A Summary of Key Points from CY 2025 Advance Notice - Updates for Part C and D Star Ratings

?Reminders for 2025 Star Ratings:

1. CMS annually sets a deadline for MA and Part D organizations to request reviews of Part C appeals data or CTM data. The deadline for the 2025 Star Ratings is June 28, 2024 (make your A&G team aware).
2. The question "In the last 6 months, how often did you see the person you came to see within 15 minutes of your appointment time?" will be removed from the Getting Appointments and Care Quickly measure for the 2025 Star Ratings, per the 2024 Rate Announcement. The measure will consist of two existing questions :In the last 6 months, when you needed care right away, how often did you get care as soon as you needed? In the last 6 months, how often did you get an appointment for a check-up or routine care as soon as you needed??

Key Points - Measure Updates for 2025 Star Ratings:

1. Weight Adjustment: Starting with the 2024 measurement year (2026 Star Ratings), the weight of patients' experience and complaints and access measures will be reduced from 4 to 2.
2. Improvement Measures & Categorical Adjustment Index (CAI): CMS provided tables listing measures that will be included in the QI & CAI measure calculations for Star year 2025. ?

Key Points - Extreme and Uncontrollable Circumstances Policy for the 2025 Star Ratings:

1. Extreme and uncontrollable circumstances - For star year 2025 Contracts with at least 25% of their service area in a FEMA-designated Individual Assistance area in 2022 will receive the higher of their measure-level rating from the current and prior Star Ratings years for calculating the 2025 Star Ratings & numeric scores for contracts with 60% or more of their enrollees living in FEMA-designated Individual Assistance areas at the time of the circumstance are excluded from: Measure-level cut point calculations for non-CAHPS measures & performance summary and variance thresholds for the reward factor.
2. As a reminder, the 60% rule will be removed starting with the 2026 Star Ratings covering the 2024 measurement year for most measures.

Key Points - Changes to Existing Star Ratings Measures for the 2025 Measurement Year and Beyond:

1. Feedback Solicitation on New Measures: CMS solicits feedback on new measure concepts and updates through the annual Advance Notice and Rate Announcement process. Measures with substantive changes must undergo rulemaking and remain on display for at least 2 years before becoming Star Ratings measures.
2. Universal Foundation Star Ratings Measures: CMS is committed to aligning a subset of measures across all programs, termed the "Universal Foundation," promoting consistency and reducing provider burden. Depression Screening and Follow-Up for Adolescents and Adults (Part C) and Adult Immunization Status (Part C) will be added to the 2026 display page based on the 2024 measurement year.
3. Breast Cancer Screening (Part C): NCQA is considering revising the Breast Cancer Screening measure to assess screening for members aged 40-74, aligning with updated U.S. Preventive Services Task Force recommendations.
4. Diabetes Care - Eye Exam (Part C): NCQA is reviewing administrative codes used for determining completion of a diabetic retinal eye exam, considering updates for measurement year 2025. This update is non-substantive.
5. Statin Therapy for Patients with Cardiovascular Disease (Part C): NCQA plans to add an exclusion for patients with a history of statin intolerance, aligning with feedback from the Cardiovascular Measurement Advisory Panel. This non-substantive update is set for measurement year 2025.
6. Plan Makes Timely Decisions about Appeals: CMS is considering updates to the timeliness measure, including eliminating additional days for electronically submitted appeal files and using the electronic system receipt date for defining when the appeal was received by the IRE. These potential changes would be substantive and undergo rulemaking.
7. Reviewing Appeals Decisions: Changes to the timeliness measure would impact the Reviewing Appeals Decisions measure, as both are interconnected. Any substantive changes would follow the rulemaking process, and legacy measures would remain until the updated measures have been on display for at least two years.

Key Points - Additional Updates to Star Ratings Measures for the 2025 Measurement Year and Beyond:

1. Identifying Chronic Conditions (Part C): NCQA is reevaluating the identification of chronic conditions across HEDIS measures. Changes involve simplifying measure specifications, requiring at least two encounters with the diagnosis on different dates of service. A method using clinical data is also under development.
2. Gender-Affirming Quality Measurement in HEDIS (Part C): NCQA is expanding efforts to update measure specifications for gender-affirming approaches in eligible populations. Potential changes focus on statin therapy and osteoporosis treatment measures, with a goal to ensure inclusivity and address disparities in care for transgender and gender-diverse members.
3. Care Coordination (Part C): The Care Coordination measure, a composite based on 6 questions measuring patient experience, is under consideration for updates. CMS tested alternative questions related to how healthcare providers explain test results, aiming to refresh the concept and potentially replace existing items. Items in Potential New Composite (Care Coordination): Of the potential new composite items, 3 pertain to test results, and 3 pertain to other aspects of care coordination. Some items from the existing composite are retained, with modifications to wording. CMS tested the potential new care coordination composite via a 2022 survey and noted very little difference between plans that performed well on the prior version vs the new version. Feedback Welcome: Stakeholder feedback on potential revisions to the Care Coordination measure is encouraged. These changes would constitute a substantive update to the Star Ratings measure.
4. Initial Opioid Prescribing for Long Duration (IOP-LD) (Part D):Context: CMS addresses the national opioid crisis through balanced drug utilization review (DUR) policies and quality measurement strategies. Reporting History: The IOP-LD measure has been reported to Part D sponsors since measurement year 2020 and publicly reported on the Part D display page since 2023 (2021 data). (PQA serves as the measure steward).Intention to Propose Addition: CMS intends to propose adding the IOP-LD measure to the Part C and D Star Ratings in future rulemaking.

Key Points - Proposed Updates to Part C & D Star Ratings Measures for the 2025 Measurement Year and Beyond:

1. Data Source Change for Medication Adherence, SUPD, and MTM Measures: Objective: Change data sources for identifying beneficiaries with hospice stay or ESRD status from the Enrollment Database (EDB) to the Common Medicare Environment (CME).Rationale: Accessing enrollment information through the CME (retrieved from the Integrated Data Repository) is expected to improve data availability for monthly Patient Safety reports. Impact: CMS anticipates no impact on measure calculations; it's considered a non-substantive update.
2. Members Choosing to Leave the Plan Measure: Adjustment in Service Area Data: CMS plans to adjust the years of service area data used to identify beneficiaries leaving a contract due to a move out of the contract service area. Timing of Adjustment: For disenrollments occurring at the end of the measurement year (December 31), service area data for the year following the measurement year will be used for both old and new contracts. Effective Year: The adjustment will be effective starting with the 2026 Star Ratings. Applicable Integrated Plans Exclusion: Enrollments into plans designated as Applicable Integrated Plans will be excluded from the measure numerator for the old contract, with exceptions outlined. Non-Substantive Update: These changes are considered non-substantive, with minor impacts on the measure numerator.
3. Applicable Integrated Plans Definition: Definition: Applicable Integrated Plans are D-SNPs with exclusively aligned enrollment with a Medicaid managed care organization. Enrollment Exclusion: Enrollments into an Applicable Integrated Plan are excluded from the measure numerator for the old contract, with exceptions outlined. Exceptions: Enrollments are not excluded if the plan in the old contract is also an Applicable Integrated Plan. Effective Year: The exclusion of Applicable Integrated Plans enrollments will be implemented beginning with the 2026 Star Ratings. Non-Substantive Update: This change is considered non-substantive as it narrows the population covered by the measure.

Key Points - Retirement of Star Ratings Measure: Care for Older Adults – Pain Assessment (Part C)

Reasons for Retirement:

1. Multidimensional Approach: The current indicator lacks the ability to ensure multidimensional pain assessments.
2. Acute vs. Chronic Pain: The indicator does not differentiate between acute and chronic pain.
3. Lack of Follow-Up Assessment: The indicator does not assess follow-up care, and evidence suggests that pain assessment alone does not significantly improve the quality of care.
4. Broader Population Benefit: The current measure is reported only for Special Needs Plans. A wider population of Medicare Advantage (MA) members could benefit from a more comprehensive pain assessment and follow-up measure.

Development of New Measure:

NCQA is working towards developing a new measure that addresses the shortcomings of the current indicator. The new measure is described in the "Potential New Measure Concepts and Methodological Enhancements for Future Years" section.

CMS Rule:

The April 12, 2023, final rule allows CMS to remove a Star Ratings measure, without separate rulemaking, when the measure steward (e.g., NCQA) retires a measure.

The removal of the Care for Older Adults – Pain Assessment measure is in accordance with this rule, starting with the 2025 measurement year and 2027 Star Ratings. CMS is announcing the removal of the measure in advance of the measurement period, as required by the regulatory rule, based on NCQA's retirement of the measure.

Key Points - Potential New Measure Concepts and Methodological Enhancements for Future Years:

1. Health Outcomes Survey (Part C): CMS exploring enhancements and refinements to existing Health Outcomes Survey (HOS) measures. Field test includes new items related to physical function, anxiety, and health-related social needs. Focus on evaluating measurement properties, effects of revised content, and web-based survey mode.
2. Blood Pressure Control for Patients with Hypertension (Part C): NCQA exploring a new blood pressure control measure for digital quality measures. New approach includes expanded denominator, lower evidence-based threshold, and leverages electronic clinical data. Being explored for measurement year 2025 and beyond.
3. Breast Cancer Screening Follow-Up (Part C): NCQA exploring a new measure for documenting and following up on abnormal mammogram results. Developed as an Electronic Clinical Data Systems (ECDS) measure. Currently in development for measurement year 2025.
4. Social Connection Screening and Intervention (Part C): NCQA developing a new measure for measurement year 2025. Assesses the percentage of members aged 65 and older screened for social isolation, loneliness, or inadequate social support. Includes indicators for social connection screening and intervention. Proposed reporting using electronic clinical data.
5. Chronic Pain Assessment and Follow-Up (Part C): NCQA developing a new measure for measurement year 2025. Intended to replace the retiring Pain Assessment indicator. Assesses the percentage of members aged 65 and older screened for pain, with a documented multidimensional assessment and follow-up. Proposed reporting using ECDS.

Your Voice Matters:

Remember, CMS welcomes & considers feedback on these proposed changes. Make sure to share your thoughts by commenting on the proposals before March 1, 2024, 6:00 PM Eastern Time at www.regulations.gov (CMS-2024-0006).

Questions or need more details? Don't hesitate to reach out!