CMS Revamps Star Program For Medicare Advantage
The Centers for Medicare and Medicaid Services published a draft Medicare Advantage (MA) and Part D rule for 2027 that would make sweeping changes in the MA Star program. Beginning primarily in the 2027 measure year (MY) or Star Year (SY) 2029, CMS proposes to remove 12 (really 14) measures, largely focused on administrative processes or those that no longer show variability in quality among plans. (The call center measures will be removed in MY 2026/SY 2028.)
These are:
Administrative/Operational measures removed:
- Two Part C Appeals
- Part C and D Call Center
- Part C Special Needs Care Management HRA completion
- Part C and D Complaints
- Part C and D Disenrollment
- Medicare Plan Finder Price Accuracy
No longer showing variability:
- Diabetes Care – Eye Exam
- Statin Therapy for Patients with Cardiovascular Disease
- CAHPS Customer Service
- CAHPS Rating of Health Care Quality
The above has the effect of transferring so-called Star power to clinical, drug, and remaining CAHPS survey and HOS survey measures.
The Excellent Health Outcomes for All (EHO4all, the former Health Equity Index), will not be implemented for SY 2027 (MY 2025). The Reward Factor would be maintained for consistently high-performing plans.
CMS also proposes to introduce a new Depression Screening and Follow-Up measure that would begin with MY 2027/SY 2029.
The changes could have a huge impact on plans. CMS says this is the estimated impact on Star ratings:
- 62% of contracts will have no impact to Star ratings
- 13% of contracts will have an increase of one-half Star
- 25% of contracts wll have a decrease of one-half Star
- One conract would drop by one Star
CMS proposed a number of other changes for MA in the draft rule and issued three requests for information.
I will get into more details on all this in a blog later this week.
Additional articles: https://www.cms.gov/newsroom/press-releases/cms-proposes-new-policies-strengthen-quality-access-competition-medicare-advantage-part-d and https://www.cms.gov/newsroom/fact-sheets/contract-year-2027-medicare-advantage-part-d-proposed-rule
(Some articles may require a subscription.)
#cms #medicareadvantage #stars #quality
https://www.modernhealthcare.com/politics-regulation/mh-medicare-advantage-star-ratings-cms-2027
2025 Medicare Drug Negotiations Conclude
The Centers for Medicare & Medicaid Services (CMS) announced conclusion of the 2025 Medicare Part D negotiations for 15 drugs. This was the second year of negotiations. Between January 1, 2024, and December 31, 2024, about 5.3 million people with Medicare Part D coverage used these 15 drugs to treat a variety of conditions, such as cancer, type 2 diabetes, and asthma. These selected drugs accounted for about $42.5 billion in total gross covered prescription drug costs under Medicare Part D, or about 15%, during that period.
The Maximum Fair Prices (MFPs) for these 15 drugs will become effective January 1, 2027, bringing the total number of negotiated drugs to 25 when combined with the 10 previously negotiated drugs with MFPs taking effect January 1, 2026.
The announcement says the savings are well above what was finalized under the Biden administration – 44% vs. 24%.
#drugpricing #medicare #partd #branddrugmakers #ira
CMS Streamlines Medicare Advantage Program Audit Process
The Centers for Medicare & Medicaid Services (CMS) announced a significant streamlining of the Medicare Advantage and Part D program audit process. Current audit protocols will continue. I will have a blog on this next week.
#cms #medicareadvantage #audits
https://mhk.com/resource/blog/cms-announces-significant-process-changes-for-2026-program-audits
Humana Appeals Stars Suit
Humana is appealing a federal court’s decision to uphold its Star Year (SY) 2025 Medicare Advantage (MA) Star ratings. The Tuesday filing with the Fifth Circuit Court of Appeals marks Humana’s latest legal attempt to reverse its loss of billions due to declining overall Star performance.
Membership in 4 Star or greater Humana plans has dropped from 94% in SY 2024 to 25% in SY 2025 to 20% in SY 2026.
Additional article: https://www.modernhealthcare.com/insurance/mh-humana-medicare-advantage-ratings-lawsuit-appeal/
(Some articles may require a subscription.)
#cms #medicareadvantage #stars #quality
https://www.fiercehealthcare.com/payers/humana-loses-second-legal-challenge-ma-star-ratings
Medicare Backs Off Hospital Recoupments
While hospitals were not happy with some of the 2026 Medicare outpatient reimbursement rule, including a slow start on site neutral payments, lobbyists earned their money by getting the Trump administration to cave to hospital demands to delay a major clawback of revenue to the tune of $7.8 billion related to drug spending.
The Trump administration, though, will move forward with drug cost surveys that will pinpoint how much drugs cost for hospitals. If the results of the survey reveal excessive profit margins on drugs, hospitals may face cuts from Medicare in the future.
(Article may require a subscription.)
#medicare #cms #hospitals
https://www.statnews.com/2025/11/24/medicare-hospitals-payment-rule/
Trump Exchange Plan Puts GOP In Tough Spot
President Donald Trump’s potential Exchange extension plan, which could be as long as two years with some modifications, is being criticized by many Republicans and contradicts what the party and even Trump has said the past many weeks.
Conservative GOP members could openly revolt when votes come up, while several dozen GOP moderates will vote with Democrats. The issue is that the House Speaker, Mike Johnson, R-LA, has refused to commit to a vote. In the Senate, Majority Leader John Thune, R-SD, has.
Advocates are worried about the huge surge in premiums – more than doubling for subsidized individuals and families — if enhanced subsidies expire. Health plans have increased rates in anticipation of lost membership and higher risk.
Additional article: https://thehill.com/homenews/house/5621146-trump-health-care-plan-gop-leaders/
#exchanges #healthcare #coverage
https://www.beckerspayer.com/payer/aca/how-payers-are-preparing-amid-aca-subsidy-uncertainty/
— Marc S. Ryan
