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Medicare2016 Part C & DStar RatingTechnical NotesFirst Plan PreviewDRAFTUpdated – 08/05/2015

DRAFTDRAFTDocument Change LogPreviousVersion-Description of ChangeInitial release of the 2016 Part C & D Star Ratings Technical Notes(Last Updated 08/05/2015)DRAFTRevisionDate08/05/2015Page i

DRAFTDRAFTTable of ContentsDOCUMENT CHANGE LOG . IINTRODUCTION . 1Table 1: Contract Year 2016 Organization Types Reported in the 2016 Star Ratings . 1DIFFERENCES BETWEEN THE 2015 STAR RATINGS AND 2016 STAR RATINGS . 1CONTRACT ENROLLMENT DATA . 2HANDLING OF BIASED, ERRONEOUS AND/OR NOT REPORTABLE (NR) DATA . 3HOW THE DATA ARE REPORTED . 3Table 2: Highest Rating by Contract Type . 3Table 3: Relation of 2016 Organization Types to Contract Types in the 2016 Star Ratings . 4METHODOLOGY FOR ASSIGNING PART C AND D MEASURE STAR RATINGS . 4METHODOLOGY FOR CALCULATING STARS FOR INDIVIDUAL MEASURES . 4A.Relative Distribution and Clustering: . 4B.Relative Distribution and Significance Testing (CAHPS): . 4C.Fixed Cut Points . 5METHODOLOGY FOR CALCULATING STARS AT THE DOMAIN LEVEL . 5Table 5: Minimum Number of Rated Measures Required for a Domain Rating by Contract Type . 5SUMMARY AND OVERALL RATINGS: WEIGHTING OF MEASURES . 6METHODOLOGY FOR CALCULATING PART C AND PART D SUMMARY RATINGS . 6Table 6: Part C and Part D Summary Rating Requirements . 6METHODOLOGY FOR CALCULATING THE OVERALL MA-PD RATING . 6Table 7: Minimum Number of Rated Measures for an Overall Rating . 7APPLYING THE IMPROVEMENT MEASURE(S) . 7Table 8: Minimum Number of Measures Required for an Improvement Measure Rating by Contract Type. 7APPLYING THE REWARD FACTOR . 8Table 9: Performance Summary Thresholds . 9Table 10: Variance Thresholds . 9CALCULATION PRECISION . 10ROUNDING RULES FOR MEASURE SCORES: . 10ROUNDING RULES FOR SUMMARY AND OVERALL SCORES: . 10Table 11: Rounding Rules for Summary and Overall Scores . 10METHODOLOGY FOR CALCULATING THE HIGH PERFORMING ICON. 11METHODOLOGY FOR CALCULATING THE LOW PERFORMING ICON . 11Table 12: Example LPI contracts . 11ADJUSTMENTS FOR CONTRACTS UNDER SANCTION . 11CAHPS METHODOLOGY. 12Table 13: CAHPS Star Assignment Rules . 12Table 14: CAHPS Star Assignment Alternate Representation . 13RELIABILITY REQUIREMENT FOR LOW-ENROLLMENT CONTRACTS . 13SPECIAL NEEDS PLAN (SNP) DATA . 13(Last Updated 08/05/2015)DRAFTPage ii

DRAFTDRAFTSTAR RATINGS AND MARKETING . 13CONTACT INFORMATION . 14PART C DOMAIN AND MEASURE DETAILS . 16Domain: 1 - Staying Healthy: Screenings, Tests and Vaccines . 16Measure: C01 - Breast Cancer Screening . 16Measure: C02 - Colorectal Cancer Screening . 17Measure: C03 - Annual Flu Vaccine . 17Measure: C04 - Improving or Maintaining Physical Health . 18Measure: C05 - Improving or Maintaining Mental Health . 19Measure: C06 - Monitoring Physical Activity . 19Measure: C07 - Adult BMI Assessment . 20Domain: 2 - Managing Chronic (Long Term) Conditions . 22Measure: C08 - Special Needs Plan (SNP) Care Management . 22Measure: C09 - Care for Older Adults – Medication Review . 23Measure: C10 - Care for Older Adults – Functional Status Assessment . 24Measure: C11 - Care for Older Adults – Pain Assessment . 25Measure: C12 - Osteoporosis Management in Women who had a Fracture . 25Measure: C13 - Diabetes Care – Eye Exam . 26Measure: C14 - Diabetes Care – Kidney Disease Monitoring . 27Measure: C15 - Diabetes Care – Blood Sugar Controlled . 28Measure: C16 - Controlling Blood Pressure . 29Measure: C17 - Rheumatoid Arthritis Management . 30Measure: C18 - Reducing the Risk of Falling . 31Measure: C19 - Plan All-Cause Readmissions . 32Domain: 3 - Member Experience with Health Plan . 34Measure: C20 - Getting Needed Care . 34Measure: C21 - Getting Appointments and Care Quickly . 35Measure: C22 - Customer Service . 36Measure: C23 - Rating of Health Care Quality . 37Measure: C24 - Rating of Health Plan . 38Measure: C25 - Care Coordination . 39Domain: 4 - Member Complaints and Changes in the Health Plan's Performance . 40Measure: C26 - Complaints about the Health Plan. 40Measure: C27 - Members Choosing to Leave the Plan . 41Measure: C28 - Beneficiary Access and Performance Problems . 42Measure: C29 - Health Plan Quality Improvement . 43Domain: 5 - Health Plan Customer Service . 45Measure: C30 - Plan Makes Timely Decisions about Appeals . 45Measure: C31 - Reviewing Appeals Decisions . 46Measure: C32 - Call Center – Foreign Language Interpreter and TTY Availability . 47PART D DOMAIN AND MEASURE DETAILS . 48Domain: 1 - Drug Plan Customer Service . 48Measure: D01 - Call Center – Foreign Language Interpreter and TTY Availability . 48Measure: D02 - Appeals Auto–Forward . 49Measure: D03 - Appeals Upheld . 50Domain: 2 - Member Complaints and Changes in the Drug Plan’s Performance . 51Measure: D04 - Complaints about the Drug Plan . 51Measure: D05 - Members Choosing to Leave the Plan . 52Measure: D06 - Beneficiary Access and Performance Problems . 53Measure: D07 - Drug Plan Quality Improvement . 54Domain: 3 - Member Experience with the Drug Plan . 56Measure: D08 - Rating of Drug Plan . 56Measure: D09 - Getting Needed Prescription Drugs . 57Domain: 4 - Drug Safety and Accuracy of Drug Pricing . 58Measure: D10 - MPF Price Accuracy . 58(Last Updated 08/05/2015)DRAFTPage iii

DRAFTDRAFTMeasure: D11 - High Risk Medication . 59Measure: D12 - Medication Adherence for Diabetes Medications . 60Measure: D13 - Medication Adherence for Hypertension (RAS antagonists) . 62Measure: D14 - Medication Adherence for Cholesterol (Statins) . 64Measure: D15 - MTM Program Completion Rate for CMR . 65ATTACHMENT A: CAHPS CASE-MIX ADJUSTMENT . 68Table A-1: Part C CAHPS Measures . 68Table A-2: Part D CAHPS Measures . 69ATTACHMENT B: COMPLAINTS TRACKING MODULE EXCLUSION LIST. 70Table B-1: Exclusions since September 25, 2010 . 70Table B-2: Exclusions prior to September 25, 2010 . 71ATTACHMENT C: NATIONAL AVERAGES FOR PART C AND D MEASURES . 72Table C-1: National Averages for Part C Measures . 72Table C-2: National Averages for Part D Measures . 73ATTACHMENT D: PART C AND D DATA TIME FRAMES. 74Table D-1: Part C Measure Data Time Frames . 74Table D-2: Part D Measure Data Time Frames . 75ATTACHMENT E: SNP MEASURE SCORING METHODOLOGIES . 76A.Medicare Part C Reporting Requirements Measure (C08: SNP Care Management) . 76B.NCQA HEDIS Measures - (C09 - C11: Care for Older Adults) . 77ATTACHMENT F: CALCULATING MEASURE C19: PLAN ALL-CAUSE READMISSIONS . 78ATTACHMENT G: WEIGHTS ASSIGNED TO INDIVIDUAL PERFORMANCE MEASURES . 79Table G-1: Part C Measure Weights . 79Table G-2: Part D Measure Weights . 80ATTACHMENT H: CALCULATION OF WEIGHTED STAR RATING AND VARIANCE ESTIMATES . 81ATTACHMENT I: CALCULATING THE IMPROVEMENT MEASURE AND THE MEASURES USED . 82Calculating the Improvement Measure . 82General Standard Error Formula. 83Standard Error Numerical Example. . 83Standard Error Formulas for Specific Measures . 83Table I-1: Part C Measures Used in the Improvement Measure . 85Table I-2: Part D Measures Used in the Improvement Measure . 86ATTACHMENT J: STAR RATINGS MEASURE HISTORY . 87Table J-1: Part C Measure History . 87Table J-2: Part D Measure History . 90Table J-3: Common Part C & Part D Measure History . 92ATTACHMENT K: INDIVIDUAL MEASURE STAR ASSIGNMENT PROCESS . 93ATTACHMENT L: MEDICATION ADHERENCE MEASURE CALCULATIONS . 95Days Covered Calculation . 95Example 1: Non-Overlapping Fills of Two Different Drugs . 95Example 2: Overlapping Fills of the Same Generic Ingredient Across Single and Combination Products . 95Example 3: Overlapping Fills of the Same and Different Drugs . 96Days Covered Modification for Inpatient Stays, Hospice Enrollment and Skilled Nursing Facility Stays . 97Calculating the PDC Adjustment for IP Stays, Hospice Enrollments, and SNF Stays . 97Example 1 – IP Stay with excess post-IP coverage gap . 98Figure 1: Drug Coverage Assigned Before Modification in Example 1 . 98Figure 2: Drug Coverage Assigned After Modification in Example 1 . 98Example 2 – IP stay with post-IP coverage gap IP length of stay . 98Figure 3: Drug Coverage Assigned Before Modification in Example 2 . 98Figure 4: Drug Coverage Assigned After Modification in Example 2 . 98Example 3 – IP stay with no post-IP coverage gap . 99(Last Updated 08/05/2015)DRAFTPage iv

DRAFTDRAFTFigure 5: Drug Coverage Assigned Before Modification in Example 3 . 99Figure 6: Drug Coverage Assigned After Modification in Example 3 . 99ATTACHMENT M: METHODOLOGY FOR PRICE ACCURACY MEASURE . 100Contract Selection . 100PF Price Accuracy Index . 100Example of Accuracy Index Calculation . 101Table M-1: Example of Price Accuracy Index Calculation . 102ATTACHMENT N: MTM CMR COMPLETION RATE MEASURE SCORING METHODOLOGIES . 103A.Medicare Part D Reporting Requirements Measure (D15: MTM CMR Completion Rate Measure) . 103ATTACHMENT O: MISSING DATA MESSAGES . 104Measure level messages . 104Table O-1: Measure level missing data messages . 1041. Assignment rules for Part C measure messages. 1042. Assignment rules for Part D measure messages. 108Domain, Summary and Overall level messages . 111Table O-2: Domain, Summary and Overall level missing data messages . 1111. Assignment rules for Part C & Part D domain rating level messages. 1112. Assignment rules for Part C & Part D summary rating level messages. 1113. Assignment rules for overall rating level messages . 111Disenrollment Reasons messages. 112Table O-3: Disenrollment Reason missing data messages . 112ATTACHMENT P: GLOSSARY OF TERMS . 113ATTACHMENT Q: HEALTH PLAN MANAGEMENT SYSTEM MODULE REFERENCE . 116STAR RATINGS. 116B.Measure Data page . 116C.Measure Detail page . 116Table Q-1: Measure Detail page fields . 116D.Measure Detail – Auto-Forward page . 117Table Q-2: Measure Detail – Auto-Forward page fields . 117E.Measure Detail – Upheld page . 117Table Q-3: Measure Detail – Upheld page fields . 117F.Measure Detail – SNP CM page . 117Table Q-4: Measure Detail – SNP CM page fields . 118G.Measure Detail – SNP COA page . 118Table Q-6: Measure Detail – SNP COA page fields . 118Table Q-6: HEDIS 2015 Audit Designations and 2016 Star Ratings . 119H.Measure Detail – CTM page. 119Table Q-7: Measure Detail – CTM page fields. 119I.Measure Detail – Disenrollment . 119Table Q-8: Measure Detail – Disenrollment . 119J.Measure Detail – DR (Disenrollment Reasons) . 120K.Measure Detail – BAPP (Beneficiary Access and Performance Problems) . 120Table Q-10: Measure Detail – BAPP (Beneficiary Access and Performance Problems) . 120L.Measure Detail – HEDIS LE page . 121Table Q-11: Measure Detail – HEDIS LE page fields . 121M.Measure Detail – C Improvement page . 121Table Q-12: Part C Measure Improvement Results . 121N.Measure Detail – D Improvement page . 122Table Q-13: Part D Measure Improvement Results . 122(Last Updated 08/05/2015)DRAFTPage v

DRAFTDRAFTO.Measure Stars page . 122P.Domain Stars page . 122Q.Part C Summary Rating page . 122Table Q-14: Part C Summary Rating View . 123Part D Summary Rating page . 123Table Q-15: Part D Summary Rating View . 123R.Overall Rating page . 124Table Q-16: Overall Rating View . 124S.Low Performing Contract List. 124Table Q-17: Low Performing Contract List .

2016 Part C & D Star Rating Technical Notes First Plan Preview DRAFT Updated – 08/05/2015 . DRAFT DRAFT (Last Updated 08/05/2015) DRAFT Page i Document Change Log Previous Version Description of Change Revision Date - Initial release of the 2016 Part C & D Star Ratings Technical Notes 08/05/2015 .