Risk Adjustment

Announcement of Calendar Year (CY) 2020 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter

Written By
Jason Jones
Product Manager - Quality Products

On April 1, 2019 CMS released the 2020 Medicare Advantage (MA) and Part D Rate Announcement and Final Call Letter. In this document there were substantive changes that will impact the 2020 and 2021 Star Rating programs. As with prior years, the next year of Star Rating is determined based on the previous and current year programs. CMS provides responses to questions / comments from various industry participants which clarify the future goals of the CMS Star Rating programs. In the 2020 MA and Part D Rate Announcement and Final Call Letter those revisions and changes were received with a positive majority.


Upcoming Changes for 2020


Medication Adherence

  • The exclusion based on ESRD and Hospice have been adopted for the 2020 Star Rating (which will be calculated on the 2018 data). The addition of allowing a beneficiary to elect Hospice care anytime during the measurement period removes the current Proportion of Days (PDC) adjustment that is currently done. CMS believes this change narrows the population covered by the measure.

Statin Use in Persons with Diabetes (SUPD)

  • Due to feedback from the draft 2020 Call Letter, this weight of 1 will continue through the 2020 Star Ratings, while undergoing review of the measures category and consider if CMS should propose to change the technical Specifications to reclassify it in the future and allow a weight increase.

Patients’ Experience and Complaints Measures Capturing Access

  • Starting with the 2021 Star Ratings, Patients’ Experience and Complaints and Access measures will receive a weight of 2. They currently have a weight of 1.5.

Controlling High Blood Pressure (Part C)

  • The American College of Cardiology and American Heart Association have released new hypertension treatment guidelines. Due to these new guidelines, the National Committee for Quality Assurance (NCQA) is implementing updates to the Controlling High Blood Pressure measure for HEDIS 2019. These changes have revised the blood pressure target to <140/90 and have also implemented changes in the outpatient encounter to identify the denominator by allowing two encounters, with one accepted telehealth service. The addition of an administrative approach, from the previous Medical Record Review approach, has also created changes that need to be reviewed for future Star Rating programs. Therefore, CMS has moved this measure to display for the 2020- and 2021-Star Rating programs. It has been encouraged by CMS for MA contracts to continue focusing on the best way to improve in this area. This measure is expected to return in 2022.

Members Choosing to Leave the Plan (Part C & D)

  • CMS is changing how beneficiaries are identified when they leave a contract. This will affect both Part C and Part D plans.

Changes beyond 2020


Health outcomes Survey (HOS)

  • CMS has proposed to exclude beneficiaries enrolled in I-SNPSs at the plan benefit package (PBP) level from HOS Baseline beginning in 2020. CMS will explore additional enhancements to HOS in the future.

Plan All-Cause Readmissions (Part C) – PCR (HEDIS)

  • Due to changes made by the National Committee for Quality Assurance (NCQA), CMS has decided to move this measure to the display page for 2021 and 2022 Star Ratings and will return for 2023 with a weight of one based on the 2021 calendar year data.

Medication Reconciliation (Part C)

  • CMS has not made a final decision to retire the Mediation Reconciliation (MRP) measure from the Star Ratings and replace it with the Transition of Care (TRC). CMS will continue to give consideration following revisions NCQA may make to the TRC measure. Therefore, plans should continue to monitor the MRP during the 2019 calendar year.

Care for Older Adults – Functional Status Assessment Indicator (Part C)

  • Due to changes NCQA is proposing by the removal of one of the four options to meet the numerator, CMS has proposed to move this measure to display for the 2022- and 2023-Star Ratings. CMS would propose to return it to Star Ratings through future rulemaking.

Use of Opioids – PQA

  • CMS will add these measures to the display page for 2021 (2019 data). CMS will consider rulemaking to include the measures beginning with the 2023 Star Ratings (2021 data).

Adult BMI Assessment (Part C)

  • CMS will retire this measure from Part C beginning with the 2022 Star Ratings.

Appeals Auto-Forward and Appeals Upheld (Part D)

  • CMS will retire this measure from Part D beginning with the 2022 Star Ratings.


The reason for updates


The eco-system of health, that is known as the Stars Rating Program, is made up of CMS, the health plan and the provider. At the center of this eco-system is where exceptional care to the member is expected to be. Through joint communication between CMS, the health plan and provider, the focus of care is beginning to be realized. In the next few years the retirement of measures, such as Adult BMI Assessment (Part C) and Appeals Auto-Forward and Appeals Upheld (Part D) proves that the Star-Ratings Program does work.

Through the strategic initiatives laid out by the health plan to obtain the data needed by CMS, the measure has reached a point of exceptional member care. Other measures are now being reviewed by CMS to determine if their criteria should be adjusted to better determine the impact to member care. Those measures are moved to a display, which does not directly impact the overall Star-Rating for the health plan but does provide needed data for CMS to determine the next step in that measure. These changes, going forward, will only improve the overall care for MA members.


When are Star Ratings published?


CMS will publish the 2020 Star Ratings for each Medicare Advantage (MA) organization on October 9, 2019, based on the 2018 calendar year data. With this publication, the final technical notes for the 2020 Star Ratings will be released.


We simplify the management of member programs by making it radically more efficient, and increasing value to healthcare organizations and their members

Presentation @ RISE VBC: Effective Collaboration Strategies Between Payer & Provider