ensure the program aligns with CMS鈥檚 broader goals and objectives.

Prior Authorization

As MA plans have increased the use of prior authorization and drawn scrutiny among patient advocates and providers, CMS has taken important steps to streamline and improve the prior authorization process to ensure timely access to care for Medicare beneficiaries. These regulatory policy changes鈥攚hich include continuity of care requirements beneficiaries, increased oversight over UM practices, and ensuing evidence-based clinical decisions within MA are consistent with traditional fee-for-service (FFS) Medicare鈥攁re intended to ensure prior authorization and other UM tools do not create barriers to medically necessary care for Medicare beneficiaries.

Policymakers continue to look for ways to further improve the prior authorization process, and CMS has additional interest in further regulatory standards to strengthen oversight and improve beneficiary protections. Potential policy options CMS could pursue include requiring more detailed reporting by MA plans (including number of prior authorization requests, denials, and appeals by type of service), extending prior authorization standards and consumer protections to prescription drugs covered by Medicare, and improving the timeliness of prior authorization decisions to avoid delays in necessary care.

Risk Adjustment Payment Policy and Coding

CMS has adopted significant changes to the MA risk-adjustment model, which continue to be phased in over a three-year period (2024鈭�2026). These changes include important technical changes to improve the model鈥檚 payment accuracy, including a focus on conditions that are subject to more coding variation. Because CMS risk-adjustment changes will be fully implemented by calendar year 2026, policymakers and stakeholders are closely monitoring whether CMS will pursue additional regulatory policies to improve the accuracy of the risk adjustment program and address coding issues.

Since 2018, CMS鈥攁s required by statute鈥攈as applied a coding intensity adjustment that reduces MA risk scores by 5.9 percent annually to ensure consistency with Medicare FFS coding. However, MedPAC and others have continued to that MA risk scores are higher than those for similar Medicare FFS beneficiaries, even after accounting for the 5.9 reduction in MA risk scores, which results in increased payments to MA plans. As policymakers continue to evaluate changes to ensure the long-term sustainability of the Medicare program, CMS could consider further changes in this area to equalize payments between MA and FFS Medicare through risk adjustment or coding changes.

Table 1. Key 2024 Medicare Advantage Dates

Date	Event
September 2024	CMS announces average premiums, benefits, and plan choices for MA and Medicare Part D for 2025.
Early-to-mid October 2024	CMS releases MA and Part D plan Star Ratings 2025.
October 15, 2024	Medicare Annual Election Period begins. Medicare beneficiaries can enroll in MA or Part D plans for CY 2025.
October or November 2024	CMS CY 2026 Policy and Technical Changes to MA and Medicare Part D (CMS-4208).
November 2024	CMS Interoperability Standards and Prior Authorization for Drugs (CMS-0062).
December 7, 2024	End of Annual Election Period.

Next Steps

The imminent release of CMS regulations come at a critical time for the Medicare Advantage program, which continues to experience enrollment growth amid a challenging and ever-changing regulatory environment. MA plans and other stakeholders need to be prepared to engage in the formal notice and comment process as well as offer policy solutions and best practices to strengthen and enhance the program for the 33 million beneficiaries it serves.

The 量子资源网, Inc. (量子资源网), team will continue to closely monitor the timing of the release of CMS regulations and will analyze the impact of the key provisions once these rules are released. We have the depth, experience, and subject matter expertise to assist organizations engaging in the rulemaking process and assessing their impact. 量子资源网 can also assist with tailored analysis and modeling capabilities to assess the policy impacts across the multiple rules and guidance.

If you have any questions about the forthcoming CMS regulations and potential impact on MA plans, providers, and beneficiaries, contact our featured experts below.

2025 Star rating cut point changes: key updates and their impact

Read Blog

This week’s In Focus highlights a white paper that Wakely, a 量子资源网, Inc. (量子资源网), company published in September 2024, titled 鈥�.鈥� The paper provides an in-depth analysis of the latest cut point changes from the Centers for Medicare & Medicaid Services (CMS) to demonstrate how policies like the Tukey Outer Fence Outlier removal logic (Tukey), guardrails, and changes in overall quality performance have led to the highest Medicare Advantage (MA) Star Rating cut points in the program鈥檚 history.

Why Cut Points Matter

MA Star Ratings are a critical measure of the quality and performance of MA plans. The MA Star Ratings cut points are the thresholds CMS has set to evaluate the performance of MA plans. These ratings, ranging from 1 to 5 stars, are based on various quality measures, including clinical outcomes, patient experience, and plan administration. CMS applies methodologies such as Tukey to set the cut points and guardrails to stabilize them over time. MA plans are evaluated and earn a rating that is based on their performance against the cut points. Higher Star Ratings can lead to increased enrollment and higher payments from CMS, making them a key focus for MA organizations.

Key Findings

Wakely used the 2025 Star Rating Technical Notes to analyze measure-level cut point changes. The data summarize how Medicare Advantage organizations (MAOs) performed on various quality measures during the 2023 measurement year. Notably, the Tukey methodology was applied for the first time within the 2024 Star Ratings cut points. Initially, the full impact of this methodology was evident in the initial 2024 Star Ratings, but the updated 2024 Star Ratings restricted use of guardrails and spread the impact of Tukey over a few years.

The analysis reinforces expectations for changes in MA spending in 2026, in part because of changes in Medicare Advantage Prescription Drug Overall Star Ratings.

Key Considerations

The Star Ratings have been on a steady decline over the last two years while CMS continues to refine and evolve its Star Ratings methodology and areas of focus. Key issues to consider in this climate include:

MAOs are experiencing significant reductions in quality bonus and rebate payments, which potentially affects opportunities to improve member health outcomes.
Strategies to enhance Star Ratings and elevate program quality are crucial for performance and meeting the unique needs of MA enrollees.
MA plans and other stakeholders also should consider that as plans optimize performance on certain traditional quality measures, CMS is placing increased emphasis on member experience with their health plan and providers during care.
The Star Ratings is an important tool CMS uses to redirect plan focus and resources.

CMS is scheduled to release the final scores and Star Ratings for Star Year 2025 in early October 2024. These ratings will be based on the performance data from the 2023 dates of service. This release will provide MAOs with updated quality and performance metrics, which are used to determine CMS Star Ratings and subsequent quality-based payments.

Connect with Us

For further insights into the Star Ratings and more information on the report, contact our featured experts below.

Strategies and actions MAOs implement in 2024 and 2025 will affect their 2026 Star Ratings. For further insights into programmatic strategies, best practices for design of meaningful solutions to implement, and approaches to measure the effectiveness of these solutions, explore The 量子资源网 Stars Accelerator Solution.

Illinois D-SNP RFP: Highlights and signals of forthcoming trends

Read Blog

This week, our In Focus section from the 量子资源网 Weekly Roundup highlights the Illinois Department of Healthcare and Family Services (RFP) for a dual-eligible special needs plan (D-SNP) to replace its current Medicare-Medicaid Alignment Initiative (MMAI) demonstration.

Overview

Illinois is one of the states affected by the Centers for Medicare & Medicaid Services (CMS) decision to end the capitated model in the federal Financial Alignment Initiative (FAI) demonstration. Illinois is among the last states to issue an RFP that will support the transition from the demonstration program. Two states, Texas and South Carolina, have yet to issue RFPs. On September 10, 2024, CMS issued a discussing end-of-demonstration enrollment and operational considerations and deadlines by which states should make operational decisions.

The 量子资源网, Inc., (量子资源网) In Focus article June 26, 2024, discussed related changes that CMS finalized to the federal policy framework for D-SNPs to enhance care coordination, improve health outcomes, and ensure that dual-eligible beneficiaries receive accurate information about their healthcare while integrating successful features of the FAI demonstration and the Medicare-Medicaid Plan (MMP) program. These decisions are prompting more states to develop new models for integrating Medicare and Medicaid services.

Illinois D-SNP RFP Highlights

This Illinois procurement will transition the state to a fully integrated dual-eligible special needs plan (FIDE-SNP) model, which will include a requirement that plans provide managed long-term services and supports (MLTSS) for both people who are dually eligible and Medicaid-only beneficiaries beginning in 2027.

The RFP is largely focused on quality care provisions and improved care coordination across all services lines, including overall expectations to achieve the following:

Improved access and quality of community-based behavioral health services
Better quality of care in facilities
Fewer program opt-outs
A strategy for increasing the use of alternative payment models (APMs) in Medicaid managed care in Illinois, particularly for behavioral health providers

Emerging National Trends

Overall, the Illinois D-SNP procurement reflects broader national trends toward more coordinated, equitable, and outcome-focused healthcare.

Focus on Health Equity. The procurement emphasizes health equity and reducing disparities, including information on innovations that are responsive to health-related social needs (HRSNs) and social determinants of health (SDOH). The state is weighing payers鈥� experience partnering with non-traditional providers to meet Medicaid customers鈥� needs, their innovative programs to address customers who are difficult to locate, and their strategies for improving care for adults with complex needs in facility or community-based settings.

In addition, the state will require plans to report outcomes by race, ethnicity, and geography. Given the demographic and health equity reporting requirements, payers should be prepared to speak to their data collection, member engagement strategies, and relationships with community-based organizations. This capability will be an essential component of addressing both population health and health equity activities.

Alternative Payment Models. The RFP also requests detailed information on the payer鈥檚 strategy for increasing the use of APMs in Illinois Medicaid managed care, including the models the payer intends to implement. Experience supported by data-driven outcomes and explanations of work with providers or clinics to adopt, manage, and support reporting and analytics for APMs is a key area of interest for the state. Notably, the state seeks information on plans to include behavioral health providers in APMs.

Long-Term Services Related Transitions. The RFP questions also reflect the long-term services and supports that dually eligible beneficiaries need, as well as those of Medicaid-only beneficiaries who are eligible for these services. More specifically, the RFP raises questions to determine how payers will effectively implement nursing home diversion plans, incentivize hospitals to discharge patients to community settings, and approaches to transition members from institutional settings to the home and community, including by connecting members with supports for HRSNs. Payers will be expected to provide specific examples of their experience and outcomes in other states.

Emerging National Trends

The emphasis on health equity in the Illinois RFP reflects a broader national trend. States are increasingly interested in鈥攁nd in some situations required鈥攁ddressing SDOH and reduce disparities, especially for the Medicare and Medicaid dual-eligible population. As a result, payers and other healthcare organizations must develop capacity internally and through external collaborations to build their expertise and evidence base for advancing improvements.

The push for APMs in the Illinois procurement aligns with national efforts to move away from fee-for-service models. Illinois鈥檚 inclusion of behavioral health providers in APMs and requiring integrated care models highlights the growing recognition of the importance of mental health in overall health outcomes.

Illinois鈥檚 RFP also reflects heightened interest in improving care transitions and coordination. The potential for incentive programs related to community placement and increased focus on nursing home diversion will require innovative plans and a long-term commitment to working with all stakeholders to build on the federal FAI experiences.

What We鈥檙e Watching

Responses to the Illinois RFP are due October 18, 2024, and awards are expected to be announced in December. The state anticipates making awards to the top four bidders. Contract execution is estimated July 2025, with implementation January 1, 2026.

As the FAI demonstration ends and CMS鈥檚 integration requirements take effect over the next several years, there will be a steep learning curve for states, payers, and other key stakeholders adapting to this evolving environment. Compliance with new CMS rules will be crucial, and experiences in Illinois and other FAI demonstration states can provide valuable insights for other states and stakeholders.

Additional growth and program refinements in the federal Medicare Advantage (MA) landscape are expected in the coming years, especially among MA D-SNPs. Those MA D-SNPs that have yet to participate in Medicaid will need to continue make significant business decisions on participation and actively compete to secure state Medicaid contracts, which will have downstream implications for their state and local partners.

Connect with Us

量子资源网 (量子资源网) experts continue to review the evolving landscape and federal changes that will affect D-SNPs in 2025 and beyond. Contact our featured experts below for details about the nationwide D-SNP rules and landscape.

Countdown to 量子资源网鈥檚 fall 2024 conference: Spotlight on Medicare-Medicaid integration

Read Blog

The upcoming 量子资源网 event, , offers extensive opportunities to engage with leaders from various sectors who are designing and implementing Medicare-Medicaid integration initiatives. Join us for main stage panel discussions with distinguished health plan executives from national and local plans and Medicaid directors from Iowa, New Mexico, New York, and Rhode Island.

量子资源网 Principal Holly Michaels Fisher will lead a deeper dive into integration issues during the breakout session, Innovations to Improve Outcomes for Medicare-Medicaid Dually Eligible Individuals, with speakers , President and CEO of WellCare; , Medical Director for the Division of Aging at Indiana Family and Social Services Administration; , Executive Medical Director for the Center of Excellence of Medicare Duals/D-SNP at Aetna; and , Deputy Secretary for the Office of Long-term Living in the Pennsylvania Department of Human Services.

During the breakout, Meeting New Expectations for Health Equity and Improved Beneficiary Outcomes in Medicare Advantage, 量子资源网 Principal聽Greg Gierer will facilitate a conversation on the evolving landscape of MA rates and supplemental benefits, with experts聽, Health Economist and Bloomberg Distinguished Professor at the Johns Hopkins Bloomberg School of Public Health and the Johns Hopkins Carey Business School;聽, Director of the University of Michigan鈥檚 Center for Value-Based Insurance Design, and聽, Vice President of Policy and Government Affairs at the SCAN Group.

Online registration ends October 1^st.

New 量子资源网 analysis explores options to improve California鈥檚 substance use disorder treatment system

Read Blog

In recognition of this September, our In Focus section spotlights a new report from 量子资源网, Inc. (量子资源网), Substance Use Disorder in California: A Focused Landscape Analysis. Published in August 2024 with support from the California Health Care Foundation, this analysis provides valuable insights into California鈥檚 substance use disorder (SUD) treatment system and offers actionable recommendations for improvement that can be applicable for other states.

The SUD Landscape in California

SUDs continue to be a significant issue both nationally and in California. In 2022, approximately 9 percent of Californians ages 12 and older met the criteria for SUD, compared with 16.5 percent nationally in 2021. The prevalence of SUD is also on the rise: in 2015, 8.1 percent of Californians ages 12 and older met SUD criteria, rising to 8.8 percent in 2022. Of the Californians struggling with SUD, only 10 percent received treatment for their condition, compared with 6 percent nationally in 2021. Overall, 81 percent of US adults who received care for SUD reported struggling to access necessary services.

California鈥檚 public behavioral health system siloes specialty mental health (MH) services, mild-to-moderate MH services, and SUD treatment services, resulting in a fragmented and inconsistent system that struggles to effectively support people with co-occurring conditions.

County plans administer specialty behavioral health (BH) services. They all have memorandums of understanding with the state鈥檚 Department of Health Care Services that are separate from the state arrangements to provide physical healthcare services. BH programs vary significantly across the state because counties operate them differently, with key variations in access policies, quality monitoring, services, and programming. Mild-to-moderate (non-specialty) MH benefits are administered by Medicaid managed care plans. Much of the state鈥檚 SUD treatment is operated by the Drug Medi-Cal Organized Delivery System (DMC-ODS).

Barriers to Care: Key Findings

System barriers prevent many Californians with SUD from accessing adequate care. Interviewees received a pre-interview questionnaire to determine the factors they believe have the greatest impact on access to SUD treatment. According to 11 out of 14 respondents, lack of access to housing and residential services is a 鈥渉uge barrier鈥� to SUD treatment.

Other barriers to care access, ranked in order, include limited access to food, transportation, and other social drivers of health (SDOH), SUD provider shortages, stigma against people with SUD, disparities in service availability across racial/ethnic groups and other populations, and complex referral and intake processes.

Respondents also identified factors that could negatively affect clinical outcomes for people with SUD. Insufficient access to stable housing ranked first, followed by inadequate care coordination, and limited access to residential SUD treatment. Respondents ranked 11 factors as follows:

Figure 1: Factors Leading to Reduced Outcomes, Ranked from a List of 11

Service gaps pose another significant barrier to people accessing SUD treatment, and some populations are more likely to encounter challenges than others. According to the respondents, by various population groups, Latine/Hispanic populations, African American/Black populations, and Native American/Alaska Native populations are most likely to experience SUD service gaps. By age, people who are 19鈭�25 years old (transition-age youth) and adults ages 26鈭�65 are most likely to face service gaps.

Opportunities to Support Improvements in SUD Care

Findings and recommendations to enhance support for individuals are informed by surveys and interviews conducted with SUD stakeholders from across the state. Recommendations highlighted in the report include:

Investments in the workforce.聽By addressing the shortage of licensed clinicians and implementing peer support workers into the care continuum, the state would increase access to care. Many stakeholders have positioned themselves to meet SUD needs, but they cannot do so without an adequate workforce. Furthermore, the workforce would benefit from strengthening culturally responsive training in evidence-based practices.
Expansion of residential treatment services and housing options. There is a growing need, especially among transition-age youth, for residential treatment and SUD recovery housing.
Increased access to and training around harm reduction. Although stigma around harm reduction has decreased, training and access remains a barrier. Respondents highlighted the need to better manage contingencies, make methadone more accessible, establish safe consumption sites, expand medication assisted treatment for SUD and AUD, and improve the availability of Narcan.
MH and SUD treatment integration.聽Offering concurrent MH and SUD treatment with the same providers can help improve access to care for people with co-occurring conditions and minimize duplication.
Improved care coordination.聽Respondents suggested funding formal care coordination positions鈥攁 recommendation that is consistent with the national movement toward the coordinated care model applied in certified community behavioral health centers.
Improved data literacy.聽Behavioral health organizations need support and technical assistance to learn how to track and use data to support continuous quality improvement.

What to Watch

The overarching challenges facing California鈥檚 recovery system are present in other states. These states can adapt the strategies discussed in this report to address their own SUD concerns. In California, as in other states, an important aspect of addressing SUD treatment involves strategic allocation of opioid settlement dollars. These funds, resulting from legal settlements with opioid manufacturers and distributors, are expected to play a significant role in improving the state鈥檚 SUD treatment infrastructure, especially when considered alongside available federal funding, demonstrations, and regulatory flexibilities.

Connect With Us

The upcoming 量子资源网 event, , will offer more opportunities to engage with leaders from various sectors who are advancing solutions to improve access to care and reducing access disparities. Throughout the conference, federal and state officials, community leaders, and national experts will shed light on the challenges and solutions to these issues.

Navigating the impact of Medicare drug price negotiations: insights and future considerations

Read Blog

This week鈥檚 second In Focus continues the conversation on drug policies and trends, providing updates and insights into the current landscape of Medicare’s drug price negotiations.

The Centers for Medicare & Medicaid Services (CMS) recently released the negotiated prices for the first 10 Medicare Part D drugs under the Inflation Reduction Act鈥檚 (IRA鈥檚) negotiation authority. CMS plans to add more drugs to the negotiation list, including 15 additional Part D drugs in 2027 and 15 more products from both Part D (pharmacy benefit drugs) and Part B (mostly physician administered drugs). In 2029 and later years, another 20 drugs from either Part B or Part D will be chosen.

Negotiated Prices for First 10 Drugs Leave Unanswered Questions

CMS estimates the negotiated prices for 30-day supplies of each medication will result in savings ranging from 38 percent to 79 percent compared with list prices when they take effect in 2026. This comparison, however, does not account for several factors that could affect the actual savings for the Medicare program and beneficiaries, including:

Current negotiated discounts available to Medicare Part D plans
Changes in tier placement for the negotiated drugs and their impact on patient cost sharing
The exemption for manufacturers from the 10 percent discount during the initial coverage phase and the 20 percent discount thereafter once negotiated prices take effect in 2026
The effect of Medicare鈥檚 negotiations on prices paid by other payers
The impact of the IRA program on prices for other products and manufacturer investments in research and development of new products

CMS is required to provide a detailed explanation of how negotiated prices were determined by March 1. The price comparisons with privately negotiated prices, however, will remain unclear and the effects on other payers and longer-term investments in new products may not be fully understood for some time. The table below lists the negotiated discounts for the first 10 drugs, which CMS selected from the top 50 Part D drugs by spending, which lacked generic or biosimilar alternatives and met other IRA criteria.

Negotiated Drug Prices Applicable in 2026

Looking Ahead

Age of Products and Role of Generic and Biosimilar Competition: Drugs eligible for negotiation are typically the highest expenditure drugs that have been on the market for at least seven years or 11 years in the case of biologics. Importantly, products with generic or biosimilar competition are exempt from negotiation. This exemption may increase the speed at which biosimilar or generic competition comes to market, as the IRA requires competitors to engage in bona fide marketing to exempt an innovator from negotiation. Despite approval, biosimilars for some of the drugs will remain subject to negotiated prices until their marketing efforts begin.1

Impact on Medicaid and Other Payers: The IRA鈥檚 negotiated discounts are not required to be available outside of the Medicare program. It remains uncertain whether other payers will use Medicare-negotiated prices as leverage in their own negotiations. For Medicaid, the direct impact of negotiations themselves is expected to be negligible; however, the IRA鈥檚 inflation penalties could encourage more manufacturers to moderate price increases over time, potentially leading to reduced inflation penalty rebates to state Medicaid programs.

Connect with Us

To explore these topics further, join 量子资源网 at the upcoming event,鈥�. Engage with our Medicare experts below who will lead a small group discussion on trends in prescription drug policies during the pre-conference workshop.

For details on IRA pricing issues or other Medicare health policy developments, contact our featured experts below. 量子资源网鈥檚 Wakely Actuaries also are available to discuss the IRA鈥檚 role in Medicare Part D.

Highlights from 量子资源网 survey on state approaches to managing the Medicaid pharmacy benefit

Read Blog

This week’s In Focus covers key takeaways and insights from a recently released 量子资源网 report, State Approaches to Managing the Medicaid Pharmacy Benefit: Insights from a National Survey for State Fiscal Years 2023 and 2024.

The report, released in August 2024 with support from Arnold Ventures, includes survey responses from 47 states (including DC) for state fiscal years (SFYs) 2023 and 2024. The survey instrument builds on questions posed in the of all 50 states and the District of Columbia, which 量子资源网 and the Kaiser Family Foundation conducted.

The report discusses state trends for how Medicaid pharmacy benefits are administered across the country, including planned priorities and anticipated challenges in SFY 2025 and beyond. The findings are based on information provided by the nation鈥檚 state Medicaid Directors, Medicaid Pharmacy Directors, and other Medicaid agency experts.

Pharmacy Benefit Administration

In many states, managed care delivery systems play a pivotal role in administering Medicaid benefits, including prescription drugs. As of July 1, 2023, survey results found that:

A total of 33 states carved pharmacy benefits into managed care organization (MCO) contracts, with one state, Kentucky, directing its MCOs to use a single state-selected pharmacy benefit manager (PBM).
Eight states carve-out the pharmacy benefit鈥攄ouble the number in 2019.

MCO states were surveyed about their use of carve outs for certain drug products/classes, inclusive of physician-administered drugs covered under the medical benefit.

In all, 19 states reported carving out one or more drug classes or select agents within a drug class鈥攐ften high-cost specialty drugs.
Of those states, 13 reported using the carve-out as part of a risk mitigation strategy.

Bar chart titled "MCO PBM Contract Requirements as of July 1, 2023,"

Pharmacy Benefit Managers

The significant role and market power of PBMs have prompted many state legislatures to enact greater transparency practices and require health plans to accept more responsibility for monitoring the PBMs they contract with, which reflect notable changes since the 2019 survey. More specifically:

A total of 33 states reported contracting with a PBM.
The most frequently reported PBM functions included utilization management, drug utilization review, claims processing and/or payment, and rebate administration activities.

The 30 MCO states that carve in pharmacy benefits responded to survey questions about PBM transparency and spread pricing requirements. Of these states:

25 prohibit spread pricing in MCO PBM contracts鈥攎ore than double the number of states reporting prohibitions on spread pricing in 2019.
17 reported having PBM transparency reporting requirements.
10 states reported having 鈥渁ny willing鈥� pharmacy requirements.

The Role of PDLs, Prior Authorization, and Step Therapy in Controlling Drug Costs and Utilization

量子资源网鈥檚 experts also sought information on state payment strategies and utilization management protocols that are used to manage pharmacy expenditures. Nearly all responding states (44) have a preferred drug list (PDL) in place for fee-for-service prescriptions, which allow states to drive the use of lower cost drugs by encouraging providers to prescribe preferred drugs. Further, nearly two-thirds of responding MCO states (19 of 30 states) that do not carve out the pharmacy benefit reported having a uniform PDL for some or all drug classes, requiring all MCOs to cover the same drugs.

Many states鈥痟ave implemented鈥痵tep therapy鈥痑nd prior authorization (PA) guardrails in their Medicaid programs through legislation. However, 85.1 percent of responding states (40 of 47) report utilization controls like PA or step therapy applied to drugs that are reimbursed through the medical benefit to control utilization and costs. States also play an active role in managing MCO clinical protocols or medical necessity criteria, with 22 out of 30 MCO pharmacy carve-in states reporting that they require uniform clinical protocols for some or all drugs with clinical criteria. Approximately one-half of responding MCO carve-in states also require review and approval of MCOs鈥� PA criteria (15 of 30 states) and step therapy criteria (14 of 30 states).

State Adoption of VBAs: Improving Patient Access to Cell and Gene Therapies

A growing number of states are actively considering entering into value-based arrangements (VBAs) with manufacturers, as pressure to improve patient access to cell and gene therapies increases. Nine states have at least one VBA in place, and 23 states reported that VBAs are among their future solutions for addressing coverage of new high-cost therapies. States will need to address common barriers to VBA implementation, which involves more upfront costs and operational challenges to implement than traditional contracts.

Subsequent to the submission of survey responses, the Centers for Medicare & Medicaid Services (CMS) released a Cell and Gene Therapy (CGT) Access Model, which begins with a focus on sickle cell disease, anticipated to go live on January 1, 2025. Under the model, CMS will negotiate outcomes-based agreements with manufacturers on behalf of the state to ensure that treatment pricing is related to treatment effectiveness. In the coming years, experiences with this model will help determine whether a CMS-led approach to developing and administering VBAs for CGTs improves Medicaid member access to innovative treatment and their impact on expenditures, if any.

Map of the United States titled "States with Approved VBA State Plan Amendments as of March 14, 2024," — Source:

Looking Ahead

Managing the Medicaid pharmacy benefit has never been more challenging. In FY 2025 and beyond, most states will be focused on managing their Medicaid pharmacy budgets, especially the development of VBAs and other policies and strategies for managing new high-cost therapies. Other top priorities and challenges cited by multiple states include management of PBM arrangements and considering coverage of the new generation of GLP-1 anti-obesity medications. States also must react to changing drug marketplace conditions driven, in part, by federal policy changes to the Medicaid drug rebate formula and changes designed to lower Medicare drug costs. Drug manufacturer responses to these changes have implications for Medicaid state budgets, but also for state PDL management decisions and beneficiary access to needed medications.

Connect with Us

The upcoming event,鈥�, hosted by 量子资源网, will offer more opportunities to engage with report author Kathy Gifford at the pre-conference workshop Paying for Innovative Pharmaceuticals: State and Federal Trends Shaping Public Programs. Leaders from various sectors will join Kathy to discuss trends in prescription drug policies in public and commercial insurance programs.

For details about the report, contact our featured experts below.

Decoding your defense: a playbook to help your plan increase your Star rating

Read Blog

Watch a replay of our webinar Mastering Star Performance: Strategies from the 量子资源网 Stars Accelerator Program.

WATCH NOW

量子资源网 works with managed care plans to maximize Star ratings and improve program quality.

Star Ratings have been on a steady decline over the last two years resulting in large reductions in quality bonus and rebate payments, potentially impacting opportunities to improve member health outcomes.

How 量子资源网 can help improve a plan鈥檚
Star rating:

We have developed a playbook that captures The 量子资源网 Stars Accelerator Solution with proven strategies for Stars improvement based on our diverse and extensive expertise in managed care plan (MCP) operations, MCP strategy, performance improvement, actuarial science, data analytics, risk adjustment, and federal and state policy.

Using our vast experience in the Medicare and Medicaid space, 量子资源网 can help you maximize ratings in programs like Medicare Stars and Medicaid quality performance. Together with our actuarial colleagues from Wakely Consulting Group and federal policy expert colleagues from Leavitt Partners, both 量子资源网 companies, we can provide the assistance you need to move your organization to a higher Star rating level. With guidance from 量子资源网 experts, the Accelerator is scalable for both functional and matrix organizations.

Want a copy of 量子资源网’s
Stars Accelerator Playbook?

Fill out this form and one of our consultants will get back to you.

量子资源网 can help your organization create momentum by combining 量子资源网鈥檚 programmatic strategies with a robust actuarial and analytical basis, inclusive of integrated risk adjustment.

Meaningful data analysis ensures plans can prioritize the most important areas for strategic focus. Improving performance in Stars requires a multi-pronged, multifactorial approach. The 量子资源网 Stars Accelerator Solution is consumer-oriented and customizable to meet the unique needs of your members鈥� needs. It facilitates understanding of the organization鈥檚 current state, identifies opportunities for improvement, provides best practices for design of meaningful solutions to implement, and measures the effectiveness of improvements.

Diagram of seven connected hexagons forming a circle around 鈥淐ontinuous Improvement Methodology,鈥� showing six steps: SWOT Analysis, Journey Mapping, Plan Access, Member Outreach, Provider Support, and Analytics.

Why is a high Star rating important for a health plan?

This image shows a rating table with three columns: Numeric, Graphic, and Description.

The Centers for Medicare & Medicaid Services (CMS) publishes the Medicare Advantage (Medicare Part C) and Medicare Part D Star ratings each year to measure the quality of health and drug services received by consumers enrolled in Medicare Advantage (MA) and Prescription Drug Plans (PDPs or Part D plans). Star ratings impact a managed care plan鈥檚 financial performance, competitiveness, growth, and member retention. They are based on measures of multiple aspects of plan performance including:

Member experience and satisfaction

Administrative performance

Medication safety and/or adherence

Hospital readmissions

Healthcare Effectiveness Data and Information Set (HEDIS) and Health Outcomes Survey (HOS), both of which measure performance improvement.

Contracts are rated on a scale of one to five stars (rounded to nearest half star) based on approximately 45 measures related to preventive care, member experience (health plan customer service, physician point of service care, and perceived health), prescription drug monitoring, health plan operations, etc.

The industry has meaningfully improved traditional quality metrics (e.g. preventative care and medication adherence rates). As performance peaks in those measures, CMS is placing increasing emphasis on the member experience with their health plan and their providers during care.

Plans with 5 stars can market year-round.

The marketing advantage is a distinction for a high rated plan.

Poor performers (under 3 Star rating for 3 years) receive a Poor Performance Icon and may not be able to renew with CMS.

In 2024 there were 29 Part C (Medicare Parts A & B) and 11 Part D (Pharmacy) measures, and they can change every year. CMS recently released plan preview Star performance data for health plans to review. Final scores and Star ratings will be released by CMS in early October 2024 for Star Year 2025 based upon 2023 dates of service.

Star Rating High Level Timeline

CMS Star Ratings are a lagged pay-for-performance system. For 2026 Star Ratings, 2024 and early 2025 performance timeframes are critical to success, even though payments for this performance will not be received until 2027.

This image shows a high-level timeline for CMS Star Ratings from 2024 to 2027.

What plans do in 2024 and 2025 impacts your 2026 Star rating which will affect your plan鈥檚 revenues in 2027.

Is your plan building a strategy for next year based upon underperforming measures? Are you looking for ways to lean in on any remaining Consumer Assessment of Healthcare Providers and Systems (CAHPS) and HOS opportunities? Do you know where to start?

See our 量子资源网 Solutions page, Star Rating: We Can Help You Navigate to a Higher Level, for more information.

Contact our experts below for more information about 量子资源网鈥檚 Stars Accelerator Solution.

Amy Bassano

Managing Director, Medicare

Tom Lutzow

Principal

Daniela Simpson

Senior Consultant II

Mary Walter

Principal

Featured Solutions:

Featured 量子资源网 insights:

More insights from our companies:

Receive timely expert insights on topics you care about.

496 Results found.

CMS releases draft benefit and payment parameters for 2026 Marketplace

Medicaid unwinding: enrollment shifts and Q2 2024 managed care insights

24th annual Kaiser Family Foundation state Medicaid budget survey released聽

The release of 2025 Medicare Advantage Star ratings and improving future rating cycle performance

What to watch for in Medicare Advantage policy this fall

2025 Star rating cut point changes: key updates and their impact

Why Cut Points Matter

Key Findings

Key Considerations

Connect with Us

Illinois D-SNP RFP: Highlights and signals of forthcoming trends

Overview

Illinois D-SNP RFP Highlights

Emerging National Trends

Emerging National Trends

What We鈥檙e Watching

Connect with Us

Countdown to 量子资源网鈥檚 fall 2024 conference: Spotlight on Medicare-Medicaid integration

New 量子资源网 analysis explores options to improve California鈥檚 substance use disorder treatment system

Navigating the impact of Medicare drug price negotiations: insights and future considerations

Highlights from 量子资源网 survey on state approaches to managing the Medicaid pharmacy benefit

Decoding your defense: a playbook to help your plan increase your Star rating

量子资源网 works with managed care plans to maximize Star ratings and improve program quality.

How 量子资源网 can help improve a plan鈥檚
Star rating:

量子资源网 can help your organization create momentum by combining 量子资源网鈥檚 programmatic strategies with a robust actuarial and analytical basis, inclusive of integrated risk adjustment.

Why is a high Star rating important for a health plan?

Star Rating High Level Timeline

Contact our experts below for more information about 量子资源网鈥檚 Stars Accelerator Solution.

Featured Solutions:

Featured 量子资源网 insights:

More insights from our companies:

Insights

量子资源网 Insights - Blog

Receive timely expert insights on topics you care about.

496 Results found.

Why Cut Points Matter

Key Findings

Key Considerations

Connect with Us

Overview

Illinois D-SNP RFP Highlights

Emerging National Trends

Emerging National Trends

What We鈥檙e Watching

Connect with Us

量子资源网 works with managed care plans to maximize Star ratings and improve program quality.

How 量子资源网 can help improve a plan鈥檚 Star rating:

量子资源网 can help your organization create momentum by combining 量子资源网鈥檚 programmatic strategies with a robust actuarial and analytical basis, inclusive of integrated risk adjustment.

Why is a high Star rating important for a health plan?

Star Rating High Level Timeline

Contact our experts below for more information about 量子资源网鈥檚 Stars Accelerator Solution.

How 量子资源网 can help improve a plan鈥檚
Star rating: