The Centers for Medicare & Medicaid Services (CMS) released the 2025 Advance Notice on January 31 with updates to Part C and Part D Star Ratings. With the volume of changes and potential impact on revenue, health plans must have a deep understanding of these changes and how to address them should they get approved. Health plans should review the proposed measures and provide feedback to CMS by 6 p.m. EST on March 1.
Understand the key changes with a thorough breakdown by industry pros John Willis, Vice President, Consulting & Professional Services; Ana Berridge, Senior Advisor; Cherié Shortridge, Senior Advisor; and Donna Simon, Senior Advisor.
Recap of Updates from MY2023
CMS provided reminders for the 2025 Star Ratings. Below you will find the updates to keep in mind while finalizing your Measurement Year (MY) 2023 work:
- The deadline for plans to request the Independent Review Entity (IRE) to review its appeals data and for CMS to review Complaints Tracking Module (CTM) data is June 28, 2024.
- As a reminder, in the 2024 Rate Announcement, CMS stated they will remove the “15-minute wait time” question from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey for the 2025 Star Ratings (MY2023).
- CMS also provided the final measure listing for the 2025 Star Ratings, along with identifiers for both the Improvement Measure and Categorical Adjustment Index (CAI) value measures.
- Details were also provided regarding Extreme and Uncontrollable Circumstances Policy for the 2025 Star Ratings.
Proposals for MY2025 and Beyond
Looking towards the future, plans should be aware of the changes to existing Star Ratings measures for the MY2025 and beyond. CMS is soliciting feedback on measures being introduced to the Star Rating program or changes being made to existing Star measures. The following are changes to be aware of:
- CMS has submitted the Initiation and Engagement of Substance Use Disorder Treatment and Initial Opioid Prescribing for Long Duration measures to the 2023 measure under consideration list (MUC), which include measures CMS is considering for adoption through the rulemaking process.
- CMS continues to add all of the Universal Foundation measures as part of the Part C and Part D Star Ratings through pending future rulemaking. Depression Screening and Follow-up for Adolescents and Adults and Adult Immunization Status will be added to the 2026 Display based on the MY2024.
- Breast Cancer Screening updates are being considered to align with updates provided by the U.S. Preventive Services Task Force in 2023. This would change the age range from 50-74 to 40-74. Based on the vote related to these measure changes, this would be considered a substantive change, and the new measure would be on display for two years, alongside the legacy measure still in the Star Ratings program.
- Diabetes Care-Eye Exams could see some changes related to the administrative codes used to determine a diabetic retinal exam. These updates could come as early as MY2025 and would be non-substantive.
- CMS is looking to update the exclusionary criteria for the Statin Therapy for Patients with Cardiovascular Disease with the National Committee for Quality Assurance (NCQA) to implement the update for MY2025. The changes would be considered non-substantive.
- Appeals timelines are under review to align with the more frequently utilized electronic submissions and removing the five-day grace period for those submissions submitted electronically and would be considered a substantive change to the measure.
- Cross-cutting changes are being considered for measures to identify chronic conditions with measure specifications being simplified to identify members with a condition if they have at least two encounters with the diagnosis (in any setting on different dates of service). This method is planned for the new blood pressure measure under development for Healthcare Effectiveness Data and Information Set (HEDIS) MY2025.
- Cross-cutting changes are being considered to remove gendered language from quality measures. These changes would start with the evaluation of Statin Therapy for Patients with Cardiovascular Disease and Osteoporosis Treatment.
- The Care Coordination question measure set could be updated with new composite measures. CMS is seeking feedback on these potential changes. If codified, these changes would be considered substantive.
- Initial Opioid Prescribing for Long Duration is included in the 2023 measures under consideration and based on the vote, CMS proposes the addition of this measure to the Part C and Part D Star Ratings pending future rulemaking.
- The Medication Adherence Measures, Statin Use in Persons with Diabetes, and Medication Therapy Management Program Completion Rate for Comprehensive Medication Review (CMR): CMS is proposing to remove the Enrollment Database (EDB) as a data source to identify hospice enrollment and End State Renal Disease (ESRD) status and instead use the Common Medicare Environment (CME) to identify hospice enrollment and ESRD with MY2024. These changes would be considered non-substantive.
- CMS is also planning to update the methodology for Members Choosing to Leave the Plan related to disenrollments as a result of a move out of a contract’s service area. These changes would be considered non-substantive, if approved, and would be implemented beginning with the 2026 Star Ratings.
Retirement of Star Ratings Measures
CMS is looking to retire the Care of Older Adults-Pain Assessment Star Ratings measure. This indicator will be retired at the earliest with MY2025.
CMS provided an update on the Display Measures and anticipates all 2024 Display Measures will continue to be shown in the 2025 Display Measure tables, unless otherwise noted below:
- Follow-up After Hospitalization for Mental Illness: NCQA is reevaluating this measure for MY2025 for continued relevance and validity. CMS welcomes comments on the potential updates being considered.
- Social Need Screening and Intervention: This measure will be added to the Display page for the 2025 Star Ratings. NCQA is also exploring utilities insecurity screening rate and intervention rate to MY2026.
- Adult Immunization Status (AIS): For the pneumococcal vaccine, NCQA is updating the lower age range for the denominator to age 65 years starting with MY2025. NCQA is also planning to remove the option for receiving the Herpes zoster live vaccine from the zoster indicator for MY2025. Additionally, NCQA is developing a new indicator to AIS that would assess Hepatitis B vaccination for adults 19-59 in MY2025.
- Polypharmacy: Use of Anticholinergic Medications in Older Adults: CMS to align with current Beers criteria and remove 14 medications from the measure for MY2024.
- Polypharmacy: Use of Multiple CNS-active Medication in Older Adults: CMS to align with Pharmacy Quality Alliance (PQA) measure changes for the MY2024.
- Cancer related measures could see some changes coming. PQA is testing an update to exclude beneficiaries more broadly with cancer-related pain to be effective with MY2025. CMS will also consider applying the updates if approved by the PQA.
- Medication Adherence for HIV/AIDs/Antipsychotic Use in Persons with Dementia, Overall Antipsychotic Use in Persons with Dementia, in Long-Term Nursing Home Residents/Use of Opioids at High Dosage in Persons without Cancer/Use of Opioids from Multiple Providers in Persons without Cancer/Initial Opioid Prescribing -Long Duration will move to use continuous enrollment and no longer adjust for member years beginning with the MY2025.
- Poly-CNS/Poly-ACH/Use of Opioids at High Dosage in Persons Without Cancer/ Use of Opioids from Multiple Providers in Persons Without Cancer/Concurrent Use of Opioids and Benzodiazepines will move to use continuous enrollment and no longer adjust for member years beginning with MY2024, along with the removal of the anchor date.
Retirement of Display Measures
CMS will be retiring several display measures. Below you will find the measures being retired from the display page:
- Antidepressant Medication Management
- Use of Opioids from Multiple Providers in Persons without Cancer
Potential New Measure Concepts and Methodological Enhancements for Future Years
CMS is proposing the addition of many new measures within the Star Ratings system and is soliciting feedback on the following measures and measure concepts:
- Health Outcomes Survey (HOS): CMS is looking to enhance and refine measures on HOS, along with adding a web-based survey module.
- Blood Pressure Control for Patients with Hypertension: NCQA is exploring the development of a new blood pressure control measure with emphasis on digital quality measures and could potentially become a Star Rating measure pending rulemaking for MY2025 and beyond.
- Breast Cancer Screening Follow-up: NCQA is exploring the development of a new measure to assess documentation and follow-up of abnormal mammogram results. The measure is currently in development for MY2025.
- Social Connection Screening and Intervention: NCQA is developing a new measure for MY2025 that assesses the percentage of members aged 65 and older who were screened, using pre-specified instruments, at least once during the measurement year for social isolation, loneliness, or inadequate social support and received a corresponding intervention if they screened positive.
- Chronic Pain Assessment and Follow-up: NCQA is looking to development a new measure to assess pain in the MY2025 at the earliest and is intended to replace the Care of Older Adults-Pain Screen that is planned for retirement.
- Tobacco Use Screening and Cessation and Lung Cancer Screening and Follow-Up: NCQA is exploring the development of two new measures related to tobacco use and lung cancer screening. These measures would potentially become part of HEDIS no earlier than MY2026. CMS is considering proposing these measures to the Star Ratings pending future rulemaking.
- Functional Status Assessment Follow-up: NCQA is proposing a new measure to assess follow-up after a Functional Status Assessment. Implementation of this measures would come during the MY2025 at the earliest.
- Medicare Plan Finder Drug Pricing Measure: CMS is considering a new measure to evaluate the accuracy of sponsors’ pricing data displayed on Medicare Plan Finder (MPF). This measure would stand alongside the current MPF measure to ensure accurate monitoring before becoming a Star Ratings measures via rulemaking.
How Healthmine Can Help
By partnering with Healthmine, health plans can leverage both consulting expertise and effective technology solutions to be successful in changing regulatory environments. Our team of expert advisors work with health plans to build a plan-specific go-forward strategy based on the direction CMS is going. Plans can simultaneously work within a comprehensive platform that consolidates data from multiple sources and allow plans to make data-driven and measure-specific decisions.
For any help with navigating the impacts of these proposals or support in improving your Stars performance, reach out to John Willis at John.Willis@healthmine.com.