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Each year, CMS publishes Medicare Star Ratings to measure the quality of services delivered to Medicare Advantage members. As the Star Rating system has undergone substantial changes recently, Medicare Advantage plans have deployed a variety of tactics to meet a fast-changing environment. One area of opportunity that has generally not been adequately addressed is the optimization of social care within Medicare Advantage quality initiatives. As an integrated social care company, BeneLynk works on behalf of over 22 million Medicare Advantage lives to address health-related social needs (HRSN) and optimize outcomes for our health plan clients. Here are some of the areas where we believe forward-looking quality leaders should be focused.
Health Equity Index (HEI)
CMS has long considered the prevalence of dual-enrolled members (including full and partial duals and LIS recipients) in calculating Medicare Star Ratings. Historically, this has been done using the Categorical Adjustment Index (CAI). Beginning with the 2024 measure year, CMS has added a new measurement, the Health Equity Index (HEI). In the 2027 Star Ratings, CMS will replace the current Reward Factor with the HEI bonus payment.
The HEI bonus payment is predicated on plans meeting the denominator requirement. The denominator is calculated based on the number of members who are dual-enrolled, LIS-enrolled, or whose original Medicare enrollment was due to disability (referred to as members with a social risk factor or SRF). This score is translated into a reward added to the overall and summary Star Ratings for qualifying contracts. Reward ranges from 0.0 to 0.4 for plans with at least median LIS/DE/Disabled enrollment (roughly 41%) and 0.0 to 0.2 for plans with at least half that enrollment.
Quality leaders should be calculating their contract level SRF enrollment. Most importantly, this calculation is a starting point, not an end. Medicare Advantage plans can change their standing relative to the median SRF participation through a robust dual/LIS advocacy program. By helping more members apply for dual and LIS benefits, Stars leaders have an opportunity to provide invaluable benefits to members while moving contracts into HEI bonus payment eligibility and additionally increasing risk-adjusted revenue.
Veteran Health Care (VA) Utilization
A long-standing challenge for quality leaders is the gap in data caused by Medicare Advantage members’ use of the Department of Veterans Affairs. The VA can serve as an excellent source of benefits and tailored care for eligible Veterans. However, due to federal regulations, the VA does not communicate the care provided at the VA to Medicare Advantage plans. Since 5% of all MA members receive care at a VA facility each year, this presents a challenge in many areas, including quality metrics, which drive Star ratings.
By identifying the veterans who use the VA in a Medicare Advantage population and retrieving documentation of the care they receive, quality leaders can meaningfully impact a wide range of Star metrics.
Health-Related Social Need (HRSN) Systematic Documentation
In 2023, NCQA introduced the Social Needs Screening and Intervention (SNS-E) measure. This measure assesses the percentage of members screened for food insecurity, housing, and transportation needs. It then considers the ratio of members with a positive screening who were assisted with this challenge. Per recommendations from NCQA, CMS is in the process of incorporating the SNS-E measure into the Star Ratings.
To prepare for this, quality leaders should be looking to capture social care information using an approved “Pre-specified Instrument” (such as PRAPARE) to document the relevant code sets to support HEDIS reporting, including ICD-10 Z-codes, LOINC, and SNOMED. The coding of the relevant social care needs should be paired with advocacy to address these challenges. In addition to preparing for SNS-E, this connects members in need of assistance with meaningful help and produces a positive member-centered experience.
As CMS prioritizes Star Ratings and the documentation and remediation of HRSN more and more, it is incumbent on MA quality leaders to consider social care initiatives. By helping members access the help they need, forward-looking Stars leaders can make a meaningful impact.