Another Year Of Very Tough Medicare Advantage Star Measures Results

Note: This Healthcare Labyrinth blog was written and co-published in collaboration with Lilac Software, a new data analytics technology and insights firm I co-founded with Neetu Rajpal and Alex Schaefer. Lilac’s data scientists are hard at work analyzing all the Star Year 2025 results and recent trends. Check out Lilac Software’s website for additional research and analysis at https://lilacsoftware.com as well as Lilac’s LinkedIn page at https://www.linkedin.com/company/101172520/admin/dashboard/ .

While the Medicare Advantage (MA) Star program has always made it difficult for plans to achieve and maintain high Star scores, the Star roller coaster ride has been much more profound over the past several years. We have seen three years now of falling results – the 2023, 2024, and 2025 Star Years.

In some ways the 2023 year was a “return to normalcy” (with apologies to President Warren G. Harding) after banner Star ratings in the two years prior that were driven by COVID flexibilities (see the additional briefer at the bottom of the blog for more details). But we now clearly have two years – 2024 and 2025 – of very bad news. The percentage of MA-Part D (MA-PD) contracts hitting 4 Star and above as well as the percentage of enrollment in the high performing contracts are extremely low and have now dropped well below pre-COVID levels. The percentage of contracts that rate 4 Star and above barely broke 40%, down from over 44% in 2024. Enrollment in 4 Star and above contracts has now slipped to just over 62%, from over 76% in 2024.

Why are Star scores slipping?

If you look at the pre-COVID base years of 2019 and 2020, the 2025 results are markedly lower in terms of average score, the number of 5 Star plans, the percentage of 4 Star plus contracts, and enrollment in 4 Star plus contracts. For the first time since 2015, the average overall score dropped below 4.0 to 3.92.

The fact that just 40% of contracts and 62% of enrollment is in 4 Star and greater contracts is especially concerning. These figures are driven by reductions of overall Star power at the big national plans, which control over three-quarters of all enrollment in MA. Humana had the biggest decline, with United Healthcare and Elevance Health to a lesser degree. Aetna and Cigna pretty much maintained high overall performance. Centene continued its lackluster achievement. Kaiser Permanente bucked the trends by moving all of its lives into high-performing contracts.

Here are the exact statistics from a Modern Healthcare analysis using June 2024 actual enrollment against estimated 2025:

Major National PlanJune 2024 Percentage Enrollment in 4 Star or Greater Contracts2025 Estimated Percentage Enrollment in 4 Star or Greater Contracts
United Healthcare80.2%68.5%
Humana94.4%25.5%
CVS Health’s Aetna90.8%88.0%
Elevance Health52.8%40.1%
Kaiser Permanente80.5%100.0%
Centene1.2%0.0%
Cigna69.2%68.6%

Here are some thoughts on why Stars are dropping:

  • The 2021 and 2022 ratings were clearly artificial due to the COVID flexibilities. In retrospect, the Centers for Medicare and Medicaid Services (CMS) should not have had policies that essentially led to ratings inflation, which also drove benefit additions that were clearly unsustainable.
  • Some of this can be attributed to the COVID pandemic. The virtual suspension of Star rules allowed plans to take their eyes off of Star. That was short-sighted for the plans that did. The lack of discipline likely has impacted their recent scores. It is hard to get back in the groove of Star. But that was not universal and the plans that came out of the pandemic with continuing high ratings should be congratulated for their diligence and foresight.
  • MA plans may argue that quality is up and it is just ratings that are down due to a higher bar each year. To some degree that could be true. There is no doubt to me that MA plans do a better job than the traditional fee-for-service (FFS) program delivering quality in so many ways.
  • At least some of the sluggishness in ratings can be tied to the introduction of more complex measures, changed weights, and other tightening (such as the Tukey outlier). While you could argue with the changes, CMS is right that the purpose of the Star program is to continue to drive quality. Plans clearly are having issues with keeping up with the changes, including performing well on new measures. CMS telegraphs the changes via display measures and announcements, but too few plans are tracking and remediating these measures before they get promoted to Star.
  • Plans will continue to see these challenges given the road map CMS has assembled:
    • The Health Equity Index is slated to award just 0.1 of 0.4 in the first year or two to plans, down from the annual average of 0.3 of 0.4 from the retiring Reward Factor.
    • Measure Year 2024/Star Year 2026 saw the first true NCQA electronic measure in Stars known as ECDS. This is Colorectal Cancer Screening. (I don’t count Breast Cancer Screening for Star Year 2025 as it was not a hybrid measure.) More will roll out over time.
    • We have two new drug measures in Star Year 2027 and we can expect more in the future. Drug measures have been tough for plans.

Looking at high, medium, and low performance

One key finding from Lilac Software is how performance changed among high, medium, and low performing plans over the past several years.

For the purpose of this assessment, we bundled high performers as 4.5 and 5 Stars, medium performers as 3.5 and 4 Stars, and low performers as 3 Stars and below.

We found that the number and proportion of 4.5 and 5 Star plans has dropped dramatically from 2022 to 2025, going from 168 in 2022 to 92 in 2025, a 45 percent reduction. For 3.5 and 4 Star plans, the count has increased (from 268 in 2022 to 277 in 2025), but the proportion decreased over the timeframe. For 3 Star and below plans, the count increased from 27 in 2022 to 146 in 2025, which is a 441% increase. The proportion increased dramatically as well.

Additional observations from CMS

  • Tukey: CMS notes that extreme Tukey outliers were largely removed from the lower end of performance, which resulted in an upward shift in cut points to more accurately measure performance. I would add that Tukey could have outlier impacts each year based on the outlier performance at the top and bottom. But in Star Year 2025, we also had remaining Tukey impact from Star Year 2024 introduction as CMS was ordered by a court to maintain guard rails in the regulation. Thus, several measures had Tukey cut point impacts greater than 5%, which carried over to and impacted Star Year 2025.
  • Returning utilization: CMS notes that for some measures performance is returning to pre-pandemic levels, resulting in some increases in cut points. The agency also says that some lower performing plans did better on certain measures and pushed up the cut points overall. In other measures, high-scoring plans drove cut points higher at the top of other measures only. There also was a more compressed distribution of scores, which inflated cut points.
  • Profit status and tenure: CMS also notes that profit status and tenure in MA continue to contribute in a major way to higher Star scores.
    • In terms of for-profit entities, just 35.74% of contracts and 50.01% of enrollment are in 4 Star or greater contracts. For non-profits, the numbers are 56.44 and 81.74%, respectively.
    • In terms of tenure, the more years you have in the program, the greater the likelihood you achieve 4 Star or greater ratings.

Average measure scores

Star Year 2025 had 42 MA-PD measures — 30 Part C and 12 Part D.

In terms of Part C measures, from 2024 to 2025, 11 measures increased, 6 stayed the same and 13 dropped.

  • Poor performing measures include: Osteoporosis Management (2.7), Reducing the Risk of Falling (2.6), Controlling Blood Pressure (3.0), Improving Bladder Control (3.0), Statin Therapy CVD (3.0), and Transitions of Care (3.0).
  • High performing measures include: COA – Medication Review (4.1), COA – Pain Assessment (4.2), Complaints (4.2), Appeals Timely Decisions (4.2), Call Center 4.0).

In terms of Part D measures, 5 measures increased, 1 stayed the same and 6 dropped.

  • Poor performing measures include: Statin Use (2.8).
  • High performing measures include: Call Center (4.0), Complaints (4.2).
  • Of note is that the three Medication Adherence measures were all 3.2 or 3.3.  This is a problem area for plans and these measures remain 3x weighted.

5 Star Contracts

Congratulations to the seven MA-PD plans that received 5 Stars on a contract in 2025 – it is a very select group because it is down from 38 in 2024.

  • Alignment Health Plan
  • HealthSun Health Plans by Elevance Health
  • Highmark Blue Cross Blue Shield
  • Leon Health Plan
  • MCS Advantage Classicare
  • Network Health Medicare Advantage Plans
  • Optimum HealthCare by Elevance

Impact on bonus payments

From 2015 to 2023, we saw a consistent rise in Star quality bonus payments. We already saw a drop in Star payments from 2023 to 2024 of about $1 billion – $12.8 billion in 2023 to $11.8 billion in 2024. The average bonus payment per enrollee dropped from about $417 in 2023 to $364 in 2024.

Actual impacts to the quality bonus payments for Star Year 2025 is dependent on each contract’s rating, enrollment, and county benchmarks for the coverage area. I have made a few assumptions and have estimated a potential reduction ofabout $2 billion, which takes into account fewer 4 Star or greater contracts and enrollment growth. I call this a directionally correct estimate given all the variables. Remember too that plans that slipped from 5/4.5 to 4 and 4/3.5 to 3 or less also lose dollars from the rate rebate. That would be on top of the quality bonus reduction estimate.

Conclusion

Star Year 2025 continues the theme that Star achievement remains a huge challenge for plans big and small. COVID allowances led many plans to be complacent in a key revenue and competitive advantage area. That continued into Star Year 2025. Plans lost focus and many have not rebounded.

What many plans fail to appreciate too is the “long tail” of Star. What do I mean? The 40 plus measures for MA-PD plans are a curious concoction of clinical, survey, and plan performance measures. Data used to calculate a given Star year may be one year back for CAHPS and two years back for HOS surveys, clinical measures, and plan performance metrics. Within the HEDIS clinical measures, the lookback for compliancy can add one or more years as well. Once you get a Star score, it does not impact your revenue until the next year. So, what you did a year ago and do today impacts your Star score and revenue well into the future. What’s more, plans have to be working multiple Star years at once due to this lag. The point is that MA plans can never lose focus on the program or they risk huge fallout well into the future.

Many plans lack the technology, clean and timely data, and expertise to hone a consistent and high-performing program. They also lack the agility to respond to CMS changes in the Star program. Technology to analyze and keep tabs on all the years, measures, and formulas is key.

The Star Year 2025 results signal continued tough financial times moving forward. For Calendar Year 2025, the industry overall was looking at lower Star revenue and no real rate increase due to the rollout of the new risk model. That model continues to roll out in rates, which means another relatively flat rate year in 2026. The Star Year 2025 results impact revenue in 2026, which could again contract Star revenue.

The 2025 Star results, too, will lead to a fundamental reassessment in Congress and at CMS as to what is going wrong. The fact that just 40% of contracts and 62% of enrollment in 4 Star plus contracts is especially concerning. That less than two-thirds of enrollees are in highly rated plans could lead to Congress and CMS asking whether the additive nature of Star dollars should continue and might enliven debate on a major rework of the program. MedPAC, the congressional policy arm for Medicare, is especially keen on changing the program in many ways.

But let’s end with what I think is a positive note. As I alluded to earlier, the Star rating program is meant to be a continuous quality improvement program or process. We have such challenges on the cost and outcome front in healthcare that we cannot rest on our laurels and not continue to drive performance. In the end, that is what Star is all about.

So, in many ways Star is working, even with scores dropping, the bad marks we are seeing in 2024 and 2025, the criticism of Tukey and cut point surges, and more. Star scores dropping can be seen as a sign that the Star program is doing exactly what we want as a nation and what CMS’ Star mandate is for MA – good quality care for members at a lower cost and increasingly better quality over time. So, while there surely will be more turmoil as a result of the 2025 announcement, we should keep this in mind and celebrate a commitment to quality. Plans need to meet the challenge.

Sources and reading:

https://www.cms.gov/files/document/fact-sheet-2025-medicare-advantage-and-part-d-star-ratings.pdf

https://www.modernhealthcare.com/insurance/2025-medicare-advantage-ratings-humana-unitedhealth-aetna

#cms #stars #medicareadvantage #partd #healthplans

— Marc S. Ryan

Added Briefer On Stars Policy During And Post Pandemic:

During the COVID pandemic, CMS created fairly major calculation allowances for both Star 2021 (2019 and 2020 data) and 2022 (2020 and 2021 data). These allowances had the effect of boosting Star scores. We saw a surge in Star scores in 2022, including for plans that historically did not have a great track record of consistently hitting 4 Stars and above.  However, for 2023 Star measurement, almost all of the COVID calculation allowances were lifted and we saw a huge drop in Star achievement. In Star 2024, more drops and volatility occurred because calculations saw some major changes (including implementation of the Tukey outlier formula) and far-more-complex measures were added. Now in Star Year 2025, we see further reductions as remaining Tukey outlier latency rolled out. Further, measure attainment also appeared to increase as utilization returned post-COVID, but many plans did not keep up with their peers and thus saw lower measure ratings and overall ratings.

Leave a Reply

Your email address will not be published. Required fields are marked *

Available Now

$30.00