The Centers for Medicare & Medicaid Services (CMS) created the Part C & D Star Ratings to provide quality and performance information to Medicare beneficiaries to assist them in choosing their health and drug services during the annual fall open enrollment period. We refer to them as the ‘2020 Medicare Part C & D Star Ratings’ because they are posted prior to the 2020 open enrollment period. The health plans are rated on a scale of 1 to 5 stars, with 5 being the highest and 1 being the lowest. Learn more.

The Centers for Medicare & Medicaid Services (CMS) publishes the Medicare Part C and D Star Ratings each year to measure the quality of health and drug services received by beneficiaries enrolled in Medicare Advantage (MA) and Prescription Drug Plans (PDPs or Part D plans). The Star Ratings also reflect the experiences of beneficiaries and help beneficiaries find the best plan for them. The Star Ratings support CMS’s efforts to put the patient first in all of our programs. As part of this effort, patients should be empowered to work with their health care providers to make health care decisions that are best for them. An important component of this effort is to provide Medicare beneficiaries and their family members with meaningful information about quality and cost to help them be informed and active health care consumers. Learn more.

A set of standard performance measures that can give you information about the quality of a health plan. You can find out about the quality of care, access, cost, and other measures to compare managed care plans. The Centers for Medicare & Medicaid Services (CMS) collects HEDIS data for Medicare plans. (See Centers for Medicare & Medicaid Services.) Learn more. For detailed information about HEDIS please read our Quality Measure Toolkit.

CMS collects information about Medicare beneficiaries’ experiences with, and ratings of, Medicare Advantage (MA-only) plans, Medicare Advantage Prescription Drug (MA-PD) plans, and stand-alone Medicare Prescription Drug Plans (PDP) via surveys of beneficiaries who have been enrolled in their plans for six months or longer. Although all three versions have a nearly identical set of core questions, each version also includes additional questions and response categories related to the enrollees' experiences in their own particular plan type. Learn more.

The Medicare Health Outcomes Survey (HOS) is the first patient-reported outcomes measure used in Medicare managed care. The goal of the Medicare HOS is to gather valid, reliable, and clinically meaningful health status data from the Medicare Advantage (MA) program to use in quality improvement activities, pay for performance, program oversight, public reporting, and to improve health. All managed care organizations with Medicare contracts must participate. Learn more.

CMS manages the star ratings system and uses its contractor, Acumen, LLC, for the analyses of Medicare data to generate the rates for the medication measures. PQA maintains the PQA-endorsed performance measures and updates the technical specifications for the measures annually. PQA also shares new measures that are endorsed by PQA with CMS and provides some technical guidance on the use of the measures within the plan ratings. CMS tests updates to PQA-endorsed measure specifications and drug-code lists and implements them as they deem appropriate. Five PQA measures will be included in the 2021 Medicare Part D Star Ratings:

• Medication Adherence for Diabetes Medications
• Medication Adherence for Hypertension (RAS antagonists)
• Medication Adherence for Cholesterol (Statins)
• MTM Program Completion Rate for CMR
• Statin Use in Persons with Diabetes

HEDIS is the measurement tool used by the nation’s health plans to evaluate their performance in terms of clinical quality and customer service. HEDIS is a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the health care quality of different plans. For detailed information about HEDIS please read our Quality Measure Toolkit.

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) program is a public/private initiative to develop standardized surveys of patients’ experiences with ambulatory and facility-level care in commercial and Medicaid plans. Surveys were developed with the Agency for Healthcare Research and Quality (AHRQ). CAHPS data address areas such as patient ease of obtaining information from a health plan, timeliness of service, and speed and accuracy of claim processing. CAHPS results offer an indication of how well health care organizations meet member expectations.

HEDIS is the measurement tool used by the nation’s health plans to evaluate their performance in terms of clinical quality and customer service. HEDIS is a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the health care quality of different plans. For detailed information about HEDIS please read our Quality Measure Toolkit.

The MDH PHIP program is designed to provide incentives based on performance indicators that measure access quality of care and annual performance improvement. The PHIP measures may change annually, and may vary from the HEDIS measures.

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) program is a public/private initiative to develop standardized surveys of patients’ experiences with ambulatory and facility-level care in commercial and Medicaid plans. Surveys were developed with the Agency for Healthcare Research and Quality (AHRQ). CAHPS data address areas such as patient ease of obtaining information from a health plan, timeliness of service, and speed and accuracy of claim processing. CAHPS results offer an indication of how well health care organizations meet member expectations.

The Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program is a federal requirement that mandates States to cover certain benefits for Medicaid recipients from birth up to age 21. In Maryland, the preventive care component of the EPSDT Program is known as the Healthy Kids Program. The preventive health care services allow for early identification and treatment of health problems before they become medically complex and costly to treat. Please note that Medicaid’s mandates through the EPSDT Program are different than non-Medicaid health plan requirements for childhood care.

Priority Partners would like to remind providers that parents rely on you to direct their child’s care and ensure they receive all of the services they need. By understanding the EPSDT schedule and preventive requirements, you can help our members grow and develop into healthy adults.

We would especially like to remind you about lead testing and well-care visits. Every child in Maryland (not just those in high-risk areas or older homes) must be tested for lead poisoning in the year that they turn one. Also, as children age into adolescence, the attendance of well-care visits decreases. It is important to encourage your patients to continue their yearly well-care visits.

EPSDT Components

Maryland Healthy Kids Preventative Health Schedule

EPSDT laboratory screening tests

• Type: metabolic screenings (PKU) phenylketonuria
  When: 2 screenings, first test completed at birth
• Type: Lead and anemia screenings
  When: ages 12 and 24 months
• Type: Dyslipidemia screenings
  When: ages 9-11 and 18-20
• Type: HIV testing
  When: 1 test, between ages 15 and 18

EPSDT risk assessments and screenings

• Type: Tuberculosis
  When: ages 1 month, 6 months and annually
• Type: Lead
  When: age 6 months and at every well visit until age 6
• Type: Autism
  When: 18-month and 24-30-month visits
• Type: Heart disease
  When: age 2 and annually
• Type: Anemia
  When: age 11 and annually
• Type: STI/HIV
  When: age 11 and annually
• Type: Maternal depression
  When: child is age 1 month, 2 months, 4 months and 6 months
• Type: Substance abuse
  When: age 11 (or younger, if indicated) and annually
• Type: Depression
  When: age 11 and annually

We thank you for the tremendous work you do in ensuring your adolescent patients receive this important preventive care. Here are a few additional reminders:

• Update the child’s medical record with immunizations, screenings and assessments.
• Ensure the child’s vaccine history is updated and completed.
• Provide a documented referral to a dentist starting at age 2 and then annually.
• Enroll in the Vaccines for Children (VFC) program and the Maryland immunization registry (ImmuNet) to update the child’s immunization history.

We are in this together. If we can support you in caring for your adolescent patients, please call us at 888-895-4998.

More EPSDT Information:

• American Academy of Pediatrics’ Bright Futures Schedule

Department of Health and Mental Hygiene (DHMH) EPSDT Healthy Kids Program - Additional EPSDT Healthy Kids Program resources can be found on the left-hand side of the program’s home page.

HEDIS is the measurement tool used by the nation’s health plans to evaluate their performance in terms of clinical quality and customer service. HEDIS is a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the health care quality of different plans. For detailed information about HEDIS please read our Quality Measure Toolkit.

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) program is a public/private initiative to develop standardized surveys of patients’ experiences with ambulatory and facility-level care in commercial and Medicaid plans. Surveys were developed with the Agency for Healthcare Research and Quality (AHRQ). CAHPS data address areas such as patient ease of obtaining information from a health plan; timeliness of service; and speed and accuracy of claim processing. CAHPS results offer an indication of how well health care organizations meet member expectations.

Healthy People 2030 sets data-driven national objectives to improve health and well-being over the next decade. Healthy People 2030 includes a wide range of objectives developed by workgroups made up of subject matter experts in specific topics. Most Healthy People 2030 objectives are core, or measurable, objectives that are associated with targets for the decade. Core objectives reflect high-priority public health issues and are associated with evidence-based interventions. Core objectives have valid, reliable, nationally representative data, including baseline data from no earlier than 2015. If applicable, they have a measure of variability. Data will be provided for core objectives for at least three time periods throughout the decade. For more information about Leading Healthy Indicators (LHI) for Healthy People 2020, visit Healthy People 2030.