How Medicare Advantage Plans Can Succeed in Health Equity Index Scoring

Healthcare is changing, and health equity is becoming a top priority. With the Centers for Medicare & Medicaid Services (CMS) introducing health equity scoring to the Medicare Star Ratings program in 2023, it’s time for Medicare Advantage (MA) plans to pay closer attention. But what does this new scoring really mean for health plans? And how can implementing healthcare navigation services help MA plans get ahead? Let’s dive into the details.

What is health equity scoring?

In short, CMS’s new health equity scoring is a way to push health plans to actively address disparities in healthcare. For example, people of certain racial, socioeconomic and regional backgrounds often face related barriers to care, which leads to worse health outcomes. CMS is saying, “We want you to help close these gaps.” They’re rewarding plans that can show they’re making real progress in tackling these issues.

The health equity score is tied to factors like:

• Addressing social determinants of health (SDOH), such as food insecurity or transportation challenges
• Offering culturally competent care that meets the needs of diverse populations
• Identifying and closing gaps in care for groups at risk

According to CMS, these nonmedical factors can account for as much as 80% of health outcomes, leaving just 20% tied to actual medical care.

Essentially, if MA plans can prove they’re making healthcare more accessible and fairer for everyone, they’ll see a boost in their Stars Ratings. The Health Equity Index (HEI) score will account for approximately 10% of a Medicare Advantage (MA) plan’s overall Star Rating starting in 2027. 

In addition to limiting a plan’s bonus payments from CMS, lower ratings may result in decreased enrollment, as consumers tend to choose higher-rated plans. If MA plans don’t prioritize health equity and improve outcomes for underserved populations, they may struggle to compete against health plans that do.

How healthcare navigation can help

Now, how do Medicare Advantage plans get there? Enter healthcare navigation.

Healthcare navigation is about guiding members through their healthcare journey, particularly those who need extra support due to language barriers, limited resources, or unfamiliarity with the system.

These members, who are often underserved, are also the ones most likely to impact a health plan’s HEI score. Healthcare navigation goes beyond just scheduling appointments — it ensures members the necessary tools and resources to maintain their health, which improves outcomes and reduces disparities.

Here’s how healthcare navigation fits perfectly into the health equity puzzle:

Tackling social determinants of health

Many Medicare Advantage members, particularly those in populations at risk, face challenges outside of the doctor’s office that affect their health. Maybe they don’t have reliable transportation to get to appointments, or perhaps they can’t easily access or afford healthy food. A study by the Kaiser Family Foundation found that 67% of Medicare beneficiaries face at least one social risk factor, with transportation and housing being major barriers.

Healthcare navigation can help identify these issues and connect members with local resources like ridesharing, food banks or housing programs. By removing those barriers, healthcare navigation can help reduce health disparities, which directly contributes to better health equity scores.

Ensuring access to preventive care

Preventive care is one of the core metrics of the Medicare Star Ratings program. But for members in underserved communities, accessing preventive care can be tough. For example, a report from the Commonwealth Fund highlighted that low-income members were far less likely to receive preventive care, which contributes to health disparity.

Healthcare navigation provides each member with a Care Coordinator who proactively reaches out, helps solve challenges like transportation and access, and encourages members to complete health screenings, guiding them through the process. When more members, especially those who are historically harder to reach, receive their preventive care, health plans’ scores improve.

Offering culturally relevant care

One of the most important aspects of health equity is making sure care is culturally relevant and accessible. A report from Health Affairs found that 34% of Hispanic members and 27% of Black members report facing challenges in communicating with healthcare providers​. Healthcare navigation can be a bridge between members and providers, ensuring that communication is clear and care plans are tailored to members’ cultural needs.

Care Coordinators play a vital role in ensuring that care plans align with a member’s beliefs and that important medical information is accurately translated into their language. By addressing language barriers and cultural needs, Care Coordinators help build trust with members, ultimately leading to better care and improved outcomes.

Engaging members on a personal level

For members disengaged from the healthcare system, healthcare navigation offers a more personalized and supportive approach. Care Coordinators provide one-on-one assistance, helping to reduce the intimidation of navigating care by offering education, sharing resources, and understanding the unspoken needs or apprehensions that may cause members to resist care. This help includes reminding members of appointments, explaining the importance of preventive care, and following up after visits to ensure they feel supported throughout the process. This deeper level of engagement is particularly crucial for members who face barriers to care, and it’s a key strategy for improving health equity outcomes.

What’s in it for Medicare Advantage plans?

So, how does all this benefit Medicare Advantage plans?

Higher Medicare Star Ratings

By implementing healthcare navigation, you can improve your health equity score, which directly impacts your overall Star Ratings. Higher ratings could mean better reimbursements, stronger enrollment, and revenue integrity for your health plan. It’s a win-win for health plans and members.

Reduced costs

When you address your members’ unique needs and ensure their preventive care, you can help avoid costly hospitalizations and emergency room visits. That’s a huge cost-saving measure, especially for populations more prone to chronic conditions.

Better member satisfaction and prevention

People who feel supported in their healthcare journey are more likely to stay with your health plan. By offering healthcare navigation that addresses the needs of all your members, particularly those who need extra help, you’ll boost member satisfaction and retention. In a competitive market, keeping members happy is key.

CMS’s focus on health equity isn’t just a passing trend  —  it’s the future of healthcare. And for Medicare Advantage plans, the new equity scoring means there’s real incentive to get serious about closing care gaps. Implementing healthcare navigation is one of the most effective ways to make that happen. By addressing social determinants of health, improving access to care and offering culturally relevant support, you’ll not only boost your Star Ratings but also help create a more equitable healthcare system for everyone.

Is your plan ready to take on health equity? With the right tools in place, the answer can be a resounding “yes.”

Discover how navigation from Quantum Health can support your health equity efforts.