New framework shifts focus from administrative compliance to clinical outcomes and patient experience

The Centers for Medicare & Medicaid Services has proposed substantial revisions to the Medicare Advantage Star Ratings program in its Contract Year 2027 proposed rule released November 2025. These changes mark a strategic pivot toward outcome-based evaluation, streamlining administrative requirements while elevating the importance of clinical quality and member experience measures.

Streamlining Administrative Measures

Beginning with the 2027 measurement year, CMS proposes to eliminate 12 measures primarily focused on operational processes. Although these measures ensure baseline performance standards, they have demonstrated consistently high scores across plans and offer limited differentiation for beneficiary decision-making.

This shift represents a significant reallocation of focus, allowing plans to redirect resources toward initiatives that directly impact member health outcomes rather than maintaining operational compliance metrics.

Enhanced Focus on Clinical Quality

As administrative measures phase out, clinical care quality and patient experience measures gain greater prominence within the rating framework. This realignment reflects CMS's commitment to rewarding demonstrable improvements in member health rather than operational compliance alone.

The phased removal includes the removal of call center accessibility metrics such as foreign language interpreter availability and TTY access, as well as the Statin Therapy for Cardiovascular Disease measure (2028 Star Ratings). Additional measures covering appeals timeliness, member complaints, and disenrollment will be removed in the 2029 Star Ratings.

Medication adherence measures will undergo temporary weighting adjustment during the transition. The three key adherence measures-covering diabetes, hypertension, and cholesterol medications will weighting reduced from 3x to 1x for the 2026 measurement year as CMS implements social determinants of health risk adjustment. These measures will return to their 3x weighting in 2029.

Additionally, CMS proposes to introduce a new Depression Screening and Follow-Up measure starting with the 2027 measurement year, which will be reflected in the 2029 Star Ratings. This addition underscores the growing recognition of behavioral health as an essential component of comprehensive care delivery.

Retention of the Reward Factor Structure

Following stakeholder feedback, CMS will not implement the previously proposed Health Equity Index (later rebranded as Excellent Health Outcomes for All). Instead, the agency will maintain the established Reward Factor system that recognizes consistently high-performing plans.

These policy changes, combined with the restructured evaluation framework, are projected to increase CMS expenditures by $13.2 billion between 2028 and 2036, as a greater number of plans achieve higher ratings and qualify for bonus payments.

Strategic Implications for MA Plans

These regulatory changes require Medicare Advantage organizations to adjust their strategies for Star Ratings improvement:

1.      Prioritize clinical intervention programs. With administrative measures declining in influence, organizations should reallocate resources toward care management initiatives that drive measurable health outcomes. Programs targeting hospital readmissions, preventive screenings, and chronic condition management will carry substantially more weight in future ratings calculations.

2.     Strengthen member engagement infrastructure. Patient experience measures will have increased influence under the revised structure. Investment in digital engagement tools, personalized member outreach, and streamlined access to preventive care services will be essential for maintaining competitive ratings.

3.     Address challenges for SNPs and high-risk populations. Special Needs Plans (SNPs) and organizations serving higher-risk populations may face unique challenges under the revised structure. The elimination of the anticipated health equity reward means these plans will not receive additional recognition for serving more complex member populations. To remain competitive, these plans should emphasize intensive care management, SDOH interventions, and enhanced care coordination.

4.    Develop robust behavioral health capabilities. The introduction of depression screening measures requires operational preparation. Plans must establish workflows to identify at-risk members, conduct screenings, and connect individuals with appropriate behavioral health resources.

5.    Maintain medication adherence initiatives. Despite temporary weighting reductions, medication adherence remains fundamental to member health outcomes and will return to heightened importance in 2029. Continuous investment in adherence support programs remains essential for immediate member health and future rating performance.

Looking Forward

The shift from administrative compliance to outcomes-focused evaluation represents a significant evolution in Medicare Advantage quality assessment. Plans with strong member engagement and care management programs are well-positioned for success under the revised framework. Organizations still primarily focused on operational metrics will need to accelerate their strategic reorientation to remain competitive.

PDHI's platform provides the infrastructure necessary to support this transition, offering integrated solutions for gaps in care closure, member engagement, and behavioral health support. Our analytics capabilities enable plans to demonstrate performance improvements in the areas CMS now prioritizes, aligning operational excellence with measurable member health outcomes.

Sources

1. CMS Contract Year 2027 Medicare Advantage and Part D Proposed Rule

2. CMS Press Release: Proposes New Policies to Strengthen Quality, Access and Competition

3. Healthcare Dive: CMS proposes overhauling Medicare Advantage star ratings

4. STAT News: Medicare Advantage plans to gain $13 billion under Trump changes to star ratings

5. McDermott+: CMS releases 2027 policy and technical changes

6. Arine: Medicare Advantage Star Ratings MY2026 Strategy

‍