Star Changes In 2026 Final Rule And Announcement For Medicare Advantage

A lot changed in the final rule, but not in the final announcement

NOTE: This Medicare Advantage Stars blog is co-published with Lilac Software ( https://lilacsoftware.com and https://lilacsoftware.com/guide-to-the-2026-medicare-advantage-part-d-star-final-announcement/ ).

On April 7, the Centers for Medicare and Medicaid Services (CMS) issued the 2026 Final Announcement for Medicare Advantage (MA) and Part D plans. This annual announcement outlines the rates and other technical rate-setting details for the coming year as well as the final Star measures and details for Star Year 2026. In addition, the notice outlines potential changes to Star and display measures moving forward.

Little changed of significance between the January Advance Notice and the April Final Announcement on the Star front except for renaming the Health Equity Index (HEI). Substantive comments were included in the final announcement.

Although we wrote about this before, we have combed the final announcement and slightly altered our summary and analysis below for the record.

2026 Final MA and Part D rule refresher

On April 4, the Trump administration also finalized the proposed 2026 MA and Part D rule. The Biden administration had proposed major changes on the Star front. The Trump administration did not act on any of the Star proposals by Biden except finalizing the age range expansion for the Part C Breast Cancer Screening measure. This was adopted for Measure Year 2027/Star Year 2029.

Here are the Star items not finalized in the rule that we will continue to track.

• 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.
• 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 Health Equity Index (HEI) reward factor will be calculated when a contract consolidation applies, when there are data discrepancies, or when data are 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.
• Eliminating guardrails in Star Year 2028. This has pros and cons depending on circumstances.

Notice process and major new Star changes

While the final rule on April 4 did not adopt the major changes Biden had proposed on Star, the final announcement on April 7 kept major changes on the docket so to speak for Star in the future. All substantive measure specification changes, the addition of new measures, and methodological changes must go through rulemaking.

The difference in approaches between the rule and notice points to the Trump administration’s openness to further refinement of Star, but it wasn’t ready to adopt the Biden proposed changes too quickly.

The notice process provides information and updates on Star ratings as mandated by regulations and solicits input on future measures and concepts. The 2026 advance notice outlined non-substantive measure specification updates; solicits initial feedback on substantive measure specification updates and comments on new measure concepts as well as display measures. In almost all cases, the final notice maintained proposals.

Health Equity Index (HEI) renamed

CMS said that it will propose in rulemaking to preserve the “Health Equity Index” Reward intact but change its name to the “Excellent Health Outcomes for All” (EHO4all) Award. The same program but with a less controversial name in the mind of the Trump administration.

Given the Trump administration’s effort to expunge diversity, equity, and inclusion from government, some wondered if the Trump administration would simply remove the HEI and leave the Reward Factor in place.

The main obstacle, though, was that the HEI as compared with the Reward Factor saves $670M in 2028, growing to $1.08 billion in 2031.

In the end, the move is good. We know that social determinants of health (SDOH) can be a greater predictor of overall costs and outcomes than underlying disease states. Thus, tackling this issue is key to reforming healthcare, lowering costs, and increasing quality and equity.

Other key changes proposed include:

Deadlines

• CMS set deadlines for submission of complaints and appeals data discrepancies and appeals for Star 2026 and Star 2027:
  • For Star 2026, May 30, 2025 is the deadline for all contracts to request a review of 2024 CTM data. Sponsors should refer to the January 6, 2025, HPMS memorandum, “Updated Complaints Tracking Module Standard Operating Procedures,” for instructions on submitting a Plan Request in HPMS to request a review of CTM complaints.
  • For Star 2027, June 30, 2025 is the deadline for all contracts to request a review of 2024 appeals data. Sponsors can view and monitor their Part C appeals timeliness and effectuation compliance data on the Medicare Appeal Search website.
  • For Star 2027, May 18, 2026 is the deadline for all contracts to request a review of their administrative data used for the Part D Patient Safety Star Ratings measures for the 2025 measurement year for the 2027 Star Ratings.
  • For Star 2027, March 31, 2026 is the deadline for all contracts to request a review of 2025 CTM data for the 2027 Star Ratings.

Final 2026 Star Year Measures

• Sets the final list for Star measures and weights for 2026 Star ratings. The list is on pages 99 to 101. These include what measures are used in the Categorical Adjustment Index and Improvement measure calculations. Additional information can be found on the Performance Data website: https://www.cms.gov/medicare/health-drug-plans/part-c-d-performance-data

Key highlights include:

• There is one new measure — Kidney Health Evaluation for Patients with Diabetes (1x weight).
• There are two returning Health Outcome Survey (HOS) measures – Improving or Maintaining Physical Health and Improving or Maintaining Mental Health (1x weights in SY 2026 and 3x weights in SY 2027).
• Patient experience and complaint measures and access measures decrease from 4 to 2.

Disasters for Star Year 2026

• Explains and sets the list of eligible disasters for adjustment for 2026 Star ratings. This is on pages 102 to 106. As well, see the section on CAHPS survey exemptions when 25% or more of enrollees are in a county affected by a disaster. This is applicable for the LA County Wildfires.
• As well, starting with the 2026 Star Ratings CMS will no longer remove the numeric values for affected contracts with 60 percent or more of their enrollees in Federal Emergency Management Agency (FEMA) designated Individual Assistance areas at the time of an extreme and uncontrollable circumstance from the cut points clustering algorithm for non-CAHPS survey measures and from the reward factor calculations.  

Star measure changes

• To support the CMS National Quality Strategy, CMS says it is continuing to move towards a building block approach to streamline quality measures across CMS quality and value-based care programs. It is seeking to move to the Universal Foundation for all programs. CMS submitted the following Universal Foundation measures to the 2024 Pre-Rulemaking Measure Review (PRMR) process: Adult Immunization Status (Part C) and Depression Screening and Follow-up (Part C). These are likely to be adopted by CMS in Stars in the future. CMS is no longer proposing Social Need Screening and Intervention (Part C) to be added to the display page or proposing it through rulemaking to add to the Star Ratings program.
• CMS proposed the Initiation and Engagement of Substance Use Disorder Treatment measure (Part C) as well as Initial Opioid Prescribing for Long Duration measure (Part D) in the 2028 Star Ratings in the proposed rule, but did not finalize these. Nonetheless, these should be watched.
• CMS says that certain measures could be proposed for removal from Star in the future, including Medicare Plan Finder Price Accuracy (Part D), Complaints about the Health and Drug Plan (Part C and D), Call Center – Foreign Language Interpreter and TTY Availability (Part C and D), and the Plan Makes Timely Decisions about Appeals (Part C) and Reviewing Appeals Decisions (Part C) measures. These could be used by CMS to monitor plan performance and compliance outside of Star. CMS says the CAHPS survey measures in Star would still capture similar issues related to customer service, getting needed information, and overall plan performance. CMS also gathered input on retiring Medication Therapy Management (MTM) Program Completion Rate for Comprehensive Medication Review (CMR) (Part D) and Special Needs Plan (SNP) Care Management (Part C) as well as remaining Care for Older Adults Special Needs Plan measures.
• CMS obtained comments on suggestions and recommendations from its Technical Expert Panel (TEP). The TEP suggested the following: adding more evidence-based clinical outcomes measures or redesigning current measures to assess patient outcomes (such as medication adherence); considering relevance, reliability, and the small denominator for some measures; considering “gameability,” attribution issues, provider burden, and the sensitivity of measures to small changes; and considering measures focused on trust with the plan and network issues. 
• The National Committee for Quality Assurance (NCQA) is re-evaluating the Statin Therapy for Patients With Cardiovascular Disease (Part C) for the 2026 measurement year. These would be substantive changes requiring a move to the display page for at least two years. NCQA could modify the measure’s age ranges and denominator inclusion and exclusion criteria, remove the existing sex-specific age bands, and increase the upper age limit. NCQA is also examining the current value sets and method used to identify members with cardiovascular disease for any potential updates, as well as evaluating the potential for transitioning this measure to the electronic clinical data systems (ECDS)-reporting method.
• NCQA is re-evaluating the Transitions of Care measure, which includes four indicators related to care coordination after a patient is discharged from an inpatient setting to home. The first two indicators relate to notification of inpatient admission and receipt of discharge information and currently use the chart review reporting method only. The second two indicators, patient engagement after discharge and medication reconciliation, utilize chart review and administrative reporting methods. NCQA intends to develop a new ECDS-reported version of the measure that will also consider changes from the current specification based on expert feedback and testing. NCQA plans to conduct measure testing in 2025 and implement the new ECDS-reported measure for the 2027 measurement year. NCQA plans to maintain the current Transitions of Care measure alongside the new measure for a period of time to allow for transition to the new measure. If the changes are substantive, CMS would keep the current measure in Star Ratings while the updated measure goes through rulemaking and is on the display page for at least two years.
• NCQA is reevaluating the COA measures with the goal of considering measure modifications and transitioning the measures to the ECDS-reporting method. This could result in new ECDS-reported measures for the functional status assessment and medication review indicators. These could be implemented for measurement year 2027 at the earliest. The current COA measures would be maintained for a period of time to allow for transition.
• NCQA is reevaluating Monitoring Physical Activity, Reducing the Risk of Falling, and Improving Bladder Control (Part C) for measurement year 2027 at the earliest. If these measures are updated, it would be considered a substantive change. CMS would keep the legacy measures in Star Ratings while the updated measures are on the display page and the updated measures are proposed through rulemaking. Being looked at is the relevance and evidence supporting the use of these measures in Medicare patients under 65 years of age.
• NCQA is developing a new ECDS-reported version of Diabetes Care – Blood Sugar Controlled (Part C) for measurement year 2027. It will conduct testing for ECDS feasibility in 2025, prior to implementation. The current hybrid measure would be maintained in parallel with the ECDS measure during a two-year transition period, until the hybrid measure is replaced with the new ECDS measure in measurement year 2029. CMS sees this as non-substantive.
• The Pharmacy Quality Alliance (PQA) updated the Concurrent Use of Opioids and Benzodiazepines (COB) (Part D) measure specifications in the draft 2025 PQA Measure Manual to exclude beneficiaries with cancer-related pain treatment diagnosis during the measurement year. CMS plans to exclude beneficiaries with cancer-related pain treatment diagnosis from the COB measure beginning with the 2025 measurement year. CMS sees this as non-substantive.
• For Medication Adherence for Diabetes Medications, Medication Adherence for Hypertension (RAS Antagonists), Medication Adherence for Cholesterol (Statins), Statin Use in Persons with Diabetes (SUPD), Concurrent Use of Opioids and Benzodiazepines (COB), and Polypharmacy: Use of Anticholinergic Medications in Older Adults (Poly-ACH), CMS will align with the PQA and exclude from the Star ratings contracts with 30 or fewer enrolled members in the denominator. This is effective for the 2025 measurement year. CMS sees this as a non-substantive update.

Display measure changes

• NCQA is looking at potential updates or replacements for Pharmacotherapy Management of Chronic Obstructive Pulmonary Disease (COPD) Exacerbation (Part C). This is due to recent clinical guideline updates. This effort may result in new measures for HEDIS if NCQA finds there are gaps in COPD measurement. Any updates or new measures would be available for the 2027 measurement year at the earliest.
• The PQA updated the Polypharmacy: Use of Multiple CNS-Active Medications in Older Adults (Poly-CNS) (Part D) measure specifications in the draft 2025 PQA Measure Manual. It added the skeletal muscle relaxant class of medications. The six new skeletal muscle relaxants added to the Poly-CNS measure in 2025 are carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, and orphenadrine. CMS will align with the PQA measure specification updates and add the new skeletal muscle relaxant class of medications to the Poly-CNS measure for the 2025 measurement year.
• The PQA also updated the Use of Opioids at High Dosage in Persons Without Cancer (OHD) and Initial Opioid Prescribing for Long Duration (IOP-LD) (Part D) measure specifications in the draft 2025 PQA Measure Manual to exclude beneficiaries with cancer-related pain treatment diagnosis during the measurement year. CMS will incorporate this update beginning with the 2025 measurement year.
• As with the proposal in Star measures, CMS will align with PQA and exclude contracts with 30 or fewer enrolled measures in the denominator of these measures starting with the 2025 measurement year. Note that the medication adherence measures will include risk adjustment beginning in Star Year 2028.
  • Medication Adherence for Statins with Sociodemographic Status Adjustment (ADH-Statins SDS)
  • Medication Adherence for RAS Antagonists with SDS (ADH-RAS SDS)
  • Medication Adherence for Diabetes Medications with SDS (ADH-Diabetes SDS)
  • Antipsychotic Use in Persons with Dementia (APD)
  • Antipsychotic Use in Persons with Dementia – for Long Term Nursing Home Residents (APD-LTNH)
  • Use of Opioids at High Dosage in Persons Without Cancer (OHD)
  • Polypharmacy: Use of Multiple CNS-Active Medications in Older Adults (POLY-CNS)
  • Initial Opioid Prescribing for Long Duration (IOP-LD)
  • Persistence of Basal Insulin (PST-INS)
  • Medication Therapy Management (MTM) Program Completion Rate for Comprehensive Medication Review (CMR)
• For Initial Opioid Prescribing for Long Duration (IOP-LD) (Part D), for the 2025 measurement year, CMS will adopt PQA’s refined definition for negative medication history to improve clarity in the draft 2025 PQA Measure Manual. For a beneficiary to have a negative medication history, there should be no prescription claims for opioids “with a date of service” in the lookback period.
• For the Financial Reasons for Disenrollment (Part C & D), measure, CMS is considering replacing one general cost-related leave reason (found a plan that costs less) with the following three more specific cost-related reasons to leave health or drug plans. This measure captures a variety of reasons related to the cost or affordability of services for leaving a plan. The updated measure is currently being tested and will be available for the 2026 Display Page that covers the 2024 measurement year.
  • Found a plan with a lower copayment for prescription drugs (MA & PDP)
  • Found a plan with a lower copayment for doctors’ visits (MA)
  • Found a plan with a lower monthly premium (MA & PDP)
• The Use of Opioids from Multiple Providers in Persons Without Cancer (OMP) (Part D) is being retired for the 2025 measurement year.

Future possible Star measures and overall changes

• CMS is considering adding additional social risk factors (SRFs) to the renamed Excellent Health Outcomes for All” (EHO4all) Award. CMS is looking at adding geography (e.g., rural or urban). This change would have to be adopted through future rulemaking.
• NCQA is developing a new measure that assesses comprehensive foot examinations (neurological, vascular, visual) and appropriate follow-up for abnormal findings among adults with diabetes. The measure will be implemented as an ECDS-reported measure. The measure may be included in HEDIS starting with the 2027 measurement year at the earliest.
• NCQA is exploring the development of a measure to assess follow-up after colorectal cancer screening. The current Colorectal Cancer Screening measure is limited to screening only and does not assess appropriate and timely follow-up after abnormal results from an initial screening. This measure concept will be developed and tested using the ECDS-reporting method. The measure is being targeted for inclusion in HEDIS starting with the 2027 measurement year.
• NCQA is exploring the feasibility of a future measure focused on End Stage Renal Disease (ESRD) (Part C) in MA. Currently, NCQA is conducting preliminary analyses to identify MA members with chronic kidney disease (CKD) stage 4 or ESRD to help inform the development of a measure focused on this population.
• NCQA is developing three measures focused on identifying, measuring, and tracking goals over time for Person-Centered Outcomes (Part C) for those with complex care needs. NCQA will begin measure testing in fall 2024 for a potential SNP only measure to include in HEDIS starting with the 2027 measurement year. CMS welcomes comments on this measurement concept and whether SNP-specific measures should be considered given the goal of trying to simplify and refocus the Star Ratings measure set.
• As guidelines continue to develop around RSV vaccination for adults, NCQA is assessing and determining the appropriateness of incorporating this vaccine indicator in the Adult Immunization Status measure. Any potential updates would likely be included no earlier than the 2027 measurement year.
• The final announcement removed reference to NCQA exploring the development of a new ECDS-reported measure that assesses whether adults are up to date on their annual COVID-19 vaccination. The final announcement also removed reference to NCQA developing a separate measure for Intimate Partner Violence (IPV) and Disability Equity.

#medicareadvantage #cms #stars #quality

— Marc S. Ryan