The Centers for Medicare & Medicaid Services (CMS) uses a five-star rating system to measure Medicare beneficiaries’ experience with their health plans and the health care system. This rating system applies to all Medicare Advantage (MA) lines of business: Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Private Fee-for-Service (PFFS) and prescription drug plans (PDP).
The program is a key component in financing health care benefits for MA plan enrollees. In addition, the ratings are posted on the CMS consumer website, www.medicare.gov, to give beneficiaries help in choosing among the MA plans offered in their area.
CMS Goals for the Five-star Rating System
* Implement provisions of the Affordable Care Act
* Clarify program requirements
* Strengthen beneficiary protections
* Strengthen CMS’ ability to distinguish stronger health plans for participation in Medicare Parts C
and D and to remove consistently poor performers
How Are Star Ratings Derived?
A health plan’s rating is based on measures in five categories:
* Members’ compliance with preventive care and screening recommendations
* Chronic condition management
* Plan responsiveness, access to care and overall quality
* Customer service complaints and appeals
* Clarity and accuracy of prescription drug information and pricing
Benefits to Providers
* Improved patient relations
* Improved health plan relations
* Increased awareness of patient safety issues
* Greater focus on preventive medicine and early disease detection
* Strong benefits to support chronic condition management
Benefits to Members
* Improved relations with their doctors
* Greater health plan focus on access to care
* Increased levels of customer service
* Greater focus on preventive services for peace of mind, early detection and health care that matches their individual needs
CarePlus Health Plans, Inc.’s Commitment
CarePlus is strongly committed to providing high-quality Medicare health plans that meet or exceed all CMS quality benchmarks. The structure and operations of the CMS star rating system ensures that pay-for-performance funding is used to protect or, in some cases, to increase benefits and to keep member premiums low.
CarePlus encourages members to become engaged in their reventive and chronic care management through outreach, screening opportunities and Medicare member rewards.
- Medical Billing Question and Answer - Terms
- Insurance Denial Claim Appeal Guidelines.
- Medical Billing Downloads
- Understand Medical Billing
- Medical Billing Outsource
- Medicare Coverage and Plan Overview
- Advertise with us
- EVALUATION AND MANAGEMENT CPT code [99201-99499] - Full List
- Overall Medical billing process
- CPT Code 99201, 99202, 99203, 99204, 99205 - Which code to USE
- Internal Medical Billing Audit - how to do
Medical Billing Popular Articles
Procedure code and Description 99251 Inpatient consultation for a new or established patient, which requires these 3 key components: A pro...
• G0502: Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral health care manager...
Hyperlipidemia Hyperlipidemia (hyperlipemia) involves abnormally elevated levels of any or all lipids and/or lipoproteins in the blood. Hy...
HCPCS Codes Effective for claims with dates of service on June 30, 2011, Medicare providers shall report one of the following HCPCS codes...
Generally speaking, when we say 'objective measures,' what does that mean? Answer: Objective measures consist of standardized p...
Q: My patient enrolled in a Medicare Advantage (MA) plan during the middle of the inpatient hospital stay. Who should I bill? A: When a p...
Its often confused that BCBS have lot of prefixes and where to contact. However we have some guide to follow, using prefixes we could find t...
Denial code co - 45 - Charges exceed your contracted/legislated fee arrangement. Note: This adjustment amount cannot equal the total servic...
1 Deductible Amount 2 Coinsurance Amount 3 Co-payment Amount 4 The procedure code is inconsistent with the modifier used or a required mo...
1) Aetna: 120 days . 90 Days 2) Amerigroup: 180 days. 3) Bcbs: 1yr . 180 days updated. 4) Cigna: 180 days. 5) Humana: 15 mon...