If you are an insurer who operates as a Medicare Advantage Organization (MAO), you’re well-aware how a plan’s 5-Star Rating by CMS can positively impact your future sales and marketing opportunities. While there are not specific callouts for Star Ratings measures directly tied to a MAO’s marketing, marketing materials or sales practices, their persuasion lands right between the eyes staring into a plan’s overall scorecard and ultimately, their Star Rating. Let’s examine how the domino effect stemming from sales and marketing activities can visibly tip your Star Ratings and your bottom line through less obvious means.

Boiling it down to an elevator speech, a Medicare Advantage Plan’s Star Ratings are calculated by the Centers for Medicare & Medicaid (CMS), through scoring specific elements called “measures.” Those measures can be based on (for example): 

1. Plan operations 
2. Member utilization of specific benefits
3. Ensuring access to care
4. An enrollee’s overall satisfaction with the plan.

In fact, a plan with both medical and drug coverage could have up to 38 measures, with stand-alone drug plans rated on a maximum of 12 measures. Resulting data is gathered for a 12+ month period, then churned through proprietary formulas built by CMS to assign a Star Rating based on a five-point scale, with five stars being the best score. Due to changes in healthcare activities and member utilization trends, CMS can move specific measures on-or-off the list each year or create new measures to monitor quality of care and healthy outcomes.  

That said, it is surprising that there are no Star Ratings measures specifically called out for the sales and marketing activities of an insurer’s operations by CMS. However, measures scored by CMS are unquestionably influenced through sales and marketing, such as (believe it or not): 

1. Measures on preventive care and cancer screening usage 
2. Consumer satisfaction scores 
3. A rise in documented complaints. 

What is the tieback to sales and marketing activities for these types of measures? Here are two examples. 

Beneficiary Satisfaction Outcomes: 

Measures for the upcoming year which score patient experience and resulting complaints, were among those recently recalibrated by CMS to contribute double their original weight toward a Star Rating, as compared to the prior year. Data to measure beneficiary satisfaction with their plan is pulled from: 

1. Customer service areas 
2. Disenrollment data 
3. Regulator surveys 
4. Complaints details 

Knowing the drivers for customer service includes what is covered, how the benefits work, and out of pocket costs, “who ya gonna call” when things do not go as anticipated? Customer service. That is where most of us go, right?  

A surge in customer service inquiries due to sales and marketing issues can throw off the service team’s performance biome for maintaining acceptable hold times, proper handling of complaints, and accuracy in quoting benefits. Therefore, if marketing materials are riddled with errors, agents might be selling plans unsuitable for the individual, based on the benefits listed in their sales collateral. Customer service could be misquoting services from the source documents they are provided (such as the Evidence of Coverage and other benefit-rich documents), and beneficiaries might not be seeking needed services if plan documents have benefit omissions or errors, or misprints in what the member would pay. The domino effect caused by marketing materials errors or an agent inadvertently misrepresenting coverage details, can impact customer service accuracies and their service timelines as well as trigger complaints and disciplinary issues for the agents selling those plans. Whether intentional or not, if the errors are egregious enough, repeated over time, and with high beneficiary impact, a plan can be sanctioned from selling some or all of its plans for a period of time or pay hefty penalties. It is important to consider the double weight in some of CMS’ measures for the coming year, that could cumulate toward a double win or double trouble for a plan’s Star Ratings from sales and marketing’s influence. 

The Sales Conversation and influence on Member Benefit Use 

Insurance agents are nicknamed “Trusted Advisors” by many carriers, for a very good reason. Health insurance is already confusing, and when someone becomes eligible for Medicare, it is helpful to work with someone in-person to help with plan decisions and explain benefits.  

Having agents explain benefits that contribute to Star Ratings, is a way to increase members’ use of measured services. Breast cancer screening, annual flu vaccines and colonoscopies are among the services tabulated for Star Ratings. Plans with members who use those services will score well in those areas, and hopefully avoid high claims payout with early detection of serious health conditions. If benefits contributing to Star Ratings are not utilized, the measure takes a hit. And when not explained correctly by either agents or customer service, or are misprinted in outward facing materials, the beneficiary may not seek those services or could be disadvantaged with unexpected costs prompting complaints and calls to customer service.  
It is critical that your organization’s agents are well-versed in all the benefits you offer, and that they understand (and can explain) what has changed in someone’s plan year-over-year. A beneficiary’s clear understanding of their coverage is critical toward alleviating complaints to customer service, for supporting good scores in Star Ratings and their measures. 

We recognize that Star Ratings are complicated and reach far into clinical topics and an array of other performance factors. But it is important to identify diamonds in the rough to bolster those heavily weighed customer satisfaction and benefit utilization measures. Coaching your sales force and customer service team on benefits details can make a difference, as they are the primary face of your organization interacting with the public to drive future enrollment. This sort of scrutiny with your sales and marketing team’s activities and marketing materials can play a significant role in maintaining good scores for Star Ratings measures.  

As a leader in integrated marketing communications and CMS compliance, Toppan Merrill can help you create and deliver personalized Medicare Advantage member communications with security, accuracy, and compliance.  

Let Toppan Merrill show you how we can help guide and prepare you for your upcoming benefits year. 

Summer Beach, Associate Director, Medicare Compliance Solutions at Toppan Merrill

With over 25 years in the insurance industry, Summer’s focus is Medicare-related compliance. With past roles as Regulatory Compliance Manager and Director for state, regional and national insurers, her areas of SME include CMS-regulated documents and guidelines, agent/broker and sales compliance, designing CMS-approved investigation processes, audits and Corrective Action Plans, and training with re-education formats following CMS disciplines. Summer brings expertise in policies and procedures, auditing compliance programs, and has measurably reduced plans’ member complaints to CMS through remedial initiatives. Well-versed on CMS insights, Summer identifies risks to avoid, for staying compliant. Summer’s experience supports Toppan Merrill and our clients in staying compliant with CMS and regulatory requirements.