2025 CMS Quality Star Measures
Medicare Advantage
Policy Number: MA-X-056
Last Updated: Dec. 3, 2024
|
Area |
Measure |
Description |
|
Clinical |
Breast cancer screening |
Percentage of plan members aged 52-74 who had a mammogram to screen for breast cancer. |
|
Clinical |
Colorectal cancer screening |
Percentage of plan members aged 45-75 who had appropriate screenings for colorectal cancer. |
|
Clinical |
Controlling blood pressure |
Percentage of plan members aged 18-85 with high blood pressure who received treatment and were able to maintain a healthy pressure
|
|
Clinical |
Eye Exam for Patients with Diabetes |
Percentage of members ages 18–75 with diabetes (types 1 and 2) who had any one of the following:
|
|
Clinical
|
Glycemic Status Assessment for Patients with Diabetes |
The percentage of members 18–75 years of age with diabetes (types 1 and 2) whose most recent glycemic status (hemoglobin A1C [HbA1c] or glucose management indicator [GMI]) showed their blood sugar is under control during the measurement year (<9%) |
|
Clinical |
Kidney Health Evaluation for Patients with Diabetes |
Percentage of members aged 18–85 with diabetes (types 1 and 2) who had a kidney health evaluation in the measurement year. Both an eGFR and a uACR test are required on the same or different dates of service.
|
|
Clinical |
Transitions of Care |
Percentage of members aged 18 and older who had each of the following related to hospital discharges Jan. 1 through Dec. 1 of the measurement year;
|
|
Clinical |
Osteoporosis management in women who had a fracture |
Percentage of female plan members aged 67-85 who broke a bone and received screening or treatment for osteoporosis within six months. |
|
Clinical |
Plan all–cause readmissions |
For members 18 years of age and older, the number of acute inpatient and observation stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission. |
|
Clinical |
Follow-Up After Emergency Department Visit for People With Multiple High-Risk Chronic Conditions
|
Percentage of emergency department (ED) visits for members ages 18 and older who have multiple high-risk chronic conditions who had a follow-up service within seven days of the ED visit. |
|
Clinical |
Statin therapy for patients with cardiovascular disease |
Percentage of male plan members aged 21-75 and female plan members aged 40-75 who were identified as having clinical atherosclerotic cardiovascular disease and dispensed at least one high or moderate- intensity statin medication and remained on a high or moderate- intensity statin medication during the measurement year. |
|
Clinical
|
Pharmacy Part D medication adherence for diabetes medications |
Percentage of plan members aged >18 who adhere to their prescribed medications and had a PDC of 80% or greater. |
|
Clinical |
Pharmacy Part D medication adherence for hypertension (RAS antagonists) |
Percentage of plan members aged >18 who adhere to their prescribed medications and had a PDC of 80% or greater. |
|
Clinical
|
Pharmacy Part D medication adherence for cholesterol (statins) |
Percentage of plan members aged >18 who adhere to their prescribed medications and had a PDC of 80% or greater. |
|
Clinical |
Pharmacy Part D Statin Use In Persons With Diabetes |
Percentage of Medicare members with diabetes ages 40–75 who receive at least one fill of a statin medication in the measurement year |
|
Clinical
|
Operations Part D Medication Therapy Management |
Percentage of members >18 enrolled in a medication therapy management (MTM) program who received a comprehensive medication review (CMR)
|
|
Clinical |
Concurrent Use of Opioids and Benzodiazepines |
Percentage of members >18 with at least two prescription claims for an opioid medication and two claims for a benzodiazepine with at least 30 cumulative days of overlapping prescriptions during the measurement period. |
|
Clinical |
Polypharmacy; Anticholinergic Medications in Older Adults |
The percentage of individuals >65 years old with concurrent use of >2 unique anticholinergic medications |
|
Member survey |
Annual flu vaccine |
Percentage of plan members who received a flu vaccine prior to the flu season |
|
Member survey |
Improving or maintaining physical health |
Percentage of all plan members whose physical health was the same or better than expected after two years |
|
Member survey |
Improving or maintaining mental health |
Percentage of all plan members whose mental health was the same or better than expected after two years |
|
Member survey |
Monitoring physical activity |
Percentage of members aged >65 who had a doctor’s visit in the past 12 months and who received advice to start, increase or maintain their level of exercise or physical activity |
|
Member survey |
Improving Bladder Control |
Percentage of members >65 who reported having a urine leakage problem in the past six months and who and discussed the ways to control or manage the leaking of urine with their health care provider |
|
Member survey |
Reducing the Risk of Falling |
Percentage of Medicare members ages 65 and older who had a fall or had problems with balance or walking in the past 12 months (Question 46), who were seen by a practitioner in the past 12 months, and who received fall risk intervention from their current practitioner |
|
Member survey |
Getting needed care |
Percentage of the best possible score the plan earned on how easy it is for members to get needed care, including care from specialists |
|
Member survey |
Getting appointments and care quickly |
Percentage of the best possible score earned on how quickly members get appointments and care |
|
Member survey |
Rating of health care quality |
Percentage of the best possible score the plan earned from members who rated the quality of the health care they received |
|
Member survey |
Getting needed prescription drugs |
Percentage of the best possible score the plan earned on how easy it is for members to get the prescription drugs they need using the plan |
|
Member survey |
Care coordination |
Percentage of the best possible score the plan earned on how well the plan coordinates members’ care |
Please note that the methodology used by CMS is subject to change and final guidelines are released each spring after the measurement year.
Blue Cross and Blue Shield of Nebraska’s Goals for the Five-Star Rating System
Blue Cross and Blue Shield of Nebraska (BCBSNE) is strongly committed to providing high-quality Medicare Advantage health plans to meet or exceed CMS quality benchmarks, operational and marketing requirements. BCBSNE works with providers and members to ensure appropriate and timely care was received, chronic conditions are well-managed and satisfaction with the level of service obtained from BCBSNE and in-network providers.
BCBSNE uses mailings and personal and automated phone calls to remind members about needed care and to help maintain optimal health.
BCBSNE partners with our MA providers by identifying their Medicare Advantage patients who need specific medical services to encourage providers to contact those patients and schedule necessary services:
Provider Tips for Improving Star Ratings and Quality Care
- Continue to encourage patients to obtain preventive screenings annually or when recommended
- Create office practices to identify noncompliant patients at the time of their appointment
- Submit complete and correct encounters/claims with appropriate codes
- Understand the metrics included in the CMS rating system
- Review the gap in care files listing members with open gaps
- Ensure documentation includes assessment of cognitive and functional status
- Identify opportunities for you or your office to have an impact
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