A federal judge in Texas on Friday ruled that the Centers for Medicare & Medicaid Services (CMS) made a mistake when it calculated the insurer’s Medicare Advantage quality scores for 2025. The agency must recalculate the score and immediately publish the updated rating on the Medicare Plan Finder.
UnitedHealthcare sued CMS and the Department of Health and Human Services in late September for downgrading its quality score based on an arbitrary and capricious assessment of how its call center handled a single phone call from a CMS test caller that lasted less than 10 minutes.
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UnitedHealthcare said the caller was routed via its single call center to a French-speaking United customer service representative. During the call, which was connected for more than eight minutes, the recording picked up faint resulting and breathing sounds from the test caller, but the caller never asked the required introductory question. As a result, the customer service representative did not have an opportunity to respond. Although the caller was never put on hold, the representative disconnected the call after not hearing the introductory question within eight minutes of the call.
Because of the disputed call, UnitedHealthcare saw its Star ratings drop from a 5 to a 4 in 2025.
Judge Jeremy Kernodle of the U.S. District Court for the Eastern District of Texas, sided in part with UnitedHealthcare, finding CMS’ determination that the disputed call was “unsuccessful” was arbitrary and capricious and it failed to evaluate the call based on its own guidelines. He ordered CMS to recalculate UnitedHealthcare’s Star rating without consideration of the disputed call. The recalculated score could mean the insurer will receive a significant increase in quality bonus payments for 2026.
However, Kernodle did not agree with UnitedHealthcare’s complaint that CMS evaluated it differently than it did when it reviewed Elevance’s call centers. He said CMS’ decision to treat the two calls differently was not arbitrary and capricious.