Winter 2020-2021 HOS Newsletter
Volume 10, Issue 1
Winter Snowflake
Welcome to the Winter 2020-2021 edition of the Medicare Health Outcomes Survey (HOS) Newsletter. This newsletter is designed to provide general updates about the HOS Program and is shared with all who request it. The current issue and all previous issues are available on the HOS website.

The newsletter is also intended to provide a mechanism to share best practices, research results and other HOS-related material. What information would be helpful for research, quality improvement, or other endeavors? Let us know and it will be considered for future editions. Medicare Advantage Organizations (MAOs) and other stakeholders are encouraged to send suggestions and ideas to [email protected].
What's New
Changes in the HOS for 2021
Several changes have been implemented in the HOS during the second half of 2020 and moving forward into 2021.

  • In response to the impact of the COVID-19 Public Health Emergency (PHE), administration of the 2020 HOS and HOS-Modified (HOS-M) was delayed compared to prior years and occurred from August to November 2020.
  • 2020 marked the first time in an HOS cycle that the availability of HOS Performance Measurement (PM) data coincided with the release of the corresponding PM reports. This enhancement will be continued in 2021 and data availability will coincide with report distribution.
  • To accommodate this earlier data availability, Baseline and HOS-M reports will be distributed in the Fall of 2021 instead of Summer. This also applies to HOS-M data, which will be available for distribution to MAOs in Fall 2021.

New HEDIS HOS Report in 2021
In 2021, a new report will be released with the PM reports. This report will be titled the Healthcare Effectiveness Data and Information Set (HEDIS) Health Outcomes Survey (HOS) Effectiveness of Care Report (HEDIS HOS Report). The new report will present results of the HEDIS measures derived from HOS (a.k.a., the “HEDIS Effectiveness of Care” measures) for each MAO based on data from the HOS Round 23 surveys (combined Cohort 23 Baseline and Cohort 21 Follow Up data) collected in 2020. In the past, these results were released as part of the Baseline reports, but beginning in 2021 they will be released in concert with the PM reports. This enhancement will provide MAOs the opportunity to evaluate the Star Ratings and other measures in their HEDIS HOS results and HOS Performance Measurement results for the purpose of targeting health improvement interventions for their beneficiaries.

PFADL Display Measure
The Physical Functioning Activities of Daily Living (PFADL) measure examines, at the contract level, the change over two years in the physical functioning of beneficiaries enrolled in Medicare Advantage (MA) contracts and complements the measurement of physical health status. The PFADL scale combines two physical functioning (PF) questions (limitations in moderate activities and climbing stairs) with the six activities of daily living (ADL) questions to create a Likert-type scale. PFADL scale scores are created from responses to the baseline and the two-year follow-up questions. The measure was first included in the 2017-2019 Cohort 20 Performance Measurement reports that were released in the Summer of 2020 and is reported as a display measure on HPMS. More information about the PFADL change score, including the methodology for creating the PFADL scale score, can be found on the HOS website.
HOS Timeline
Each annual round of HOS data collection, data management, and reporting of results follows standardized protocols. The baseline and follow up surveys are administered together each year by the approved HOS survey vendors. After the final survey data files are submitted by the survey vendors in November, the data are then evaluated, analyzed, case-mix adjusted, scored, and aggregated. Baseline and Performance Measurement reports and data sets are created and then delivered to the Centers for Medicare & Medicaid Services (CMS), MAOs, and other data users.

HOS 2021 Administration Cycle
The next session of the annual HOS survey vendor training will take place in Spring 2021. To administer the HOS, conditionally-approved survey vendors must participate in the annual survey vendor training and successfully complete the post-training evaluation. Survey vendors receive an overview of survey vendor requirements including data submission and coding, quality oversight, and data management. Prior survey vendor training slides can be found on the Survey Administration page on the HOS website. Additional resources to learn more about the HOS such as technical reports, webinars, and manuals can be found on the Resources page.

The fielding phase of the 2021 HOS will begin in the summer after survey vendor training is complete. The 2021 HOS Approved Survey Vendors list will be found along with other timeline information on the HOS website Program page in the Survey Vendors section. The 2021 Survey Administration Memos will be found on the Survey Administration page. Links to copies of the HEDIS® MY 2020, Volume 6: Specifications for the Medicare Health Outcomes Survey and the 2021 Quality Assurance Guidelines and Technical Specifications V2.5 will also be provided when available.

Medicare HOS Survey Administration and Star Ratings Timeline
The following table depicts the timeline for HOS data collection, report distribution to MAOs, Star Ratings year, and Quality Bonus Payment (QBP) year.
HOS Star Ratings
The highlighted sections of the table above depict the relationship between recent data collection and reporting periods. The 2021 Medicare Star Ratings data are from the Cohort 20 HOS measures and the HEDIS Effectiveness of Care measures that were collected in 2019. The 2021 Medicare Star Ratings will be used to set the 2022 quality bonus payments as shown in the green highlighted sections of the table. The yellow highlighted sections show how the 2022 Medicare Star Ratings will be used to set the 2023 quality bonus payments.

HOS Reports Available
The most recently available HOS reports include:

  • 2019 Cohort 22 HOS Baseline Reports
  • 2017-2019 Cohort 20 HOS Performance Measurement Reports
  • 2019 HOS-M Reports

Registered Health Plan Management System (HPMS) users have access to these reports through the HPMS site. The following CMS site has information about how to establish access to HPMS: If you require assistance accessing reports in HPMS, please contact CMS via email at [email protected].

There is a table available on the HOS website Survey Results page that provides general survey status information. The table includes cohort sample sizes and response rates for the baseline and follow up surveys that have been administered and reported through 2019.

The HOS website also provides downloadable sample HOS-M, Baseline, and Performance Measurement Reports with actual aggregate national benchmark data compared to example plan data. These sample reports may be downloaded from the Overview section on the Resources page.

HOS Data Sets Available
HOS data sets are available that provide member-level HOS survey responses for each participating MAO. Designated MAO data recipients (refer to your HPMS memo for details) may request their HOS data sets. The data sets and accompanying Data Users Guides (DUGs) available by request include:

  • HOS Cohorts 1-20
  • HOS-M 2007-2019

The DUG included with each data set provides detailed documentation about file construction and contents for the data set. In the DUG you will find information on methodology and design, the survey instrument, data file characteristics, data file layout by position, annotated baseline surveys, and follow up surveys. The first request for a cohort data set is provided without charge to the plan’s designated data recipient. Additional copies may be requested by the designated data recipient of your organization for a fee per data set.

Contact the HOS Team at [email protected] to request data for your MAO or Program of All-Inclusive Care for the Elderly (PACE) organization. Encrypted data are distributed to designated recipients via secure file transfer.
Medicare Star Ratings
Medicare Star Ratings are in part derived from the two functional health outcome measures and three effectiveness of care measures calculated from beneficiary responses to HOS questions. CMS uses these Star Ratings to help consumers compare health plans based on quality and performance and to reward top-performing health plans. The measure scores obtained through the HOS contribute to individual Star Ratings that are created on a five-star rating scale. When combined with other measurement results, these measure scores contribute to the summary-level Part C Star Ratings which are reported on the Medicare Plan Finder page ( Consumers can search for health plans in their geographic area and compare costs, coverage, and quality information.

Functional Health (Outcome) Measures
The Functional Health (Outcome) Measures are longitudinal. The plan scores from these measures are calculated from responses of the same cohort of beneficiaries to the survey at baseline and two years later at follow up.

  • Improving or Maintaining Physical Health
  • Improving or Maintaining Mental Health

Effectiveness of Care (Process) Measures
The Effectiveness of Care (Process) Measures are cross-sectional, and the plan scores are calculated using data collected from a single round. The Effectiveness of Care measures use the data collected in a single survey year for both the baseline cohort and the follow up cohort combined. As noted above, beginning in 2021, the HEDIS HOS measures results will be found in a new report available at the same time as the PM reports.

  • Monitoring Physical Activity
  • Improving Bladder Control
  • Reducing the Risk of Falling

Guidance on Calculating PCS and MCS
There are two major steps in the scoring for the physical component summary (PCS) and mental component summary (MCS). The first step is to calculate the unadjusted PCS and MCS scores from the Veterans RAND 12-Item Health Survey (VR-12) set of questions that are embedded in the HOS 3.0 questionnaire. The second step is to calculate the adjusted change scores for the HOS Performance Measurement analysis. Beneficiaries age 65 or older, who completed the HOS at baseline and follow up, for whom PCS and MCS scores could be computed at both time points and who remained in their original MAO at follow up, were included in the analysis of PCS and MCS outcomes (i.e., Respondent sample).

The Modified Regression Estimate (MRE) is used for missing data imputation and scoring of the unadjusted scores. The algorithm uses complete cases (no items missing) to estimate a regression equation for cases with missing items, where only those items that are present are used. The final adjusted measures are based on the case-mix adjusted PCS and MCS change scores between baseline and follow up surveys, as well as death status. Please refer to Appendix 1 of the Sample PM Report under “Calculating Performance Measurement Results” located on the HOS website Survey Results page, which describes the questions included in the calculation of PCS and MCS scores, and the case-mix adjusted outcomes for the PM results. The PM results were computed using rigorous case mix/risk adjustment procedures. Case-mix adjustments are used so that all MAOs are as comparable as possible in terms of the socio-demographic characteristics (age, gender, race, etc.), chronic medical conditions, baseline health status, and other design variables obtained from the survey. The coefficient tables of the covariates used in the series of case-mix models for expected death, PCS, and MCS (“Medicare HOS Performance Measurement Coefficient Tables”) are available on the HOS website Survey Results page.

Beneficiary-level actual and expected results are then aggregated, and the resulting scores are used to derive the MAO-level Improving or Maintaining Physical Health (PCS better or same) and Improving or Maintaining Mental Health (MCS better or same) measures that are reported in the Medicare Part C Star Ratings.

Further details about the HOS variables (e.g., race and ethnicity) are provided in the Performance Measurement DUG that is provided to MAOs with their requested data or refer to the online document.

The following reference articles contain more detailed information about the scoring for the unadjusted PCS and MCS scores and a schematic of the items used in the scoring.

For more information and for scoring algorithms, go to the VR-12 developer’s website at

The following article contains more detailed information about the creation of HOS case-mix variables and the case-mix adjustment of the MAO-level Improving or Maintaining Physical Health and Improving or Maintaining Mental Health measures.

Please note: The information presented here will permit an MAO to closely approximate its expected PCS better or same (without death) and expected MCS better or same results. However, exact replication of the final MAO-level PCS Alive and better or same results may not be possible because MAOs do not have access to records of disenrolled beneficiaries that are used in the case-mix adjustment for death, which is used for PCS results. 
Of Note
Of Note
The Surveillance, Epidemiology, and End Results-MHOS (SEER-MHOS) is a linked data set created in collaboration with CMS and the National Cancer Institute (NCI). The SEER-MHOS data set links the SEER cancer registries with MAO enrollees who participated in the HOS in order to provide detailed clinical, demographic, and cause of death information for Medicare beneficiaries with cancer. Additionally, Medicare claims during the beneficiary’s Medicare eligibility (until death) are included in the data. The linked SEER-MHOS data resource includes HOS data covering the years from 1998 through 2018. For the past several years, NCI has made SEER*Stat software available that identifies SEER patients who responded to the HOS as well as the number of surveys they completed before and after cancer diagnosis. In 2021, NCI is developing a web-based sample size estimator that will allow investigators to quickly estimate research sample sizes as they consider using the SEER-MHOS linked data set. More information about the data set and how to apply for a data use agreement (DUA) can be found on the SEER-MHOS website. The following research articles highlighted in this section use the SEER-MHOS as their data source.

Rural–urban differences in health-related quality of life: patterns for cancer survivors compared to other older adults
Socioeconomic factors, including geographical determinants, have been an influence on health outcomes across the population. Given the need to strategize improvements for consistent access to healthcare and overall health-related quality of life (HRQOL), it is necessary to first understand the barriers that geography can impose in healthcare and diseases. It is also imperative to understand the variation in health-related concerns between rural and urban living.

Chronic conditions, including various cancers, may impact HRQOL and require consistent access to resources for care. This makes location an important factor. A new article that used SEER-MHOS data, “Rural–urban differences in health-related quality of life: patterns for cancer survivors compared to other older adults” was released in November 2020 and may be found here.[1]

The researchers studied the effect of rural-urban differences on HRQOL among cancer survivors age 65 and older and a control group also included in the study. Socio-demographics, multi-morbidities, and HOS cohort of the cancer survivors were controlled in the linear regression analysis of the physical, social, and emotional HRQOL measures. Additionally, the models incorporated a multiplicative interaction term for rural residence by cancer status. Overall, HRQOL was higher in urban areas compared to rural areas, and cancer survivors had a lower HRQOL compared to the control group.[1] Based on these findings, which suggest rural-urban differences in HRQOL, it is essential that future research also focus on this subject in order to combat health disparities and improve overall HRQOL.

[1] Moss, J. L., Pinto, C. N., Mama, S. K., et al. Rural–urban differences in health-related quality of life: patterns for cancer survivors compared to other older adults. Quality of Life Research. 2020: 1-13. Available at: Accessed on January 12, 2021.

Health-related quality of life and medical comorbidities in older patients with pancreatic adenocarcinoma: An analysis using the 1998–2011 Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey data
Considering the current climate in healthcare, HRQOL is becoming increasingly important to overall health. HRQOL may also be used as an indicator to direct health-related efforts, which is crucial for targeting particular diseases and chronic conditions such as cancer. A new article for a case-control study that used the SEER-MHOS data, “Health-related quality of life and medical comorbidities in older patients with pancreatic adenocarcinoma: An analysis using the 1998–2011 Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey data” was released in May 2020 and may be found here.[2]

The main objective of the study was to compare HRQOL between the cases and controls. Cases were defined as Medicare beneficiaries with pancreatic ductal adenocarcinoma, and controls were those without a history of cancer. Using linear regression and mixed effects modeling, the researchers investigated the effect of medical comorbidities on HRQOL, MCS scores, and PCS scores.

The results of the study showed statistical significance for lower PCS and MCS scores among cases when compared to the control group. However, the association of comorbidities with lower PCS and MCS scores was statistically significant in the control group. Additional findings showed aggregated comorbidities and total comorbidities did not have statistically significant associations with PCS or MCS scores in the case group.[2] Given the variation in results, further investigation on the effect of cancer on HRQOL would provide more insight on the impact that chronic diseases have on overall health. Continued efforts toward interventions in chronic conditions and identifying triggers for worsening conditions is necessary for improving HRQOL.

[2] Wong, S. S., Hsu, F. C., Avis, N. E., et al. Health-related quality of life and medical comorbidities in older patients with pancreatic adenocarcinoma: An analysis using the 1998–2011 Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey data. Journal of geriatric oncology. 2020: 11(4), 633-639. Available at: Accessed on Jan 12, 2021.
HOS Applications
Frequently Asked Questions
Recent questions received by our Medicare HOS Information and Technical Support site include:

Where can I find the current survey administration documents?
The 2021 survey administration documents are available via the Survey Administration link. The documents include the HOS and HOS-M survey administration memos for MAOs and PACE organizations, and the HOS exclusion memo. Information about HOS program requirements may be found in the HEDIS MY 2020, Volume 6: Specifications for the Medicare Health Outcomes Survey Manual and 2021 Quality Assurance Guidelines and Technical Specifications Manual, Version 2.4, available on the Resources page. Information about HOS survey vendors is available on the Program page in the Survey Vendors section. Survey vendors approved to administer the 2021 HOS survey will be posted during the spring of 2021.

An HPMS memo release has indicated that HOS PM data are available for distribution. My plan participates in the HOS, does that automatically mean I have Performance Measurement data available?
Availability of HOS PM data during the annual distribution period is dependent on the year the baseline collection occurred for the plan. Data are first collected for the baseline sample and then two years later the follow up data collection occurs. Only upon completion of both data collection periods can the data be processed and made available for distribution. Due to the longitudinal nature of the HOS, there is about a three-year difference between the initial baseline data collection and when that completed cohort of data will be available for distribution to the plan. A completed cohort of data is defined as one that has both baseline and follow up data. The table below provides an outline of the currently projected timeline for data collection and data distribution periods.
HOS Data Available
*Tentative year for data distribution, based on current timeline projections and CMS guidelines.

Are the HOS data that are provided via a secure file transfer different from the data that are available through the HPMS site?
Yes. The data distributed to MAOs through the secure file transfer application are the member-level data that contain members’ actual survey responses and Personally Identifiable Information (PII) that are not available from the HPMS site. Actual member-level survey responses are not made available until after the follow up data are collected and reported. The Quality and Performance/HOS module in HPMS provides contract-specific Baseline and Performance Measurement Reports. The HPMS ZIP file containing each report also includes a comma separated values (CSV) file with summary information, such as contract-level survey responses, demographic data, and the HOS quality measures from each report that are used in the Medicare Part C Star Ratings.

I am interested in using HOS data for research purposes. What are my options for data sets, and what approval do I need?
General information about the available HOS data files, variables contained in each file, and requirements for obtaining files may be found on the Research Data Files page of the HOS website. There are three categories of research data files, and they are described in more detail below.

HOS Public Use File (PUF):
  • Baseline and Analytic HOS PUFs, and corresponding PUF Data Users Guides (DUGs), are available for each cohort of data. The PUFs are constructed in a manner that prevents the identification of any single beneficiary or plan through the removal of identifying fields and aggregation of demographic categories. HOS PUF files are available for download on the HOS website Research Data Files page. Corresponding information about the DUGs may be found on the Data Users Guides page.

Limited Data Set (LDS) File:
  • HOS LDSs, by cohort, contain all of the HOS survey items with the exception of direct person and plan identifiers. These data files are available as SAS datasets, and a signed Data Use Agreement (DUA) with CMS is required to obtain an LDS file.
  • Research requests for LDS files must be submitted through the CMS Limited Data Set File Process, and the instructions are available at

Research Identifiable File (RIF):
  • HOS RIFs have all of the HOS survey items, including the direct person and plan identifiers. Consistent with LDS files, RIFs are available as SAS files, and a signed DUA with CMS is required to obtain a RIF.
  • Requests for HOS RIFs are processed through the Research Data Assistance Center (ResDAC) at the University of Minnesota.

What are the requirements for oversampling in HOS?
All MAOs required to report HOS will have the option of oversampling for the 2021 Cohort 24 Baseline survey. Oversampling involves surveying a sample of members that is larger than the required sample size of 1,200. There is currently no upper limit on oversampling for HOS; however, this guidance may change in future survey administration years. Oversampling can only occur at the contract level for the Baseline sample. The follow-up sample is still selected based on follow-up members with eligible PCS and MCS scores from two years prior. Oversampling requests should be expressed as a whole number percentage of the sample size. MAOs must notify the HOS Project Team at NCQA ([email protected]) of oversampling requests by the due date that is specified in the HOS documentation memo, and all oversampling requests are subject to approval by CMS.

Where can a PACE organization find the CMS frailty rate that is calculated from the HOS-M?
The HOS-M report distribution occurs electronically to participating plans through HPMS. Two separate HOS-M reports are derived from the annual HOS-M for PACE organizations. The CMS Survey Results for Frailty Adjustment can be accessed through the HPMS Risk Adjustment module in the winter following data collection and provide the CMS frailty rate and ADL distributions considered for payment purposes. CMS provides the HOS-M Feedback Reports through the Quality and Performance/HOS module one year after the data collection. This report includes summary measures of physical and mental health functioning of the PACE organization’s members.

The definition of a completed survey for the HOS-M Feedback Report is based on the VR-12 summary measures, while a completed survey for the frailty assessment is based on the ADL questions. Therefore, the ADL distributions derived for each report may differ somewhat due to the differing sample selection. Questions about the HOS-M Feedback reports may be directed to the [email protected] mailbox, and questions about the Risk Adjustment reports may be directed to the CMS mailbox at [email protected].

Can you clarify what is meant by the “blackout period” for contacting beneficiaries?
The annual Medicare HOS data collection generally occurs across a designated four-month period. Health plans should not field other HOS-like surveys during, and four weeks prior to, the HOS data collection period, except for other CMS sponsored surveys (i.e., CAHPS). This is the time frame that is sometimes referenced as the “blackout period.” Specific dates for the annual data collection period can be found on the Program page of the HOS website in the Program Timeline section.

What specific topics and activities should plans avoid with beneficiaries during the blackout period?
CMS explicitly prohibits MAOs from implementing practices that could bias or otherwise improperly influence scores. MAOs should also be aware that any internal surveys fielded by the health plan to Medicare beneficiaries during HOS administration could have a negative effect on response rates and scores. Member outreach or communication on a variety of topics that are not specific to HOS-related topics and occur throughout the year is acceptable. However, member outreach that is specific to HOS topics should occur outside of the HOS administration period. Health plans may conduct focus groups with HOS-like questions during the HOS data administration, assuming the focus groups address broader health topics, are not specific to HOS-related topics, and are conducted throughout the year. A healthcare provider may discuss healthcare concerns with a patient that may relate to HOS survey questions. It is also permitted for a provider to suggest to the patient to recollect that discussion in the event that a patient receives an HOS survey in the future.
Medicare HOS Contacts

General Questions about the Medicare HOS:
Contact Medicare HOS Information and Technical Support
Telephone: 1-888-880-0077

Questions about the HOS Program or Policy:
Contact the Centers for Medicare & Medicaid Services at [email protected].

Medicare HOS website:
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