New measures and major Star changes coming
The just released 2026 Medicare Advantage and Part D rule from the Centers for Medicare and Medicaid Services (CMS) has a number of important Star program measure and policy updates. As promised, here is my thorough assessment of the Star changes from the rule. See Monday’s blog here for the rest of the proposals in the rule: https://www.healthcarelabyrinth.com/large-ma-and-part-d-rule-issued-for-2026/ .
Will the changes really go into effect?
What will happen to these proposals is anyone’s guess right now. The Biden administration did not publish the rule in time to finalize it before the current president leaves office. That will allow the incoming Trump administration the ability to delay final publication and remove significant portions if it wants to. I don’t expect the new administration to disturb some of the technical changes and customary roll out of Star measures, but it likley will stop some of the more controversial parts of the rule. The Trump administration also is known to be targeting Diversity, Equity, and Inclusion (DEI) initiatives for elimination throughout government. Given the huge impact that social determinants of health (SDOHs) have on ultimate healthcare costs, it is unfair to characterize Health Equity initiatives as some radical DEI agenda. But could the Health Equity Index (HEI) be targeted for elimination in the overall DEI purge effort? Time will tell.
The complexity of the Stars road map
Understanding the Stars roll out over time – what is being added, eliminated, and changed – is no easy feat. As CMS even admits in the 2026 proposed rule, the agency does not publish a comprehensive road map of Star changes. The agency leaves it up to the industry and each plan to cobble together a road map of changes by reading various proposed and final rules, annual advanced notices, annual technical notes, other CMS communication, and changes made by the National Committee for Quality Assurance (regarding HEDIS clinical and drug measures) and the Pharmacy Quality Alliance (regarding drug measures). The changes proposed in this 2026 rule add to the confusion. As such, I will publish a quick blog and graphic soon to lay out how I see the changes coming as proposed over the past few years. Stay tuned for that.
A note on the Universal Foundation
As CMS has said on a number of occasions, the agency intends to migrate all quality assessment in government programs across lines of business, including commercial coverage and private plans, to the so-called Universal Foundation of quality measures and the CMS Quality Strategy. For sure, different populations in government will need different measures. But CMS correctly points out that migrating to as many common measures and methodologies as possible will reduce costs for both plans and providers and drive better quality holistically. It will also reduce disparity and allow comparison of quality achievement across populations and coverage programs. The migration will take time.
Summary of changes at a glance
(Note: while it is not be called out specifically, some verbiage from this point on may be taken directly from the CMS rule to ensure accuracy.)
CMS is proposing the following in terms of the Star program.
- Inclusion of the Initiation and Engagement of Substance Use Disorder Treatment (IET) as a Part C Star measure.
- Inclusion of the Initial Opioid Prescribing for Long Duration (IOP-LD) as a Part D Star measure.
- Expanding the population covered in the Breast Cancer Screening measure in Part C.
- Changing certain calculations in the Plan Makes Timely Decisions about Appeals in Part C.
- Changing certain calculations in the Reviewing Appeals Decisions in Part C.
- Clarifying how the HEI reward factor will be calculated when a contract consolidation applies, when there are data discrepancies, or when data is missing.
- Clarifying how the HEI reward will be calculated when Dual Eligible Special Needs Plan (D-SNPs) offerings migrate from master contracts to free-standing ones.
- Clarifying how the HEI reward will be calculated for Institutional Special Needs Plan (I-SNP)-only contracts.
- Clarifying how the hold harmless provision for highly rated plans is calculated in terms of the addition of the HEI.
- CMS may finalize the permanent removal of guardrails that apply for non-CAHPS measures from Star cut point calculations based on a proposal in an earlier rule.
The details
New Star measures proposed in 2026 rule
The Initiation and Engagement of Substance Use Disorder Treatment (IET — Part C) measure would be added for Measure Year 2026/Star Year 2028 and beyond. CMS says adding the IET measure to the Part C Star Ratings would further align the ratings with the Universal Foundation measures. The IET measure is a composite measure that averages two separate rates: Initiation of Substance Use Disorder Treatment and Engagement of Substance Use Disorder Treatment. To lessen the number of new measures, CMS is proposing to average the initiation and engagement rates into one measure for reporting in the Star Ratings program. This is similar to the approach taken for Transitions of Care. A contract would have to have scores on both rates to receive a score for this measure.
The Initial Opioid Prescribing for Long Duration (IOP-LD — Part D) measure would be added for Measure Year 2026/Star Year 2028 and beyond. CMS says the measure is being moved to Star because it is an important measure to promote safer prescription opioid use and will be an additional tool to monitor initial opioid prescription exposure to reduce the risk for long-term opioid use and opioid use disorder.
The IOP-LD measure is intended for retrospective population-level performance measurement and not to guide clinical decision-making for individual patients. The measure does not address opioid dosage, only the duration of an initial opioid prescription.
Updated Star measures in the 2026 rule
The Breast Cancer Screening (BCS — Part C) is being substantively updated for Measure Year 2027/Star Year 2029 and beyond. The change is tied to recommended clinical guidelines. In April 2024, the U.S. Preventive Services Task Force (USPSTF) issued final updated guidance for the age at which breast cancer screenings should begin. CMS is proposing to expand the age range for the measure to women aged 40-49, for an updated age range of 40-74. The updated measure will be on the display page for the 2027 and 2028 Star Ratings and will be included in the 2029 Star Ratings.
The Plan Makes Timely Decisions about Appeals (Part C) and the Reviewing Appeals Decisions (Part C) measures are being substantively updated. The proposed rule may have a technical error. It indicates the changes would go into effect as of Star Year 2029, but the regulation as written may only allow it to go into effect for Star Year 2030 if the changes below go on the Display Page as of 1/1/2026. This may need to be clarified in any final rule. The measure year lags two years.
The Plan Makes Timely Decisions about Appeals measure evaluates the percent of appeals timely processed by the plan (numerator) out of all the plan’s appeals decided by the Independent Review Entity (IRE) (includes upheld, overturned, partially overturned, and appeals not evaluated by the IRE because the plan agreed to cover) (denominator).
The technical change surrounds the fact that cases are now submitted electronically via the portal to the IRE. CMS is eliminating the additional days the IRE allows for appeal files that are submitted electronically. Currently, the IRE includes additional days to make allowances for any mail delays. But the IRE now receives over 99 percent of case files electronically via the portal. CMS has already updated the language in the IRE Manual to use a deadline for these electronic submissions that aligns with the timeliness requirements for submission of standard, expedited, and Part B drug cases. The IRE currently adds five calendar days to the timeframes listed above for all appeal file submissions.
Since CMS is eliminating this 5-day period for all cases submitted electronically starting on January 1, 2025, the Plan Makes Timely Decisions about Appeals measure is proposed to be changed to align the measure with the timeframe used by the IRE in processing appeal files submitted to it. The timeliness of case files submitted by mail would continue to be subject to the 5-day grace period.
The second technical update CMS is implementing (starting January 1, 2025) is to use the electronic system receipt date and time (for electronic submissions only) as the date the appeal was received by the IRE, regardless of whether it is during the IRE’s business hours. Currently, the IRE uses the system receipt date as the date the appeal was received if it is during the IRE’s normal business hours. If the system receipt time or date is outside of the IRE’s normal business hours, the following business day is currently used as the receipt date. These proposed specification changes would only affect electronic submissions.
The change technically impacts the Reviewing Appeals Decisions measure as well since the appeals used in the measure calculation are based on the date in the calendar year the appeals were received by the IRE.
Health Equity Index and related clarifications
The Health Equity Index (HEI) reward will be implemented beginning with Star Year 2027 and has Measurement Years of 2024 and 2025. The HEI reward replaces the current Reward Factor. If plans have sufficient penetration of social risk factor (SRF) enrollees, they receive the HEI reward if they have high measure performance for these populations. The SRFs initially will be Low Income Subsidy, Dual eligibility, and Disability.
The HEI calculation was adopted in an earlier rule, but the proposed 2026 rule clarifies a few areas.
- Beginning with Star Year 2027, CMS would clarify how the HEI reward enrollment thresholds are assessed in the case of calculating the HEI reward for contract consolidations for the second year following the consolidation. The combined enrollment from the consumed and surviving contracts from the most recent year of data used in calculating the HEI will be used to assess whether the surviving contract meets one of the enrollment thresholds. When two or more contracts consolidate, the enrollment data used for the second year following the consolidation are from prior to the consolidation since the HEI is measuring performance prior to the contracts combining. This is similar to how enrollment is combined for the calculation of enrollment for the second year following a consolidation for the categorical adjustment index.
- CMS is also clarifying how the enrollment-weighted measure score is calculated when a consumed or surviving contract is missing data for a measure.
- Beginning with Star Year 2029, CMS would clarify how the HEI reward will be calculated for contracts that are required by a state Medicaid agency to move one or more D-SNP plan benefit packages from an existing MA contract to an MA contract that only includes one or more D-SNPs with a service area limited to that state. As of plan year 2025, five states have implemented the provision to have D-SNP-only contracts. The number of states with D-SNP-only contract requirements will increase by another eight or nine states in 2026. To promote the breakout of SNPs to drive quality outcomes and not cause plans’ legacy contracts to miss qualifying for the HEI, calculation of eligibility for an HEI reward and the size of the HEI reward for legacy MA contracts is addressed for those that no longer meet either of the percentage SRF enrollment thresholds due to state contracting requirements. The changes generally would take into account previous enrollment in the legacy contract to determine the potential HEI reward.
- CMS clarifies that in order for I-SNP-only contracts to have the rating-specific HEI calculated, these contracts must have data for at least half the measures included in the rating-specific HEI for the subset of measures that I-SNP-only contracts are required to report.
- Further changes specify how to determine if a new SNP contract is eligible to calculate the HEI, including enrollment, the number of measures, and data issues.
- CMS also clarifies that the improvement measure “hold harmless,” currently applicable to plans with 4 Stars or greater, is determined based on the rounded rating before the addition of the HEI reward, if applicable. This is consistent with how the improvement measure hold harmless rules have historically been applied based on the rounded rating. To operationalize this, CMS would determine the application of the improvement measures for the highest rating using the rating rounded to the nearest half star before the addition of the HEI reward, if applicable. Then when adding the HEI reward if applicable for the highest rating, CMS would go back to the unrounded rating either with or without the improvement measures, add the HEI reward, and then round to the nearest half star.
Removing guardrails
In the rule, CMS says it is considering finalizing its earlier proposal to remove guardrails for non-CAHPS (survey) measures when calculating cut points for measures. This would begin with Measurement Year 2026/Star Year 2028.
Guardrails are the bi-directional caps that restrict upward and downward movement of a measure’s cut points for the current year’s measure-level Star Ratings compared to the prior year’s measure-threshold specific cut points. Generally, the guardrail is plus or minus 5 percentage points for each cut point (or a 5% difference up or down on some measures).
CMS argues that such guardrails are no longer needed with the implementation of the Tukey outer fence outlier deletions and the fact that extreme outliers are removed before the clustering algorithm is applied for applicable measures. This, the agency says, minimizes the need for guardrails to achieve predictability and stability of cut points. It argues the removal of guardrails would allow cut points to adjust when there are unanticipated changes in performance across the industry.
CMS says it will address comments received regarding the removal of guardrails to the December 2022 proposed rule in the final rule.
I am of two minds on removing guardrails.
The arguments for keeping them are:
- CMS seems to argue that volatility will be less. We have not seen that of late. And an argument can be made that guardrails take out volatility overall and over time.
- They can help some plans and a lot is going on right now in Star. As an example, some plans are protected by guardrails if they underperform others during the COVID utilization recovery and perhaps with newer measures after year one.
- There are a handful of measures where guardrails have delayed the full and significant impact of Tukey outliers on cut points (e.g., Call Monitoring). CMS should keep the guardrails to allow plans to adjust to this impact that could still be significant — particularly on the lower end of performance levels.
The arguments for getting rid of them are:
- Why shouldn’t cut points be able to go up more than 5% if plans are performing better?
- Guardrails also stop measures from dropping more than 5% when the market changes are resulting in lower performance across most plans. Sometimes that happens and plans would benefit.
- At the very least, we need a modification to guardrails as ECDS (electronic) measures roll out. The first true ECDS measure (I don’t count Breast Cancer Screening in Star Year 2025 as it was not hybrid) is Colorectal Cancer Screening in Star Year 2026 and we likely will see a major drop in scores because of the conversion to ECDS from manual chart reviews.
In my view, it also appears that the agency is again making a rule-writing mistake with regard to guardrails. It has not included the guardrail proposal in the actual proposed regulation section and only references it in the commentary section. Courts have made clear it is not actual regulation. Simply referencing the earlier rule is not correct either, as the proposal then was not adopted in the final rule. I do not think the agency can now include elimination in the final 2026 rule as it has not really been proposed for comment at this time. In the Scan lawsuit regarding 2024 Star ratings, CMS famously lost its attempt to remove guardrail application when Tukey was implemented.
#medicareadvantage #cms #stars #partd #pdp #regulations
— Marc S. Ryan
