Centene sues CMS over Medicare Advantage star ratings
The star rating drop will cause Centene to lose an estimated $73M in gross revenue, lawsuit says.
Photo: Erik Isakson/Getty Images
Centene has joined the list of insurers that are suing the Centers for Medicare and Medicaid Services over the 2025 Medicare Advantage Star Ratings.
Centene of Missouri and 10 affiliated plans such as Meridian Health Plan of Michigan and several Wellcare plans filed the lawsuit Tuesday in federal court in Missouri.
WHY THIS MATTERS
Centene is suing over one of the measures used by CMS to calculate star ratings, the success rate of calls that CMS interviewers, called secret shoppers, make to the plan through text-to-voice teletypewriter (TTY) services. Secret Shoppers use internet protocol enabled text-to-voice-teletypewriter services (IPTTY) to make these calls. A score is based on the number of successful calls that connect to the plan's call center compared to the number of calls made, the complaint said.
CMS held a single call against Centene, the lawsuit said. This call never reached the call center.
"Rather, the CMS secret shopper's own call notes show that the shopper's IPTTY 'chat window closed unexpectedly' which is a clear failure of CMS's software," court records said.
Getting a 5-star rating requires 100% of TTY calls to be successfully completed, the complaint said.
The "arbitrary decision" to hold a single call against them resulted in a lower score and lower Part D summary star ratings and overall star ratings for several contracts, Centene said.
"While CMS's mistake affected only a single call, the impact of CMS's decision is profound," the company said.
Centene said it would lose potential enrollees searching for plans on the Medicare Plan Finder.
The star rating drop will cause Centene to lose an estimated $73 million in gross revenue, which Centene would have reinvested in reduced premiums and increased benefits.
Centene said it could also lose other opportunities available to other plans, jeopardizing the plans' ability to operate.
Since CMS requirements hold that TTY calls must connect to the call center and the particular call never connected, Centene wants an injunction recalculating Centene's star ratings without the disputed call.
THE LARGER TREND
Several plaintiffs in the complaint, Wellcare Health Insurance Company of Washington, Wellcare Health insurance of the Southwest and Wellcare Health Plans of Vermont, each received 2.5 stars in the star ratings released on October 10.
Both Humana and UnitedHealth Group have sued CMS over star rating downgrades, with the call center coming under fire.
Email the writer: SMorse@himss.org
