In the near term, healthcare organizations are rightly focusing on helping their members stay healthy and navigate a historic pandemic. To provide value for their members, these organizations also need to consider how COVID-19 will impact the entire healthcare system in the long term.


Medicare Advantage organizations are impacted greatly by COVID-19 because of the high-risk nature of the population they serve, and because a portion of their financial compensation from CMS is determined by rewards and rebates based on the quality of care derived from their star rating. Plans are struggling with forecasting their performance in today’s unpredictable healthcare environment. They’re dealing with doctors’ offices being closed and elective surgeries being postponed to shore up resources for hospital ICUs. Due to the amount of volume and stress on providers, the flow and accuracy of claims data also has been a concern. Fortunately, as expected, CMS issued new rules and regulations to help plans sort through some of the uncertainty surrounding their 2021 and 2022 star ratings.

As the impact of COVID-19 is better understood, we expect additional modifications to the rules. The rule changes for 2021 will hold most of the industry consistent with their 2020 star ratings, while there should be significant fluctuations in ratings for 2022 since this will cover the 2020 performance year that’s been impacted by COVID-19.



The HEDIS and CAHPS measures will revert back to their 2020 scores and star ratings. This change is aimed at relieving some of the administrative burden on Medicare Advantage organizations and providers. All other measures outside of HEDIS and CAHPS will be calculated per existing rules, unless any unforeseen issues in data collection or validation occur.



CMS expects plans to submit HEDIS data in June 2021 and administer the CAHPS survey in 2021. The health outcome survey is being postponed from spring 2020 to later in the summer. Outside of the administrative deadlines, CMS is making additional adjustments to help plans navigate COVID-19. CMS is delaying a rule that would have prevented cut points moving more than five points in one year. This should help alleviate plans’ concerns that overall measure level scores will decrease due to the current climate, but they would be held against higher cut points that were capped from prior years. Plans will also not be held responsible when it comes to negative improvement scores in the 2022 star ratings.


Once plans start to understand the impact of the changes to the 2021 and 2022 star ratings, they can implement strategy and principles that will help guide them through COVID-19 and beyond.



At this point, the 2022 star ratings will be based on the 2020 performance period. CMS is expecting a national performance decline based on their recent removal of five-point guardrails for 2022 cut points. This expectation is built on members’ everyday obstacles and the challenges of delivering care. Medicare Advantage plans should therefore make sure that members are being supported and receiving the best care possible by expanding telemedicine offerings, relaxing refill edits, educating members through targeted outreach and removing cost barriers to COVID-19 testing. These solutions are not only the right thing to do for members, but they’ll also help ensure better quality perception and possibly better future CAHPS survey results.



The CMS rule changes should push Medicare Advantage plans to focus on medium- to long-term strategies that fit into the new normal. Here’s how:


1. Focus on members. Identify members that have gaps in care due to their inability or preference not to seek care during this time. This is part of the normal strategy of any Medicare Advantage plan, but the sheer number of gaps could be unlike any other year. Determine how to segment this population based on their overall risk and likelihood of closing their gap in care. Create a resource allocation plan for when normalcy returns.

2. Leverage virtual technology. The outbreak of COVID-19 has been a catalyst for more virtual health visits over the past two months but adoption has been slow, particularly for older demographics. Look for innovative ways to leverage virtual technology to provide efficient and convenient ways to serve your members. More people will adopt virtual programs over the long term as COVID-19’s impact lingers.


3. Evaluate provider relationships and opportunities. Provider and health system offices have been temporarily closed to help stop the spread of the virus, driving a major decline in overall revenue and leading to layoffs. Medicare Advantage organizations will need to evaluate their existing relationships with providers and health systems that treat a large percentage of their beneficiaries. The administrative disruption can make collecting and validating claims data for the chart chasing process difficult. If members are having trouble interacting with their physician’s office, they may believe their quality of care is decreasing, negatively impacting member survey scores. Evaluate these provider partnerships to determine what technological solutions can be implemented to overcome some of these administrative challenges.

Medicare Advantage plans have a great opportunity to support their members through COVID-19 and adapt their longer-term performance strategy in light of changes in the healthcare landscape. Plans can feel relatively confident that their 2021 star rating will not deviate much from their 2020 star rating due to the rule changes put in place by CMS. Plans should continue to focus on member quality and service in the short term and think about how their operating model fits into the post-pandemic world. The greatest impact will be felt in the 2022 star ratings and beyond. By focusing on members, virtual technology and provider relationships now, plans can get ahead of the curve.