An Discussion on Medicare Part C & D Plan Ratings

An Discussion on Medicare Part C & D Plan Ratings

September 5, 2012

Cynthia G. TudorVikki OatesElizabeth Goldstein

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• Accountability, quality, and responsibilities of plans

• Level of measurement• Maintaining Integrity of the Plan Ratings• Future directions

Session OverviewSession Overview

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• CMS’s mission is oriented toward raising the quality of services provided to Medicare beneficiaries

• We are increasing the level of accountability for the care provided by physicians, hospitals, and other providers in the FFS program

• Similarly, Parts C and D sponsors are accountable for the care provided by physicians, hospitals, and other providers to their enrollees

Accountability, Quality, and Responsibilities of Plans

Accountability, Quality, and Responsibilities of Plans

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• Plans’ quality improvement (QI) strategies should focus on improving overall care that Medicare enrollees are receiving across the full spectrum of services

• QI strategies should not be limited to only the Plan Ratings measures

Quality Improvement StrategiesQuality Improvement Strategies

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• Evaluate different measures for appropriate unit of analysis– Parent organization– Contract level– Plan benefit package (PBP) – Region– Formulary

Level of MeasurementLevel of Measurement

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• NCQA changes to HEDIS audit for 2013 submissions

• Evaluating measures for gaming potential• Examining other sources of data to validate

current measures• Data found to be inaccurate or incomplete may

result in a one-star rating for the specific measure

Maintaining Integrity of the Plan Ratings

Maintaining Integrity of the Plan Ratings

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Highlights from CMS memo issued May 5, 2012:• …Plans are prohibited from submitting prescription drug PDEs

based on data collected through other means than claims submitted by network pharmacies or requests for reimbursement from beneficiaries.

• …Part D sponsors are encouraged to develop incentives for network pharmacies to submit claims under the plan unless beneficiaries have explicitly requested otherwise.

• CMS will not accept PDEs for claims that were not submitted for processing and/or reimbursement under the plan by either a network pharmacy or enrollee…Part D plans must delete any such previously reported PDEs…

Prohibition on Submitting PDEs for Non-Part D Prescriptions

Prohibition on Submitting PDEs for Non-Part D Prescriptions

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• Continue to raise the bar to demand a strong level of quality and performance

• Expand our focus on improving beneficiary outcomes and experience

• Adopt new measures developed by consensus-based organizations to create a more robust measurement system

• Alternative methods to evaluate improvement

Future DirectionsFuture Directions

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• Send questions to these CMS mailboxes: • Part C Measures: PartCRatings@cms.hhs.gov

• Part D Measures: PartDMetrics@cms.hhs.gov

2013 Plan Ratings Anticipated to Go Live October 11, 2012

Questions?Questions?

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