Resuming Outreach to Medicare Members to Close HEDIS® Gaps

Posted September 14, 2020

Every year the Centers for Medicare & Medicaid Services (CMS) evaluates Medicare Advantage (MA) plans’ performances and scores them in a five-star scale known as the CMS Stars Ratings. This includes Blue Cross Medicare Advantage (PPO)SM and Blue Cross Medicare Advantage (HMO)SM plans. Due to COVID-19, CMS made several changes as to how the star ratings are calculated. In March 2020, CMS asked MA plans to put a hold on all outreach that was non-COVID related. Due to this request, all activities that promoted closing Healthcare Effectiveness Data and Information Set (HEDIS) care gaps were suspended.

As each state starts to open and allows for non-emergent health services to resume, the Blue Cross and Blue Shield of Illinois (BCBSIL) Quality and Stars teams are working on strategies to reengage members to achieve HEDIS gap closure targets, while also addressing safety requirements.

Our MA members may contact you with questions, so we want to make you aware of the ways we are engaging with them.

  • HEDIS campaigns – We are scheduling outreach to members based on Illinois opening phases, to remind about pending gaps and offer assistance for coordinating preventive screenings. Outreach methods include calls, letters, and/or email; based on member preferences. Our outreach to members begins with those who have gaps in Comprehensive Diabetic Care (CDC) measures, followed by Breast Cancer Screening (BCS) and Colorectal Cancer Screening (COL).
  • In-home test kits – We understand some members might not feel comfortable leaving their homes, so we have sent in-home tests kits for COL, CDC-Kidney Disease Monitoring, CDC-A1c test to all eligible MA members, except those who have opted out, who are required to complete the preventive test based on health conditions, age groups and other HEDIS requirements. Participation is voluntary. Results will be shared with the member’s provider, unless otherwise requested.
  • In-home assessment – As Illinois regulations permit, we are resuming our in-home assessment program. During the assessment, members will be offered the option to complete any of the following preventive tests: CDC-Kidney Disease, CDC-A1c, CDC-Diabetic Retinal Exam (DRE), Bone Density test, COL.
  • At-home screenings – Members who have an open gap for CDC-DRE and/or Bone Density tests, will be offered the option to schedule an at-home screening through one of our vendors. Coordination of the screenings will depend on Illinois regulations and will follow safety guidelines. Results will be shared with the member’s provider, unless otherwise requested.

Below are a few ways we are engaging with providers.

  • HEDIS Medical Record Review – Due to Illinois regulations and the safety of both our staff and provider office staff, we are encouraging groups and practices with electronic health records systems (EHR) to coordinate with our Clinical Practice Consultants for external access.
  • Coordination of Care, Out-of-Area Program – In January 2020, the Blue Cross Blue Shield Association launched the Coordination of Care Program. The purpose of this program is for Blue Plans throughout the country to work together to help collect medical records for out-of-area members. BCBSIL is collaborating by reaching out to the providers who have serviced members from out-of-area Blue Plans to request medical records for Risk Adjustment, HEDIS and Star Gaps closure. The program was put on hold in April 2020 due to COVID-19, restarted in July 2020 and will continue as permitted. This program helps to ensure continuity of care and compliance among the Blues health plan participants.
  • Stars Update – For measurement year 2020, CMS is bringing back the Controlling Blood Pressure measure and is retiring the Body Mass Index (BMI) measure. As for pharmacy measures, we encourage providers to review members information for those who are under treatment for rheumatoid arthritis, as well as those who have prescriptions for statins to ensure compliance with treatment.

For more information or to learn more about our initiatives, please contact your BCBSIL Clinical Practice Consultant or Illinois Stars Lead.

HEDIS is a registered trademark of NCQA

The above material is for informational purposes only and is not intended to be a substitute for the independent medical judgment of a physician. Physicians and other health care providers are encouraged to use their own best medical judgment based upon all available information and the condition of the patient in determining the best course of treatment. References to third party sources or organizations are not a representation, warranty or endorsement of such organizations. Any questions regarding those organizations should be addressed to them directly. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.