How CAPs can improve your Stars performance

LAUREN SANSBURY:  Hello again. I'm Lauren Sansbury, here today to chat again with Tejaswita Karve, our Stars practice leader here at Optum Advisory. Thanks for being with me today, Tejaswita.

TEJASWITA KARVE: Great to be here again, Lauren.

LAUREN SANSBURY: So we're chatting again about Stars ratings. But we're going to talk today about one of the lesser discussed and probably lesser pleasant aspects of the Stars ratings programs, CAPs, or corrective action plans. So first, let's start with just grounding ourselves with the concept of  corrective action plans in Medicare Advantage. Tejaswita, can you summarize what these are, their drivers, and how it's impacting health plans this season?

TEJASWITA KARVE: Sure, sure. So one of the key requirements of Medicare Advantage Plan to operate is to implement an effective compliance program. The goal here is to ensure that the plans meet and regularly monitor their Part C and Part D, and other compliance requirement, programmatic requirements needed to participate in the program. And when a plan fails to meet the compliance or is non-compliant with certain requirements due to self-reporting or CMS detected in compliance analysis, CMS issues compliance letters, such as notices of non-compliance, or an NONC, warning letters, or WL, and corrective action plan, or CAP requests, among others, depending on the nature of your non-compliance event or events. And these letters carry up to six penalty points.

LAUREN SANSBURY: Okay. So those are the letters. How many points do CAPs carry?

TEJASWITA KARVE: Great question. So the caps carry the highest point penalty, which is six points. And these points of non-compliance events are tracked and accounted by CMS during plan's annual bid, as part of their past performance review. And if a plan gets 12 points, so two CAPs, 12 points, they are denied the service area expansion, which means there is impact on your growth strategy. And remember, these CAPs are publicly reported on CMS.gov so beneficiaries can understand the nature of non-compliance for their plan.

LAUREN SANSBURY: Yeah. Probably another unpleasant PR issue that they'll have to deal with.

TEJASWITA KARVE: Yep, right.