CMS' 2024 Final Notice and Rule: What You Need to Know

The Centers for Medicare & Medicaid Services (CMS) recently released the 2024 Final Rule, codifying many of the changes we saw in the 2024 Final Notice. However, CMS surprised us with the announcement of a second rule we can expect at a later date to address the changes that were not codified in the initial Final Rule. We anticipated significant change to Star Ratings since the COVID-19 Public Health Emergency paused many expected adjustments. Now, we’re seeing many of those changes come to fruition.

The volume of changes is overwhelming. Medicare plans should familiarize themselves with the updates and start making necessary operational and data mining transitions now, versus waiting and finding yourself behind the curve.

What’s Included in the Final Notice?

Changes to existing Star Ratings measures for the 2023 measurement year (MY) and beyond offered no real surprises since most changes were previously discussed, and put on hold, due to the COVID-19 Public Health Emergency. We’ve been waiting for most of these changes to be finalized for years. Within the Final Notice, CMS provided insight and updates on the items reviewed in the Advance Notice.

For the 2024 Star Ratings, we know the Tukey outlier deletion, addition of Transitions of Care and Follow-up after Emergency Department Visits for Multiple Chronic Conditions, Plan All-Cause Readmissions will move forward as expected. CMS also reminded plans that the deadline for review of appeals and complaints to Medicare is set for June 30. They also provided the list of measures included in the 2024 Star Ratings, along with measures impacting both the Improvement and the Categorical Adjustment Index calculations. The extreme and uncontrollable circumstances policy is moving back to areas impacted by natural disasters, with no COVID-19 Public Health Emergency relief available for the 2024 Star Ratings.

Additional items to note regarding changes to existing measures for the 2023 measurement year and beyond:

• Optional exclusions for Healthcare Effectiveness Data and Information Set (HEDIS) measures will now be required for Controlling Blood Pressure, Colorectal Cancer Screening, Kidney Health Evaluation for Patients with Diabetes (KED) and member death across all measures.
• Care for Older Adults (COA)-Pain Assessment potentially retired in MY2025 is approved by the Clinical Measure Performance committee in May 2023.
• CMS is exploring new measure concepts with a broader population for COA-Functional Status Assessment and COA-Medication Review for MY2025 and beyond.
• CMS is reviewing updates to Diabetes Eye Exam and Blood Sugar Controlled to determine identification of diabetes diagnosis and changes would be non-substantive:
  • Two encounters, excluding labs on different dates of service.
  • Requirement for diabetes diagnosis aligned with prescriptions for diabetes.
• Potential removal of hybrid specification for both Diabetes Eye Exam and Blood Sugar Controlled.
• National Committee for Quality Assurance (NCQA) is considering incorporation of Glucose Management indicator to Blood Sugar Controlled for MY2024 and beyond and there were mixed reviews from plans regarding this change.
• Breast Cancer Screening changes regarding transgender and non-binary members was supported by health plans and would be considered non-substantive.
• Statin Use in Persons with Diabetes change for MY2024 would use continuous enrollment and align with Pharmacy Quality Alliance (PQA) specifications on age criteria.
• Medication Adherence implementation of risk-adjusted criteria based on Sociodemographic Status (SDS) characteristics would be a substantive change for MY206 and would be addressed during rulemaking.
• Non-substantive changes to medication adherence would be utilizing continuous enrollment beginning with MY2024 and removal of Inpatient/Skilled nursing facility stays in MY2026.
• Medication Therapy Management (MTM) completion rate non-substantive change to use the Enrollment Database data to identify members in hospice for exclusion with no mention of other changes coming to the MTM program.

It seems most comments related to proposed changes were well received by most health plans. While there was some concern with ensuring data accuracy for new measures, before being pushed to the Star Rating, it seems plans are prepared to face the changes that could be coming. As plans continue to mature and enhance their focus, it still does not eliminate the frenzy plans will be facing with new measures and potential calculation methodology enhancements.

Many commenters requested that CMS provide additional resources to track current and future Star Ratings measures and methodological changes. During my years in Stars, I have always kept a grid with dates, if known, of when to expect changes, either codified or proposed. Download Healthmine’s roadmap of expected Star Ratings changes and which measurement years they align with.

What’s Included in the Final Rule?

With the release of the 2024 Final Rule, we can see the changes that are coming and eagerly await the surprise second rule to know what additional adjustments will be made. CMS stated that the second rule would codify the remaining items from the December 2022 Proposed Rule and would be applicable to coverage beginning no earlier than January 1, 2025

The Tukey outlier deletion methodology will be codified as of June 5, 2023, along with the removal of the Part C Diabetes Care-Kidney Disease Monitoring measure on the same date. There were many other items finalized within the Final Rule, including:

• Risk adjustment of the three medication adherence measures based on sociodemographic status will be applicable for the 2026 measurement year and is a substantive change, thus first year weighting will be 1x-wieghted, followed by an increase to 3x-weighted the following year.
• Finalization of the Health Equity Index for the 2025 measurement year, which will be based on performance in both MY2024 and MY2025.
• Finalization of the reduction of patient experience, complaints and access measures from 4x-weighted to 2x-weighted for MY2024.
• Finalization of the removal of the Part C Diabetes Care-Kidney Disease Monitoring measure, and addition of Part C-Kidney Health Evaluation for Patients with Diabetes for MY2024.
• Grant CMS the authority to remove measures from the Star Ratings, without rulemaking, should the measure steward retire or remove a measure.

With the forthcoming second rule, updates will be communicated on:

• Removing the standalone Medication Reconciliation Post-Discharge measure.
• Adding the updated Colorectal Cancer Screening and Care for Older Adults – Functional Status Assessment measures.
• Adding the Part D Concurrent Use of Opioids and Benzodiazepines, Polypharmacy Use of Multiple Anticholinergic Medications in Older Adults, and Polypharmacy Use of Multiple Central Nervous System Active Medications in Older Adults measures.
• Removing guardrails — the bidirectional caps that restrict upward and downward movement of a measure’s cut points for the current year’s measure-level Star Ratings compared to the prior year’s measure-threshold specific cut points — when determining measure-specific-thresholds for non-Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures.
• Modifying the Improvement Measure hold harmless policy.
• Adding technical clarifications related to Quality Bonus Payment appeals and weighting of measures after a substantive specification change.

What Should Plans Do Next?

CMS provided updates on display measures being considered for the Star Rating. Per previous rulemaking, CMS will place new or updated measures with substantive changes on the display page for at least 2 years prior to using the new or updated measure to calculate and assign Star Ratings. Keeping track of performance in display measures should be treated with similar urgency to work being completed for Stars, particularly for those measures CMS says may be coming to the Star Rating soon. Staying up to date on the display measures and ensuring data is in place, along with operational needs and resources to manage performance is key to success.

CMS did advise plans to participate in all requests for comment periods offered by the NCQA and PQA. There was overwhelming support of the Universal Foundation measure set in the 2024 Final Notice, with some suggestions for adding measures related to women’s health issues, tobacco use screening and intervention, patient safety, Part D medication adherence, rare diseases, patient activation and primary care provider related measures. Plans expressed concern on reporting data and whether Electronic Health Records (EHR) and Electronic Clinical Data Systems (ECDS) were available to support accurate data collection. There were mixed reviews on the Social Needs Screening and Intervention measure.

Future proofing your Star Rating also involves being aware of and tracking CMS guidance for new measure concepts being explored. The Health Equity Index, impacting the 2027 Star Rating for both Part C and Part D should be at the top of your list for changes coming that will require intense focus to ensure members are receiving equitable services. CMS is also considering new cross cutting of HEDIS measures related to sexual orientation and gender identity, and identified chronic conditions. Other new measure concepts being considered are:

• Chronic Pain Assessment and Follow-up
• New Blood Pressure Control measures
• Kidney Health
• Social Connection Screening and Intervention
• Additional Mental Health and Unmet Health-Related Social Needs in Health Outcomes Survey (HOS)

Finally, CMS will be adding a web-based mode to the CAHPS for the 2024 survey period. Best of all, CMS has said the 15-minute wait time question in the CAHPS survey will be removed from the 2024 survey. This change has been argued for years and CMS has finally agreed to remove the question. The angst experienced with the inclusion of this question, the tough conversations we have had with our provider partners and the feeling of defeat is finally being resolved. I believe we heard a very long sigh of relief upon reading this change.

Now, we wait for the second final rule to know what other changes CMS will codify, along with potential future measures and timing associated with their addition. Spending the weekend reading this Final Notice, along with the midweek reading of the Final Rule has made for a very long week. Now is the time to make those necessary enhancements to your Stars program and ensure resources and data are in place to be successful. Reach out to me at John.Willis@Healthmine.com to get your work plans in place and be ready to execute as soon as possible with the right strategies.