2024 CMS Advance Notice: Impact to Star Ratings, Focus on Health Equity, Part D, and Inflation Reduction Act

Buried deep in the Center for Medicare & Medicaid Services’ (CMS) 2024 Advance Notice are some exciting indications of where the agency intends to take Star Ratings in the near future. CMS has a lot to say, from tinkering with denominators to sending strong signals that health equity, Part D, and social needs are the next frontiers for Stars. 

The Inflation Reduction Act and Part D Impact 

Amid important takeaways (depending on whose analysis you read, average Medicare Advantage (MA) plan revenues could fluctuate from an increase of 1.3% to a decrease of 2.3%), there were additional details regarding the practical effects of the Inflation Reduction Act. Congress’s landmark legislation that was passed late in 2022 will have the following impact on MA-PD and PDP plans beginning in 2024: 

• Cost sharing will not be allowed for any Part D medications when members reach the catastrophic coverage phase. That means plan benefits must eliminate cost-sharing for any member who spends more than $7400 in out-of-pocket costs on Part D drugs. 
• The Low-Income Subsidy (LIS) program will be extended to members earning between 135% and 150% of the Federal Poverty Level (FPL). Previously, this program was only available to members who made less than 135% of the FPL. This means that single members earning between $1457 and $1561 per month and married couples earning between $1973 and $2114 per month may now qualify for premium subsidies. 
• The legislation’s highest-profile achievement was the elimination of deductibles and a $35 cost-sharing cap on Part D-covered insulin products (during the initial and coverage gap phases). The $35 cap on insulin took effect in January 2023, and plans have until the end of March 2023 to update their systems to reflect the change. Members charged more than $35 for a 30-day supply of insulin covered by Part D must be reimbursed within 30 days of purchase. 
• A similar deductible, copay, and cost-sharing elimination applies to vaccines the Advisory Committee on Immunization Practices recommends. 
• The Part D base beneficiary premium (which for 2023 is $32.74) cannot increase by more than 6% per year. Depending on the potential increase, plans may be required to use the amount that would have been applied if the Inflation Reduction Act had not been passed if it is lower than 6%. 

The Universal Foundation of Quality Measures

Beyond the dollars and cents, there are compelling changes that CMS has declared and is still contemplating in forthcoming Star Ratings years. One idea still under consideration is the creation of a “Universal Foundation of Quality Measures.” Put simply, these would comprise a collection of HEDIS and CAHPS measures that would be included in all CMS programs.  

The 2024 CMS Advance Notice doubles down on 3 key trends evident in CMS priorities for the last few years: 

#1 Re-Emphasis of Cancer Screenings, Immunizations, and Chronic Condition Management

Domains 1 and 2 of Stars saw declines when measure weighting skewed heavily toward member experience. 2023 Stars told the tale of how plans took their eye off the ball on these process measures. If you haven’t already, it is time to refocus your efforts in these areas. Additionally, make sure communications to members are well-planned and meaningful to address multiple open gaps instead of disparate one-off messages that can overburden members.   

#2 Continued Recognition of the Need for Depression and Substance Use Disorder Screening, Treatment

Both are existing display measures, and CMS states that they “are considering potentially adding this measure to the Star Ratings in the future pending rulemaking” for the Initiation and Engagement of Substance Use Disorder (SUD) Treatment (Part C) measure. Plans should prepare now for how they will engage and educate members about these important programs.

#3 Ongoing Drive to Identify and Address Social Drivers that Play a Critical Role in Health

The introduction of required social needs assessment questions in health risk assessments was a first step, with NCQA’s social needs screening and interventions (SNS-E) HEDIS measure a substantial addition. As the agency continues to work on effective criteria to evaluate social needs assessment and intervention, plans should prepare to see a new Star measure on their list by 2026. Plans need to start planning beyond the survey now to be prepared for how to effectively intervene with members with plan offerings (such as flexible rewards and incentives).   

The measures proposed for inclusion are:  

Specific Measures Expected to Be Added to Stars

Another measure (or set of measures, depending on your perspective) that is expected to become a part of official Star Ratings is Timely Follow-up After Acute Exacerbations of Chronic Conditions (Part C). CMS signaled its intent in the Advance Notice by saying, “CMS is planning to add this measure to the display page starting with the 2024 Star Ratings and is considering potential future inclusion of this measure in the Part C Star Ratings pending rulemaking.”  

In short, members who require an emergency department visit or hospitalization for any of 6 chronic conditions must be seen for a non-emergent follow-up within a designated timeframe:

1. Hypertension: Within 7 days
2. Asthma: Within 14 days
3. Congestive Heart Failure: Within 14 days 
4. Coronary Artery Disease: Within 14 days 
5. Chronic Obstructive Pulmonary Disease: Within 30 days 
6. Diabetes: Within 30 days 

Plans need to begin addressing real-time data and intervention techniques to ensure members receive follow-up care within these deadlines. Time-bound follow-up in conditions like these can ensure patient safety and prevent avoidable readmission. In just one example, medication errors cause anywhere from one-quarter to one-third of all hospital readmissions within 30 days. Medicare is the payer with the highest percentage of readmissions at 26% and spends more than $17 billion per year on unplanned readmissions. Reducing the incidence of readmissions among MA members is imperative for the agency as entitlement budgets get tighter.  

Another measure CMS intends to add to the 2024 measurement year for 2026 Stars is Concurrent Use of Opioids and Benzodiazepines (COB), Polypharmacy Use of Multiple Anticholinergic Medications in Older Adults (Poly-ACH), Polypharmacy Use of Multiple Central Nervous System Active Medications in Older Adults (Poly-CNS). That’s a mouthful, but at its heart, the measure is meant to increase focus on the dangers of drug-to-drug interactions and the use of risky combinations that may be slow to metabolize.

CMS initially signaled its intent in the Proposed Rule published in December, stating, “Concurrent use of opioids and benzodiazepines can increase the risk of respiratory depression and fatal overdoses. In addition, concurrent use of 2 or more unique anticholinergic medications in older adults was associated with an increased risk of cognitive decline, and the concurrent use of 3 or more unique CNS active medications in older adults was associated with an increased risk of falls and fractures.” 

Those familiar with previous Star Ratings will notice that the intent of this measure bears many similarities to the High-Risk Medications measure that was retired in 2020. This new measure is consistent with CMS’ recent focus on member experience, safety, and Part D measures.   

Star Measures Being Considered for Retirement

CMS also indicated its intention to retire the Care for Older Adults (COA) Pain Assessment. The agency believes the existing measure is too narrow, and pain assessment should be focused on the broader MA population, not limited solely to the Special Needs Plan (SNP) population. Following the public comment period, CMS would follow suit if NCQA seeks approval to retire this measure in 2025. It is likely to be replaced by a redefined and broader measure later. 

Similarly, CMS is exploring a review of COA—Functional Status and Medication Review. Like its stance on Pain Assessment, the agency believes that a broader MA member population could benefit from these clinical reviews. 

Web-Based Survey Mode for CAHPS: More Than a Footnote

As the leading health action company, we would be remiss if we did not point out that CMS plans to implement a web-based survey mode in time for the 2024 CAHPS survey (used for 2025 Star Ratings). This welcome innovation should improve member response rates to the heavily weighted CAHPS survey.  

This multi-channel approach is expected to increase response rates by 4%. An improvement like that means an increase of 8000 to 10,000 members to the annual CAHPS survey—which is meaningful to any individual MA plan given how much each respondent counts. Icario applauds this addition and recommends that all plans execute similar, multi-modal designs (orchestrated outreach using all available channels—text messaging, interactive voice response, email, direct mail, and live agent calls) to ensure they are reaching their members in ways and at times that they wish to be contacted.  

What Should You Do Next?

Icario’s teams of subject matter experts can help your health plan prepare for these changes in the 2024 CMS Advance Notice and make swift advances in measures that are already in place. From additional analyses of the effects these changes have on your population to real-world strategies that demonstrate concrete returns, Icario can help turn the uncertainty ahead into pragmatic solutions. Contact us today at go@icariohealth.com.