Premera applies the Star Rating methodology used by the Centers for Medicare & Medicaid Services (CMS) to evaluate the quality of Medicare Advantage plans. A Medical group’s Star Rating is on a scale of 1 to 5 stars, with 5 stars being the highest rating. A medical group that achieves 3.5 or more out of 5 stars is awarded the Premera Medicare Quality Star designation.

How are providers measured?

The star rating is determined using clinical care quality measures developed by National Committee for Quality Assurance (NCQA) and medication management measures developed by Pharmacy Quality Alliance (PQA). These are the same measures used by CMS to evaluate Medicare Advantage plans.

A star rating for each measure is calculated based on performance compared to other Medicare Advantage plans, as reported by CMS, with some measures weighted more than others. A weighted average of all measures is then used to determine the final Quality Star rating for a medical group. Measures are subject to change annually based on CMS.

While we use the best available information, there are some limitations:

• Claims data is used to calculate performance on all measures. There may be health care services performed or medications dispensed for which no information is provided to Premera, such as instances where a second payer was billed or a member paid out-of-pocket.
  
• The clinical quality measures are based on claims data as well as other sources submitted by the medical group. If the medical group does not elect to submit additional data sources to Premera, performance may be lower for some measures.
• Medical groups with less than 200 members do not have enough data to create an accurate assessment using a star rating method. Premera does not calculate a star rating for medical groups who do not meet this minimum threshold.
  The Medicare Quality Star designation is awarded based on the medical group’s performance. There may be variation among providers in a medical group, a provider may be new to a medical group and not included in measures for the performance time period or may lose the designation when moving to a new medical group that did not achieve high performance.

A clinic’s Star Ratings are calculated using the members assigned to a medical group at the end of the most recent measurement year. Each medical group with 200 or more Premera Medicare Advantage members is assigned a Star Rating. Medical group that achieve 3.5 or more out of 5 stars will receive the Medicare Quality Star designation. The Medicare Quality Star Rating is then applied to all PCPs at that medical group.

The designation is applied only to PCPs. Medicare Advantage is an HMO model. The PCP is responsible for the majority of a member’s routine healthcare needs, and for coordinating care with any needed specialists. The Medicare Quality Star designation reflects the care received from and coordinated by the PCP.