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iCare Quality & HEDIS 5 Star and P4P Programs

Quality & HEDIS 5 Star and P4P Programs

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In early 2008, the Centers for Medicare & Medicaid Services (CMS) contracted with the National Committee for Quality Assurance (NCQA) to develop a strategy to evaluate the quality of care provided by Medicare Advantage Special Needs Plans (SNPs). This strategy relies on a phased approach, beginning with defining and assessing desirable structural characteristics and followed by assessing processes and, eventually, outcomes. The evaluation approach includes several types of assessments.

  • HEDIS® measures
  • CAHPS measures
  • HOS measures
  • CMS specific measures
  • Measures that evaluate structure and process requirements through submission of documentation


The State of Wisconsin has a similar program to CMS to evaluate the quality of care provided by Medicaid Plans.  The goal of this program is to improve the quality of care received by BadgerCare Plus and Medicaid SSI members.  The Pay-for-Performance (P4P) Program uses HEDIS specifications for all of the P4P measures.  MY2021 baselines for HEDIS measures are set using the latest available MY2019 HEDIS state-wide averages and the MY2019 national HEDIS percentiles as published in the Quality Compass.


Objectives of CMS's SNP Assessment Program

  • Evaluate the quality of care SNPs provide to their beneficiaries
  • Evaluate how SNPs address the special needs of their beneficiaries
  • Provide data to CMS to allow plan-to-plan and year-to-year comparisons



The Focus of DHS Quality Initiatives

  • Potentially preventable readmissions
  • SSI HMO care management
  • Wisconsin early and periodic screening, diagnostic, and treatment program
  • Health disparities reduction performance improvement project
  • Wisconsin core reporting
  • HMO pay-for-performance


Did you know...

iCare successfully completed the NCQA-Certified HEDIS® Compliance Audit™ for Medicaid and Medicare. 

NCQA Medicaid Seal  NCQA Medicare Seal

NCQA is a private, non-profit organization dedicated to improving health care quality.






5-Star and P4P Measures for MY2021/BY2023


The documents below show the current quality measures for CMS Five Star Quality Program for Medicare Advantage Plans and the Medicaid Pay-for-Performance Plans.


 MY2021 CMS Part C and Part D 5-Star Rating Measures


MY2021 SSI Medicaid and BC+ P4P Measures Overview




Did you know...

...that iCare conducts Provider Satisfaction Surveys? 

 Show me the Results 


Independent Care Health Plan’s Annual Diagnoses Collection and Confirmation Project


As part of Independent Care Health Plan ’s contract with The Centers for Medicare & Medicaid Services (CMS), it is required to compile and report diagnostic profiles annually. This information must be obtained via a medical record review of individual member diagnoses that were treated or impacted within a claim (calendar) year.

Independent Care Health Plan has partnered with Cognisight to perform the annual collection of data and confirmation project. Cognisight’s goal is to obtain a “complete diagnostic member profile,” while attempting to minimize disruptions to your office workflow and staff.

CMS will only accept submission of diagnoses when they are listed on an encounter note rather than on an active problem list, signed lab result or consult. This does not imply that a provider’s documentation for the purposes of patient care is not sufficient, only that CMS has specific requirements to recognize existing diagnoses for a patient.

This information is time-sensitive and a response is needed as soon as possible.

If you have additional questions, please contact Mark Clausen, Cognisight Account Manager at 585-662-4290 or Amanda Harcus, iCare Director of Financial Data Analytics at



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