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What you should know about CMS’s 2023 Medicare Advantage (MA) final rule

To continue to improve the Medicare Advantage (MA) program, CMS recently released the Contract Year 2023 MA final rule. We’ve highlighted several of CMS’s key upcoming changes below. 

1. Different calculation for some HEDIS measures in 2023 Star Ratings 

For 2023 Star Ratings, due to COVID-19, CMS removed the “60% rule,” resulting in all MA contracts receiving the higher of the 2022 or 2023 Star Rating and corresponding measure score for each of three Healthcare Effectiveness Data and Information Set (HEDIS) measures collected through the Health Outcomes Survey (HOS)—Monitoring Physical Activity, Reducing the Risk of Falling, and Improving Bladder Control. This change enables CMS to calculate these three HEDIS-HOS measures for the 2023 Star Ratings and include them in the 2023 reward factor calculation. As a reminder, the other two HEDIS-HOS measures—Improving or Maintaining Physical Health and Improving or Maintaining Mental Health—were moved to the display page because of validity concerns related to COVID-19, weren’t included in 2022 Star Ratings, and won’t be included in 2023 Star Ratings.  

2. Star Ratings impact ability to create new contracts or expand service areas 

To ensure MA plan and Prescription Drug Plan (PDP) sponsors can fully manage their current contracts and books of business before expanding, CMS expanded the bases for application denial to include Star Ratings history, bankruptcy proceedings, and certain CMS compliance actions. This means that CMS can deny an application for a new contract or a service area expansion if organizations have 2.5 or less stars for their Part C Summary rating, their Part D Summary rating, or a combination of Part C and Part D Summary ratings for two years. 

3. Increased transparency in D-SNP performance 

CMS has given states the flexibility to require an MA organization to apply and seek CMS approval for one or more Dual Eligible Special Needs Plan (D-SNP)-only contracts. This will ultimately provide consumers with greater transparency in D-SNP plans within states, as plans' performance would no longer be combined, and would allow for customizing marketing materials for the dual-eligible population. 

4. Enrollee participation in D-SNP plan governance 

Any MA organization offering one or more D-SNP must establish and maintain one or more enrollee advisory committee to solicit direct input on enrollee experiences. The committee must include a reasonably representative sample of individuals enrolled in D-SNP(s) and solicit input on, among other topics, ways to improve access to covered services, coordination of services, and health equity for underserved populations. Insights from enrollee advisory committees, combined with data from the MA-PDP CAHPS survey and other member outreach, will help MA organizations to identify and address barriers to high-quality, coordinated care for dually eligible individuals. 

5. SNP health risk assessments must include housing, food insecurity, and transportation questions 

CMS already requires that all Special Needs Plans (SNPs) conduct an initial and annual health risk assessment (HRA) for all their members. Beginning in contract year 2024, HRAs are required to include at least one question on each of three social risk factors—housing stability, food security, and access to transportation—given the significant impact these factors have on health plan members’ physical, psychosocial, and functional needs. While CMS doesn’t require the use of specific standardized questions, they plan to publish a list of screening tools currently in use from which SNPs can select questions to include in their HRAs.  

6. Plans must meet MA network adequacy rules at time of application 

CMS is now requiring plans to demonstrate that they meet network adequacy standards at the time they are applying for a new or expanding service area. This raises the bar for plans that, up until now, have only had to attest to meeting the network adequacy standards, but then were able to subsequently make changes to their network.

As you prepare for the 2023 contract year, Press Ganey can help you measure, analyze, and improve your member experience and Star Ratings. Speak with a Press Ganey expert to discuss how your organization can prepare for these updates. 

About the author

Press Ganey, a leading healthcare performance improvement solutions company, offers an integrated suite of solutions that put Human Experience at the center of healthcare enterprise transformation. Delivered through a cutting-edge digital platform built on a foundation of data security, Press Ganey solutions address patient experience, healthcare consumer experience, workforce engagement, safety, clinical excellence and more. Guided by its team of renowned healthcare thought leaders, Press Ganey works with more than 41,000 healthcare facilities to reduce patient suffering, enhance caregiver resilience and improve the overall safety, quality and experience of care. Press Ganey is a PG Forsta company.

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