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Wondering if the insurer-CMS drama got left behind in 2024? It didn’t.
Florida Blue is the latest insurer to sue the Centers for Medicare and Medicaid Services (CMS) and US Department of Health and Human Services (HHS) over its Medicare Advantage star ratings. The insurer filed suit on December 27 in the US District Court for the District of Columbia.
The insurer is arguing that its performance during a flood was unfairly counted against it in its 2025 star rating, a quality metric that helps consumers choose a plan and awards bonus payments to high performers.
CMS did not respond to comment by deadline, and Florida Blue declined to comment.
Other insurers have also sued CMS over their 2025 star ratings, including UnitedHealth Group, Humana, and Centene, though their complaints were over different issues.
“Quality measures should have important consequences when gaps are not closed. As a result, those participating in Medicare Advantage are often expected to achieve levels of performance that are incredibly challenging. The conflict we’re seeing play out over star ratings is an example of that,” Luke Hansen, chief medical officer of Arcadia, a healthcare data platform used by payers and providers, told Healthcare Brew.
The nitty gritty. Florida Blue claims flooding from an intense rainstorm in April 2023 in Broward County “caused major disruptions” in its ability to deliver care.
CMS’s 2025 payment policies say the agency adjusts star ratings for certain “extreme and uncontrollable circumstances” in order to avoid punishing plans for things that weren’t their fault.
Florida Blue argued in the suit that its score should have been adjusted, but it wasn’t because of an “arbitrary and capricious” technicality. Specifically, plans don’t get this adjustment unless a few conditions are met, including the secretary of HHS declaring a public health emergency and waiving certain requirements, according to the suit.
“[This] is self-defeating because it leaves affected plans at the mercy of political or policy-based decisions without regard to the negative impacts an objectively consequential natural disaster or extreme weather event may actually cause,” the suit reads.
The lawsuit alleges Florida Blue’s HMO plan would have netted a 4.5 star rating with the adjustment. As it stands, it sported a 3.5 star rating during open enrollment, which it claims could have led some consumers to choose a different plan.
The insurer also says in the suit that not adjusting the rating lost it “tens of millions of dollars in revenue.”
The bigger picture. Other insurer suites against CMS have also out the classic “arbitrary and capricious” accusation, even though they sued for different reasons—largely centering on CMS’s call center metric, which measures factors like hold times and number of abandoned calls.
The agency announced in November that the call center metric would have less weight going forward.