The Centers for Medicare & Medicaid Services (CMS) created the Five-Star Quality Rating System to improve the quality of care for Medicare beneficiaries electing Medicare Advantage coverage from health plans versus traditional Medicare.
The CMS Star Rating System is designed to improve quality of care, overall health outcomes, and access to affordable health care, while helping Medicare beneficiaries select the best Medicare Advantage plan for their health care needs.
Some Star measures focus on metrics not directly influenced by providers, such as assessing benefit information, service, or customer experience with the Medicare Advantage plan. However, many of the measures included in the Star Rating System assess patients’ interaction with providers. This guide focuses on these areas and how they affect your practice and patients.
Provides one of the many ways that health care consumers make informed choices about their health plan and providers.
Affects payments to Medicare providers and managed care organizations.
Helps patients enhance relationships with providers and health plans by ensuring accessibility to care, enhanced quality of care, and optimal customer service.
Places greater focus on preventive care and early detection of disease.
Increases investments in health plan benefits that help your patients.
There are different opportunities for providers to engage with patients to help ensure quality and timely care while helping them manage their health. The information in this guide is not meant to preclude clinical judgment. Treatment decisions should always be based on the clinical judgment of the physician or other health care providers at the time of care.
The CMS Five-Star Quality Rating System is based on a range of approximately 40 quality metrics that come from the areas listed below. The weighted average of these measures results in the overall Star Rating.
Click each domain title for a list of measures.
DOMAIN KEY
See how each patient interaction is related to a corresponding domain.
The example also covers Star measures including:
Getting Needed Care, Getting Appointments and Care Quickly, Care Coordination
Doctors Who Communicate Well, Customer Service
Getting Needed Prescriptions, Controlling High Blood Pressure, Eye Exam for Patients with Diabetes, Kidney Health Evaluation for Patients with Diabetes, Statin Use in Patients with Diabetes, Medication Adherence
Rating of the Health Plan, Rating of Health Care Quality, Rating of Drug Plan
You can learn more about these measures in this guidebook.
The Cigna HealthcareSM mission is to improve the health and vitality of those we serve. Star rating domains and measures are a big part of that. But we can’t improve ratings or get seniors to their healthiest selves without you. We’d really appreciate your help. Here are some actions you can take.