More Challenges to CMS MA Star Ratings

Medicare Advantage and Part D prescription drug plans

The Centers for Medicare & Medicaid Services (CMS) uses a five-star rating system to evaluate the quality of various health care services including Medicare Advantage (MA) health plans and Part D prescription drug plans.

CMS publishes annual star ratings for Medicare Advantage and Part D prescription drug plans. These ratings help Medicare beneficiaries compare the quality of health plans and prescription drug plans. The ratings are published on the Medicare Plan Finder at www.medicare.gov.

Star ratings also determine the payment methodology applied to the Medicare Advantage plan by CMS. A lower rating results in lower allocated dollars for certain beneficiary programs, and plans with less benefits are less attractive to Medicare beneficiaries.

Lawsuits

Initially, United Health and Humana initiated lawsuits over the 2025 star ratings, possibly encouraged by legal success of SCAN Health Plan and Elevance Health over their 2024 star ratings being favorably recalculated. Centene is now joining the lawsuits by taking the federal government to court over the scoring of their star ratings.

Centene argued (PDF) that a secret shopper call from an anonymous surveyor was miscategorized and was held against the insurer when the call’s failure is the fault of the Centers for Medicare & Medicaid Services.

$73 Million Centene Phone Call

Centene alleges “CMS has decided to hold a single call against Centene despite the fact that the call never reached Centene's call center, and there was no call failure attributable to Centene,” the lawsuit said. “Rather, the CMS secret shopper’s own call notes show that the shopper’s ‘chat window closed unexpectedly,’ which is a clear failure of CMS’ software.”

If even one phone call conducted by CMS is not successful, a five star rating is impossible. And even one unsuccessful call can negatively impact health plans’ finances because the metric is heavily weighted. Centene estimates the phone call will cost them $73 million in gross revenue

UnitedHealth also attributed the scoring issues to one phone call, while Humana said three phone calls were scored unfairly.

Thoughts - Replace the MA Star Ratings Systems

Currently risk scores, patient phone surveys, and burdensome quality measures reported by healthcare providers drive plan design and reimbursement for MA health plans.

Some thoughts on criteria to replace the current MA Star Rating system might include:

• Score health plan on outreach (touchpoints) to the consumer and healthcare providers.
• Healthcare providers implement their own quality programs focused on the needs of their assigned populations instead of mandated measures.
• Score on health plan status of prior authorization and denials simplification.

Kris Gates, connect@healthendeavors.com