Measure weights shift
Among the most significant changes is that for the 2026 Star Ratings year—CMS proposes to decrease the weight of Patient Experience/Complaints and Access measures from four times to two times—meaning that 16 measures are losing half their weight. This is especially significant as MA plans have invested time and resources into these qualitative measures in the past several years, prompted by their prior increase in weight from one to four times, only to see their weight now cut in half. While this can be discouraging, this change offers an opportunity for plans to shift their focus and keep up with the new quantitative and qualitative measures CMS is adding to the program.
Hold Harmless provision scaled back
Initially introduced in 2018, the original intent of the Hold Harmless provision was “to recognize that higher performing contracts have less room to improve.” Therefore, a health plan’s overall rating was calculated both with and without the Health Plan Quality Improvement and Drug Plan Quality Improvement measures. Contracts achieving four stars or more were held harmless from having their rating reduced by the inclusion of these measures. However, CMS adjusted the provision for the 2026 Star Ratings year by only allowing five-star plans to apply it. This will make it harder for high-performing plans to achieve and maintain even higher Star Ratings.
Cut point methodology altered
CMS has recently introduced several changes to the cut point methodology, which determines the level of performance required to achieve a particular rating. The first change, aimed at stabilizing cut points, introduced mean resampling to reduce the sensitivity of the clustering algorithm to outliers. For 2024, CMS then introduced the Tukey outlier methodology to remove exceptionally high and low scores compared to the rest of the industry. For 2026, CMS proposes to remove guardrails for non-CAHPS® measures. For example, many plans saw a drop in preventative screenings during the COVID-19 pandemic, but guardrails prevented the cut points from fully reflecting the market’s drop in those rates. Removing these guardrails could now have a significant impact on a plan’s overall score.
Four key steps to success to improve Star ratings
Amid all these changes, consider the following four steps as you seek to enhance your Star Ratings performance in years to come.
- Create a baseline
Start by conducting a comprehensive assessment of your plan's performance across different measures included in the Star Ratings program performance data, such as health care outcomes, member satisfaction scores, and adherence to clinical guidelines. This serves as a reference point for tracking progress and measuring the impact of your efforts. Benchmark your performance against industry averages and top-performing plans.
- Evaluate against predicted cut points
Assess how changes in cut point methodologies may impact your plan's ratings. Utilize historical data and industry trends to predict potential cut point, evaluate your performance against these predicted points, and proactively develop strategies to improve your performance. Prioritize measures that contribute the most to your overall ratings.
- Prioritize performance improvement with collaboration and analytics
Engage stakeholders, including providers, care teams, and administrative staff to provide insight on the resources, infrastructure, and training programs they need. They can also give valuable perspectives and innovative ideas to enhance your performance.
Leverage data analytics and performance management tools to monitor performance, track progress, and identify areas that require further enhancement. You should also proactively measure the impact of program changes on your plan before those changes are implemented. A predictive tool that can forecast cut point changes and predict the plan’s performance at the measure level can enable you to simulate the impact of key initiatives and understand where to apply your resources.
- Engage with members and providers
Connecting with your members and providers is crucial for achieving improved Star Ratings and can lead to better health outcomes, increased member satisfaction, and improved adherence to preventive care measures. Engage members with educational materials, personalized communication, preventative screenings, care management initiatives, feedback surveys, and tools to help them make informed decisions about their health. Work with providers to implement care management protocols, establish regular communication channels, and promote evidence-based practices. Make sure to engage providers in quality improvement activities, such as peer learning and sharing best practices.
The most successful plans will take a proactive and data-driven approach to navigating changes to the Star Ratings program. By continuously monitoring industry updates, staying informed about changes in methodologies, adapting your strategies accordingly, and engaging with key stakeholders, MA plans can enhance their success in both achieving higher quality scores and delivering better care to their members.
CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).
About the author
Marge Ciancetta is the product manager of Cotiviti’s Star Intelligence solution, which helps health plans and providers improve their quality ratings and star scores. She ensures that Star Intelligence represents the voice of Cotiviti’s customers and aligns with industry best practices. She also works closely with our development team, as well as with customers and stakeholders, to ensure that their feedback is incorporated into the product roadmap. With over a decade of experience in the quality space, Marge has a unique perspective on the challenges and opportunities facing health plans and providers today.