Medicare STARs

Medicare STAR Measures (48 measures for Part C and D)

The Centers for Medicare & Medicaid Services (CMS) uses a STAR Rating System to measure how well Medicare Advantage and Part D Health Plans are performing.  CMS scores how well Health Plans perform in several categories including quality of care and customer service.  CMS rating of Health Plans range from one to five STARs, with five being the highest and one being lowest performing Health Plan.

Medicare Part C

  • 34 measures
  • Healthcare Outcomes Survey (HOS)
  • CAHPS Survey (Member Experience Survey)
  • HEDIS measures

Medicare Part C HEDIS Measures

Adult BMI Assessment (ABA): (18-74 age)

  • BMI Value: Document calculated BMI value in chart and submit code based on BMI value (Z68.1 – Z68.54).
  • Current measurement year or one (1) year prior to measurement year

Breast Cancer Screening (BCS): (50-74 age)

  • Breast Cancer Screening (weight: 1) : Mammogram (77055-77057 or G0202)
  • One or more mammograms any time on or between October 1 two years prior to the measurement year and December 31 of the measurement year.

Colorectal Cancer Screening (COL): (50-75 age)

  • Colonoscopy during measurement year or 9 years prior or
  • FOBT during measurement year or
  • CT Colonography during measurement year or 4 years prior or
  • FIT-DNA test during measurement year or 2 years prior or
  • Flexible Sigmoidoscopy during measurement year or 4 years prior

 Controlling High Blood Pressure (CBP): (18-85 age)

  • Members 18-59 years of age whose BP was < 140/90 mmHg
  • Members 60-85 years of age with a diagnosis of diabetes whose BP was <140/90 mmHg
  • Members 60-85 years of age without a diagnosis of diabetes whose BP was <150/90 mmHg Documentation requirements are the
  • Ensure documentation and coding of Hypertension DX code I10

Comprehensive Diabetes Care (CDC): (18-74 age)

  • Hemoglobin A1c Screening and Control (most current A1c < 9.0%)
  • Blood Pressure Control (<140/90)
  • Dilated Retinal Eye Exam (Optometrist or Ophthalmologist)
  • Nephropathy Screening

Care of Older Adults (COA): (66 & older)

  • Functional Status Assessment
    • Activities of Daily Living (1170F)
  • Medication Review
    • Document list of all Medications taken by the member (1159F and 1160F)
    • Document “no medications taken” if member is not taking any medications
  • Pain Assessment (1-10)
    • Document pain level from 1-10: (1125F is 1-10 and 1126F is 0 – pain level)

Medication Reconciliation Post-Discharge (MRP): (18 & Older)

  • PCP visit within 30 days from Inpatient Discharge Date (1111F)
  • Reconcile and document all medications taken by member in medical record

Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (ART): (18 & Older)

  • At least one prescription dispensed for a DMARD during the measurement year

Osteoporosis Management in Women Who Had a Fracture (OMW): (67 -85 age)

  • Woman with a fracture between 7/1 prior to the measurement year and 6/30 during the measurement year.
  • A bone mineral density test, osteoporosis therapy, or dispensed prescription to treat osteoporosis in the 180 days (6 months) period after the fracture diagnosis).
  • If the fracture diagnosis was an inpatient stay, a bone mineral density test or long-acting osteoporosis therapy during the inpatient stay.

Medicare Part D

  • 14 measures
  • Mainly pharmacy related measures (examples below):
    • The percent of Health Plan members with a prescription for hypertension, diabetes and/or Cholesterol medication(S) who fill their prescription often enough to cover 80% or more of the time they are supposed to be taking the medication:
      • Hypertension (Medication Adherence)
      • Cholesterol Management (Medication Adherence)
      • Diabetes A1c Control (Medication Adherence)
      • Statin Therapy for Patient Diabetes (SPD): (40-75 age)
      • At least one dispensing event for a high or moderate-intensity statin medication during the measurement year.

Member survey:

  • Consumer Assessment of Healthcare Providers and Systems (CAHPS)
  • CAHPS is a patient experience survey
  • Medicare Health Outcomes Survey (HOS)
    • Baseline and Follow-up HOS:
    • Baseline Survey:
      • Survey asked patient how they perceived their current mental and physical health status
      • Follow-up Survey (2 years later same members):
        • Same members are surveyed to ask patient how they perceived their mental and physical health status.
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