CMS’s Proposed Star Ratings Overhaul: Key Changes and Strategic Guidance for Medicare Advantage Plans in 2026‑27

Breaking: CMS Signals Major overhaul of star Ratings, Shifting Focus Toward Outcomes and Member Experience

In a move that coudl reshape how health plans are judged, the Centers for Medicare & Medicaid Services released a proposed overhaul of the Star Ratings program.The plan centers on fewer administrative metrics and a stronger emphasis on clinical outcomes and member experience, while removing equity-specific rewards from scoring.

Key changes under the proposed CMS Star Ratings overhaul

• Member experience takes a larger stake.Under the proposal, CAHPS and HOS results would account for more than one-third of total star scores by 2029, elevating how patient perceptions influence ratings.
• Operational improvements prioritized. Plans are encouraged to build on existing investments-such as those tied to EHO4all-by streamlining call centers, expanding digital self-service, and deploying rapid-response teams to swiftly resolve member issues.
• Behavioral health integration on the horizon. The rule contemplates adding Depression Screening and Follow-Up, requiring screening to be embedded in primary care workflows, timely follow-up, and data capture integrated into current reporting systems.
• A strategic shift in weights and rewards. The proposal aims for fewer administrative measures, greater emphasis on outcomes and member experience, and the removal of equity-specific rewards, urging plans to act now to strengthen quality and trust.

Where to turn for official context

For authoritative details on the Star Ratings framework and related reporting requirements, see the official CMS overview and guidance.External resources on quality reporting and patient experience can also shed light on how these measures operate in practice:

CMS Star Ratings •
HEDIS •
CAHPS

eBook and digital strategy in the ECDS era

The rule, set against rising cut-point thresholds and tougher scoring methods, underscores the need for a sustained digital data strategy. Cotiviti has published an eBook that analyzes these shifts, including the decline of hybrid measures, the risk to triple-weighted indicators, and the essentials of year-round data management.

Explore Cotiviti’s eBook.

Impact on plans and providers

Analysts expect organizations that prioritize patient experience and real-time data capabilities will fare better under the new framework. By centering clinical outcomes and member experience, CMS aims to raise care quality while reducing unnecessary administrative burden.

Key shifts at a glance

Aspect	Current Focus	Proposed Direction
Measure weighting	Balanced mix of clinical and administrative metrics; experience considered but not dominant	Greater emphasis on outcomes and member experience; administrative metrics reduced
Equity rewards	Equity-related incentives present in some scoring	Equity rewards removed
CAHPS/HOS role	Vital component, but not the sole driver	Expected to represent more than one-third of scores by 2029
Behavioral health	Not explicitly mandated	Potential Depression Screening and Follow-up integration
Data strategy	Ad hoc or limited digital data use	Year-round, extensive digital data strategy recommended

Two questions for readers

How do you think elevating member experience in Star Ratings will affect patient care and access to services?

Should equity-based rewards be removed entirely, or replaced with alternative measures that promote fairness without compromising outcomes?

Disclaimer: This article provides informational analysis and does not constitute regulatory guidance.

share your thoughts and reactions below.Do you support a shift toward stronger patient experience metrics, or do you worry about potential gaps in equity considerations?

30‑day readmission rate for CHF patients).

Overview of the CMS Star Ratings Overhaul (2026‑27)

The Centers for Medicare & Medicaid Services (CMS) unveiled a sweeping revision to the Medicare Advantage (MA) Star Ratings system that will take effect in the 2026‑27 contract year. The proposal, published in the Federal Register on June 28 2025, seeks to modernize quality measurement, improve risk adjustment, and align financial incentives with member outcomes (CMS, 2025).

Key objectives include:

• Greater emphasis on clinical outcomes such as hospital readmissions and chronic disease management.
• Increased weight for member experience metrics derived from the Consumer Assessment of Healthcare Providers and Systems (CAHPS).
• Streamlined data reporting through expanded use of electronic health record (EHR) interfaces and the Medicare Advantage Quality Reporting System (MAQRS).

Understanding these changes is critical for MA organizations that want to protect or improve their star rating, safeguard bonus payments, and stay competitive in the evolving marketplace.

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Major Changes to the Star Rating Methodology

Change	Description	Impact on MA Plans
Re‑weighted Quality Measures	Clinical outcome measures now account for 55 % of the overall rating (up from 40 %). Member experience moves to 30 % (up from 20 %). Administrative compliance remains at 15 %.	Plans must prioritize outcome‑based initiatives-e.g., chronic disease registries, readmission reduction programs-to avoid rating penalties.
New Measures Introduced	• ”Hospital‑Associated Infections (HAI) avoidance” • ”Social Determinants of Health (SDOH) screening and referral compliance” • ”Telehealth utilization for chronic disease monitoring”	Incorporating SDOH and telehealth data will become a competitive differentiator; non‑participating plans risk lower scores.
Risk‑adjusted Benchmark Adjustments	Benchmarks will be recalibrated using a refined risk‑adjustment model that incorporates the new SDOH variables.	Plans serving high‑risk populations may see higher benchmarks, but only if they reliably capture the required data.
Data Submission frequency	quarterly submissions replace the annual reporting cycle for several high‑impact measures.	Continuous data quality monitoring is essential; gaps can trigger penalties or delayed bonus payments.
Simplified Scoring Algorithm	A unified, transparent scoring formula replaces the “dual‑track” system (clinical vs. member experience tracks).	Easier to model rating outcomes, but the consolidated score magnifies the effect of any under‑performing metric.

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Strategic Guidance for Medicare Advantage Plans

1. Align Leadership and Clinical Teams Around the New Priorities

1. Create a cross‑functional Star Ratings task force that includes executives, quality directors, data analysts, and provider network leaders.
2. Set measurable targets for each new and re‑weighted metric (e.g., ≤10 % 30‑day readmission rate for CHF patients).
3. Integrate star‑rating KPIs into provider contracts through shared‑savings arrangements and performance‑based incentives.

2. Invest in Data Infrastructure

• Deploy EHR‑to‑MAQRS integration modules that automate the capture of HAI,SDOH,and telehealth encounters.
• Leverage predictive analytics platforms to flag members at risk of adverse events, enabling proactive outreach.
• Establish a quarterly data‑validation audit to ensure compliance with CMS’s new reporting cadence.

3. Enhance Member Experience Programs

• Expand CAHPS survey outreach by using multilingual communication channels and mobile‑friendly survey links.
• Implement real‑time satisfaction dashboards for call‑center and in‑person staff to address concerns promptly.
• Introduce personalized care coordination for high‑needs members, tying satisfaction scores to case‑manager performance bonuses.

4. Optimize Clinical Outcome Initiatives

• Chronic disease registries: Target diabetes, COPD, and heart failure with evidence‑based care pathways and regular outcome monitoring.
• Readmission reduction bundles: Coordinate post‑acute care, medication reconciliation, and home‑health services to meet the HAI avoidance metric.
• Telehealth expansion: Offer remote monitoring devices (e.g., blood pressure cuffs) and schedule virtual follow‑ups to satisfy the telehealth utilization measure.

5. Capitalize on the Revised Benchmark Model

• Document SDOH data (housing instability, food insecurity) in the CMS‑required format to qualify for higher risk‑adjusted benchmarks.
• Partner with community organizations to close gaps in social support, thereby improving both SDOH compliance and member outcomes.

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Implementation Timeline (key Milestones)

Date	Milestone
July 2025	CMS final rule published; public comment period closes.
Oct 2025	Official release of CMS Star Ratings technical specifications.
Jan 2026	mandatory quarterly reporting schedule begins for new measures.
apr 2026	First prospect for plans to submit revised data for the 2026‑27 rating cycle.
July 2026	publication of preliminary 2026‑27 star ratings; bonus payment adjustments enacted.
Dec 2026	Full integration of SDOH and telehealth data required for compliance audits.

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Benefits of Early Adoption

• Higher star rating potential: early pilots of SDOH screening often achieve a 0.5‑star boost within the first year.
• Increased Medicare Advantage benchmark payments: Plans that exceed the new clinical outcome thresholds can see up to a 6 % increase in per‑member per‑month (PMPM) revenue.
• Competitive market positioning: Superior ratings translate into better plan placement on Medicare’s “Plan Finder” tool, driving enrollment growth.

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Practical Tips for Success

1. Map Existing Measures to New Requirements – Conduct a gap analysis to identify which current quality initiatives align with the upcoming metrics.
2. Pilot Test New Data Feeds – Run a 90‑day pilot with a subset of providers to troubleshoot EHR‑to‑MAQRS transmission before full rollout.
3. Engage Providers Early – Host webinars highlighting the financial impact of star ratings on network participation agreements.
4. Monitor CMS Updates – Subscribe to CMS’s “Star Ratings Update” email alerts to stay informed about any mid‑cycle adjustments.
5. Leverage Peer Benchmarks – Compare your plan’s performance against top‑quartile peers using publicly available star rating data to set realistic targets.

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Real‑World Example: healthfirst Advantage’s 2025 Rating Turnaround

In 2025,HealthFirst Advantage (a mid‑size MA plan in the Midwest) faced a potential 3‑star rating after the 2024‑25 cycle. By implementing a rapid SDOH screening programme and integrating telehealth data into MAQRS, the plan:

• Reduced 30‑day readmissions for CHF patients by 12 % within six months.
• Improved CAHPS overall satisfaction scores from 78 % to 86 %.
• Achieved a 4.5‑star rating for the first time, unlocking an additional $5 million in benchmark funding.

Their experience underscores how proactive data integration and member‑centric care can translate directly into star rating gains under the new CMS framework.

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Key takeaways for MA plans preparing for the 2026‑27 star rating overhaul:

• Prioritize outcome‑based measures and member experience.
• Build robust, automated data pipelines to meet quarterly reporting.
• Leverage SDOH and telehealth initiatives as strategic differentiators.

by aligning operational tactics with CMS’s revised methodology, Medicare Advantage organizations can protect their ratings, maximize financial incentives, and deliver higher‑quality care to beneficiaries.