CMS Medicare Advantage Star Program To Get Tougher

November 28, 2025

NOTE: This blog is co-published with Lilac Software. See the end of the blog for more information on Lilac’s Stars platform and agentic AI solutions.

The skinny on Star changes in the future and how tough it may be, especially for Special Needs Plans.

On November 13, I did a blog (see it here: https://www.healthcarelabyrinth.com/cms-likely-to-remake-star-ratings/ ) that said the Centers for Medicare and Medicaid Services (CMS) plans on remaking the Medicare Advantage (MA) Stars program by eliminating easy-to-hit operational measures and replacing them with tougher clinical measures. Sure enough, CMS acted on this on November 25, publishing a draft MA and Part D rule for 2027 that would make sweeping Star changes.

The CMS Stars announcement

Beginning primarily in Measure Year (MY) 2027 or Star Year (SY) 2029, CMS proposes to remove 12 (really 14 based on duplication in Parts C and D) measures, largely focused on operational/administrative processes or those that no longer show variability in quality among plans. (The Call Center and Statin measures will be removed in MY 2026/SY 2028.)

These are:

Administrative/Operational measures removed entirely:

Two Part C Appeals
Part C and D Call Center (MY 2026/SY 2028)
Part C Special Needs Care Management
Part C and D Complaints
Part C and D Disenrollment
Medicare Plan Finder Price Accuracy

No longer showing variability in quality:

Diabetes Care – Eye Exam
Statin Therapy for Patients with Cardiovascular Disease (MY 2026/SY 2028)
CAHPS Customer Service
CAHPS Rating of Health Care Quality

The above has the effect of transferring so-called Star power to drug, HOS survey, and quality improvement measures. Here is the impact on relative weighting of measure groups toward the overall rating from SY 2026 (the just released Star year) vs. SY 2029 (the year all proposed changes will be in effect). Note that SNP-only conracts and contracts with high-concentration of SNP lives have slightly different percentages but they are very close to these numbers.

Measure Category	SY 2026	SY 2029
HEDIS	24%	25%
Drug	16%	20%
CAHPS	23%	22%
HOS	7%	15%
Operational	16%	0%
Quality Improvement	14%	17%

The Excellent Health Outcomes for All (EHO4all, the former Health Equity Index (HEI)), will not be implemented for SY 2027 (MY 2025). The Reward Factor would be maintained for consistently high-performing plans. This creates winners and losers. While most plans would see little additional reward under EHO4all initially, many plans have invested heavily in EHO4all in anticipation of the program coming online in SY 2027. And many of these plans do not have a shot at the Reward Factor (you need to consistently score at least in the very high 3s or higher on the overall rating to get it). Those who have consistently received the Reward Factor and do not have a major penetration of health equity populations would benefit from the reversal on EHO4all.

The real question is are plans getting due process and is it equitable when the government proposes to zero out the EHO4all in a draft rule with just one month left in MY 2025 and when the final rule will not be adopted until well after the measure year has concluded. Some plans could challenge the provision. After all, the HEI proposal went through full rulemaking back in 2023. Plans had sufficient notice to prepare for the major change. They will not now.

CMS also proposes to introduce a new Depression Screening and Follow-Up measure that would begin with MY 2027/SY 2029. This was expected as Universal Foundation measures are rolled out throughout government healthcare programs.

The changes could have a huge impact on plans. CMS says this is the estimated impact on Star ratings:

62% of contracts will see no impact to Star ratings
13% of contracts will see an increase of one-half Star
25% of contracts will see a decrease of one-half Star
One contract would drop by one Star

So at least a quarter of plans could see a drop in Star ratings and therefore could see a major reduction in added revenue. And there is no question that the new approach on measures makes it even more difficult to consistently perform well.

A year-by-year look

Given all that is changing, here is an SY 2027, SY 2028, and future years breakout (confirmed, proposed and possible). I have bolded items proposed in the 2027 MA and Part D rule, which will not be finalized until late March or early April and could change. We cannot be certain all of them will be finalized so plans need to be nimble here.

MY 2025 inflight now, which contributes to the Star Year (SY) 2027 rating:

The Reward Factor was to be sunset and the EHO4all Reward was scheduled to come in. Like the Reward Factor, the EHO4all was supposed to reward an additional up to 0.4 points for high quality performance on Low Income Subsidy (LIS), dual eligible status, and Disabled populations. In the aggregate, fewer dollars would have been awarded initially under EHO4all – 0.1 of 0.4 for EHO4all vs. 0.3 of 0.4 for the Reward Factor. As noted above, the proposed 2027 MA and Part D rule would retain the Reward Factor and not implement EHO4all if the proposal is finalized.
The Health Outcome Survey measures Improving or Maintaining Physical Health and Improving or Maintaining Mental Health returned in SY 2026 with 1x weights. In SY 2027, these measures will move to 3x each. The measures look at improvement of cohorts over a two-year period. In SY 2027, the baseline year is MY 2023 and the follow-up year is MY 2025.
Care for Older Adults Pain Assessment is removed from Star and Care for Older Adults Functional Status Assessment returns.
Two new difficult drug measures are introduced — (1) Concurrent Use of Opioids and Benzodiazepines (COB) and (2) Polypharmacy Use of Multiple Anticholinergic Medications in Older Adults (Poly-ACH). These are challenging as the overlapping period for drugs impacting drug safety is extremely short. Often by the time you discover the overlapping drugs, the member is non-compliant for the year. A risk-based approach is essential to perform well.
Removal of (1) Medication Reconciliation Post-Discharge and (2) Medication Therapy Management – Comprehensive Medication Review.
Colorectal Cancer Screening is expanded down to age 45. While the ECDS electronic conversion was not deemed substantive in SY 2026 (it should have been), this change is being deemed so in SY 2027. It remains a Star measure, however, as the re-specified measure has been on the Display Page.
Diabetes Care — Eye Exam will no longer have a chart review option. This is worth about two points in performance.
A Statin tolerance exclusion is introduced in the Statin Use in Persons with Diabetes measure.

MY 2026, which contributes to SY 2028 rating:

Two major changes for all three Medicare Adherence measures – Diabetes, RAS Antagonists, and Statins. Due to the significant changes in measure specifications, the three measures will drop from 3x weights to 1x weights.
- A new risk-adjustment methodology is added, which will adjust for differences in adherence for age (various age bands), sex (male and female), Low Income Subsidy/Dual Eligible, and Disability. The risk adjustment is applied to overall medication adherence performance based on the actual rate for the contract, predicted rate for the contract, and national benchmark.
- Removal of the inpatient hospital and skilled nursing facility adjustments.
The Statin Therapy for Patients with Cardiovascular Disease (SPC) was to change significantly and therefore would move to the Display Page for two years beginning in MY 2026 before coming back to Star for SY 2030/MY 2028. The main change is that NCQA is modifying the female exclusion so that all ages for females are included in the measure. The measure will also be converted to ECDS electronic in MY 2026. As noted above, the proposed 2027 MA and Part D rule would eliminate this measure in MY 2026/SY 2028.
As noted above, the proposed 2027 MA and Part D rule would eliminate the two Call Center measures in MY 2026/SY 2028.

Verified, proposed, or possible changes down the road:

MY 2027/SY 2029:

The breast cancer screening age band will be expanded down to 40 from 50 in MY 2027/SY 2029. This tracks to the latest prevention recommendations.
As noted above, the proposed 2027 MA and Part D rule would eliminate the following:
- Two Part C Appeals
- Part C Special Needs Care Management (HRA)
- Part C and D Complaints
- Part C and D Disenrollment
- Medicare Plan Finder Price Accuracy
- Diabetes Care – Eye Exam
- CAHPS Customer Service
- CAHPS Rating of Health Care Quality
As noted above, the proposed 2027 MA and Part D rule would move Depression Screening and Follow-Up to Star in MY 2027/SY 2029. It will meet the requirement that it be on the Display Page for at least two years.

Later years:

NCQA has a goal of converting all hybrid measures to ECDS electronic measures from hybrid ones by MY 2029 and non-hybrid in MY 2030. Breast Cancer (BCS) and Colorectal Cancer (COL) are complete. As for remaining hybrid measures (which will have the most impact), Controlling Blood Pressure is slated for conversion in MY 2028/SY 2030. Controlling Blood Sugar, Transitions of Care, and all Care for Older Adult measures are scheduled for conversion in MY 2029/SY 2031. These ECDS measures can be very challenging for many plans not in interoperability rich states or with immature approaches to interoperability. We saw this with the COL conversion in MY 2024.
Initiation and Engagement of Substance Use Disorder Treatment and Initial Opioid Prescribing for Long Duration were proposed for inclusion in Star under the Biden administration but were not finalized by Trump 47. They could be proposed again for inclusion in the future. These can be tough measures to perform on.
Additional Universal Foundation measure adoption is planned but dates are unknown right now. The proposed 2027 MA and Part D rule proposes Depression Screening and Follow-Up for MY 2027/SY 2029. Others that could be adopted in the future are Adult Immunization Status and Physical Functioning Activities of Daily Living, among others. These as well can be tougher measures.
Polypharmacy: Use of Multiple Central Nervous System Medications in Older Adults could be re-proposed for Star. This measure is similar to the tough POLY-ACH measure adopted for MY 2025.
Health Outcome Survey (HOS) measure changes are planned. HOS is challenging for plans.
Measure specification changes are planned for COA-Functional Status and COA-Medication Review.
Changes are planned for Plan Makes Timely Decisions about Appeals (Part C) and the Reviewing Appeals Decisions, but the 2027 MA and Part D rule proposes retiring these measures in MY 2027/SY 2029.
A Geographic Index (urban/rural indicator) was proposed to be added to EHO4all, but that could be moot if the EH04all is actually eliminated via the 2027 MA and Part D rule.
Removal possible of guardrails for non-CAHPS measures when calculating cut points could be finalized in the future. This could both help and hurt.
Removal possible of “with and without improvement” in overall and summary rating calculations for 4- and 4.5-Star plans, effectively requiring improvement in overall and summary calculations for all plans other than 5 Star plans. This would be a huge blow to certain highly rated plans.
While the proposed 2027 MA and Part D rule eliminated all operational measures, the following were mentioned for elimination as well but not yet acted on:
- Care for Older Adult measures
- Medication Therapy Management – Comprehensive Medication Review. This measure was removed temporarily from Star in MY 2025/SY 2027 but was scheduled to return to Star as early as MY 2027/SY 2029.

Last, changes previously were proposed to clarify calculating the EHO4all Reward regarding contract consolidations, data discrepancies, missing data, when Dual Eligible Special Needs Plan (D-SNPs) offerings migrate from master contracts to free-standing ones, for Institutional Special Needs Plan (I-SNP)-only contracts, and for how the hold harmless provision for highly rated plans. These would not be necessary if the EHO4all is eliminated per the proposed 2027 MA and Part D rule.

What about the impact of SNP growth on Stars achievement?

SNP growth could have major impacts on Star ratings in the future for plans concentrating growth here. This is not only the case because more dual eligibles and SNP members will be enrolled in given contracts due to SNP product expansions, but also because CMS and states are working to split out Dual Eligible or D-SNPs lives into free-standing contracts (based on a rule several years ago).

In 2026, SNPs make up about one-third of all MA plans, up from about a quarter a year ago. As of September enrollment, over 22% of all MA enrollment, over 7.967 million, was in SNPs – about 78% of that in D-SNPs. Measure performance for dual eligible/SNP populations is much lower.

Looking at contracts with no SNP lives vs. those with 100% SNP lives, you find that performance is as much as 0.3 points lower in the formula. Those with high concentrations of SNP lives in a contract usually have performance that falls between the no-SNP lives and 100% SNP life numbers. Notably, medication adherence measures are most impacted when more duals or SNP members are in the plan. The impact is more than double the 0.3-point impact when comparing no-SNP-life contracts to 100%-SNP-life contracts. The Categorical Adjustment Index (CAI) was introduced to recognize and compensate plans with dual eligible/SNP member concentration so they are not discriminated against in Star performance and bonuses. But the consensus is that it does not fully do so.

Thus, the concentration by MA plans on SNPs and dual eligible lives as well as the contract breakouts could demonstrably impact quality bonus achievement in the future. You can argue that these lives are in the overall Medicare population already and will be served. But the concentration on SNPs and duals itself certainly could complicate achievement for many.

In summary, if CMS delivers on sunsetting some operational measures and focusing more on clinical outcomes, the Star program could become much tougher and billions in bonuses could evaporate for plans. As well, the SNP growth includes populations impacted by social determinants of health and are tougher to serve. The two together create great uncertainty in Star achievement.

To succeed, plans will need to invest more in Stars. The pivot to true healthcare outcome measures will require quicker and better data collection and analysis, better tracking and forecasting, ongoing strategy refinement, and novel tech-based interventions to close gaps on everyone.

Given where Star ratings are right now, the rollercoaster ride will be perilous but perhaps exciting at the same time.

Again, if you are an MA plan or provider group looking to excel in MA Stars, my new venture is Lilac Software. Go to https://lilacsoftware.com to learn more about our Stars dashboarding, forecasting, best practice chase lists, and agentic AI solutions to drive Stars performance.