Last month, The Centers for Medicare & Medicaid Services (CMS), released 2025 Medicare Advantage Star Ratings, and they continued to decline. It’s a troubling trend for health plans, some of whom have resorted to lawsuits. But declining ratings can also be an opportunity. Plans able to increase their Star Ratings will compete with fewer peer plans while achieving at least a 4 star rating increases performance bonuses. Now’s the time to reconsider Star Rating strategies.
Background
CMS designed the Medicare Advantage Star Ratings to measure the quality of health and drug services provided by Medicare Advantage (MA) and Part D plans. These ratings, ranging from 1 to 5 stars, with five being the highest, are based on performance across various categories, including member experience, customer service, management of chronic conditions, preventative healthcare, and drug safety.
The primary purpose of Star Ratings is to help Medicare beneficiaries compare the quality of different health and drug plans so they can make informed decisions about their healthcare coverage.
But Star Ratings also significantly impact the financial and operational aspects of Medicare Advantage Health plans, including:
- Quality Bonus Payments (QBPs): Plans achieving four or more stars are eligible for quality bonus payments, which can be substantial. Plans can reinvest these payments to improve benefits and attract more beneficiaries.
- Rebates and Premiums: Higher Star Ratings lead to increased rebates, which can result in lower premiums for beneficiaries.
- Marketing and Enrollment: Star Ratings are prominently displayed on Medicare.gov, enabling plan comparisons. High-performing plans often leverage their ratings in marketing campaigns. Additionally, 5-star plans are eligible for a Special Enrollment Period (SEP), allowing them to enroll beneficiaries outside the standard enrollment period.
Calculation and Methodology
CMS uses a complex methodology to calculate Star Ratings. Health plans must understand the calculations if they wish to improve Star Ratings:
- Performance Measures: CMS evaluates plans on quality and performance measures covering various aspects of healthcare delivery. CMS assesses MA-PD contracts on up to 40 unique measures, MA-only contracts on up to 30, and PDP contracts on up to 12 measures. Examples include breast cancer screening, annual flu vaccination, monitoring physical activity, medication review, pain assessment, and diabetes care.
- Cut Points: CMS establishes raw score thresholds, called cut points, which determine the star rating (1 to 5) a plan receives for each measure. Setting cut points involves identifying natural performance groupings among plans and has evolved since its inception.
- Weighting: Each measure is assigned a weight based on its importance.
- Overall Score: CMS determines the overall Star Rating for a plan by calculating the average of the star ratings across all measures.
With that background on how CMS calculates Medicare Advantage Star Ratings, here are eight tips to help Medicare Advantage plans improve Star Ratings:
1. Focus on Measures With High Weights
Prioritize weighted measures selected by CMS to evaluate health plan performance and significantly contribute to achieving a 4+ Star Rating.
The weighting scheme employed by CMS for the 2025 Star Ratings prioritizes some categories over others:
- Improvement measures receive the highest weight, emphasizing the ability to enhance performance year over year.
- Patient experience/complaints and access measures have the next highest weight. As a result, how well plans meet patient needs and provide easy access to care significantly impacts their overall rating.
- CMS assigns a moderate rate to outcome and intermediate outcome measures, measuring the actual health results achieved for beneficiaries.
- Process measures, which assess the procedures and steps followed in providing care, are given the lowest weight. However, some process measures, like medication reconciliation, are critical components of care management programs and indirectly contribute to improved outcomes.
The weighting system affects how plans prioritize their efforts to improve Star Ratings. Recognizing this system, payers might consider:
- Align Provider Incentives: Aligning provider incentives with heavily weighted measures can motivate providers to prioritize high-impact areas. Payers could consider hiring staff dedicated to working with providers and members on these weighted measures.
- Address Key Themes: Payers can identify themes or categories of measures that carry significant weight. For instance, diabetes and medication adherence measures have similar total weights, suggesting a focused approach to those areas.
2. Utilize Data and Analytics
Payers who leverage data analytics and business intelligence will outperform those that do not. For example, health plans can use analytics to identify members not receiving statin therapy for cardiovascular disease. Doing so enables proactive interventions to improve performance on specific quality measures.
Here are some ways to leverage data and analytics to improve Star Ratings:
- Streamline Data Collection and Integration: Health plans must streamline the collection of relevant data from various sources, including electronic health records (EHRs), patient surveys, pharmacy records, and healthcare ERP data. Aligning systems with interoperability standards, such as HL7 FHIR, can achieve a unified view of patient information throughout their healthcare journey.
- Implement Master Data Management (MDM): MDM solutions can help plans maintain a single, accurate view of critical data across the organization and its ecosystem. MDM helps improve data quality, leading to reliable reporting and analysis.
- Leverage Data Analytics and Business Intelligence: Integrating advanced data analytics and business intelligence tools enables health plans to translate raw data into actionable insights. Analytics can help identify care gaps, optimize resource allocation, and proactively address areas needing improvement to boost Star Ratings.
3. Leverage Member Data
Analyzing customer service metrics, such as call center performance and responsiveness, can highlight areas where improvements can enhance member experience and satisfaction.
Medicare Advantage plans can leverage member data to boost their Star Ratings across various domains. Here is a breakdown:
- Focus on What Matters: Weighted measures should be a priority. Plans can hire dedicated staff to track these weighted measures to ensure their contracts with providers reflect these priorities.
- Identify Care Gaps: Analyze member data to pinpoint individuals who missed recommended screenings, tests, or treatments for chronic conditions.
- Proactive Outreach: Develop targeted interventions to address these gaps, improving performance on measures like Staying Healthy and Managing Chronic Conditions. Plans could send reminders for preventive screenings or connect members with disease management programs.
- Predict Future Needs: Leverage predictive analytics to identify members at risk of developing certain conditions. Early interventions can improve long-term health outcomes and reduce costly hospitalizations, positively impacting Star Ratings.
- Analyze CAHPS Data: Health plans should dissect CAHPS survey responses to understand member satisfaction and pinpoint areas for improvement.
- Personalize Communication: Utilize member data to tailor communications and outreach efforts. Plans could send personalized appointment reminders or provide information relevant to specific health conditions.
- CRM Investment: Invest in a robust customer relationship management (CRM) system that uses real-time analytics and reporting to facilitate consistent and effective member engagement.
- Collect SDOH Data: Gather data on social risk factors, such as transportation access, food security, and housing stability.
- Tailored Interventions: Plans should design interventions to address specific SDOH needs. For instance, offer transportation assistance for members struggling to attend appointments. Or connect them with community resources that address food insecurity.
- Health Equity Index: Recognize that the new Health Equity Index, while effective in 2027, is based on data from 2024 and 2025, emphasizing the immediate need to address SDOH.
4. Implement Quality Assurance Processes
Organizations should prioritize data quality to ensure accurate and reliable reporting for Star Ratings. Implement robust quality assurance protocols like routine data audits, validation checks, error tracking, and reconciliation procedures. These processes help maintain data integrity and meet the required quality standards for Star Ratings submissions. Here are some tips:
- Routine Data Audits: Regular audits of member data can help identify discrepancies, errors, and potential areas of improvement. For instance, audits can verify the accuracy of medication adherence data. Or, they can ensure that all eligible members have received recommended preventive screenings.
- Validation Checks: Implementing automated validation checks – as we have done in our premium billing solution – during data entry and processing can help prevent errors from entering the system. For example, plans could check for inconsistent patient demographics, verify the validity of procedure codes, or ensure that claims data aligns with medical records.
- Error Tracking: Establishing a system for tracking and managing data errors is essential. This system should log the type of error, its source, and the steps taken to correct it. Analyzing error trends can help identify systemic issues that require attention. That enables plans to refine their data management processes and minimize future errors that impact Star Ratings.
- Reconciliation Procedures: Regularly reconciling data from various sources, such as claims data, medical records, and pharmacy records, is crucial for ensuring consistency and accuracy. Reconciliation helps identify instances where data may be missing or conflicting, allowing plans to investigate and resolve discrepancies. CMS has particularly emphasized the importance of Prescription Drug Event (PDE) reconciliation to prevent penalties for data integrity violations.
5. Prioritize Preventive Care
Focusing on preventive care can significantly impact Star Ratings. Encouraging and incentivizing providers to conduct annual wellness visits allows for early detection of health risks and chronic conditions. Data analytics can help identify high-risk patient populations, allowing for targeted interventions and improved management of chronic conditions.
Here are some tips to help prioritize preventive care:
- Tie Contract Incentives to Weighted Measures: Annual wellness visits contribute to several Star Rating measures. As a result, health plans can structure provider contracts to include financial incentives tied to annual wellness visit completion rates.
- Targeted Lists: Health plans can use their data analytics capabilities to generate targeted lists of patients due for annual wellness visits or those with specific health risks to address during the visit. Providing these lists to providers can streamline their workflow and encourage them to prioritize wellness visits.
- Tools for Identifying Care Gaps: Equipping providers with point-of-care tools highlighting care gaps for individual patients can encourage them to utilize annual wellness visits to address gaps. This approach can improve performance on measures related to preventive care, chronic condition management, and medication adherence.
- Support for Point-of-Care Testing: Facilitating point-of-care testing during annual wellness visits can make it easier for providers to complete necessary screenings and assessments, encouraging them to conduct these visits.
- Home Visits: Health plans can offer support for home visits to patients facing barriers to attending in-office visits, making it more convenient for providers to conduct annual wellness visits and assess living environments for safety risks.
- Share Best Practices: Regularly sharing best practices for conducting effective annual wellness visits can help providers maximize the value of these visits. Plus, it improves their performance on related Star Rating measures.
- Educational Resources: Providing educational resources about the importance of annual wellness visits and their contribution to improving patient health outcomes and Star Ratings can motivate providers to prioritize these visits.
6. Improve Member Relationships
Strengthening relationships with members is crucial for enhancing patient experience and, consequently, Star Ratings. Here are some tips to help:
- Digital Tools for Member Understanding: Adopting digital tools that compile claims, clinical, and prescription data allows plans to understand individual member needs and tailor communication accordingly. Intelligent clinical workflows that trigger outreach at appropriate times, such as when a plan flags a member for potential non-adherence, can enhance the effectiveness of communication efforts.
- Person-Centered Communication Strategies: Employing clinical staff trained in person-centered communication techniques can help encourage.
- Understanding Preferred Communication Channels: Health plans should tailor communication methods to individual member preferences. Younger members might be comfortable with online portals. However, older members may prefer direct phone calls or communication through their providers.
- User-Friendly Website: Providing a website that is easy to navigate and offers clear information about plan benefits, resources, and how to access care can lead members to take control of their health.
- Support for Community Health Initiatives: Offering resources for health fairs, mobile mammography, and home visits can increase access to care and demonstrate a commitment to member well-being.
- Case Management Programs: Developing and implementing case management programs can provide personalized support to members with complex health needs, improving care coordination and overall health outcomes.
7. Stay Updated with Regulatory Changes
Star Ratings continually evolve, with new measures and methodologies introduced periodically. Health plans must stay informed about these changes. Then adapt their strategies accordingly to remain compliant and optimize their performance based on the latest requirements.
Here are some tips to stay informed:
- Regularly Visit the CMS Website: The CMS website (CMS.gov) is the primary source for all information related to the Star Ratings program. Health plans should make it a practice to regularly visit the website to access the latest updates, announcements, and resources.
- Review Fact Sheets and Technical Notes: CMS publishes detailed fact sheets outlining aspects of the Star Ratings program, including changes for upcoming years. In-depth technical notes provide a comprehensive understanding of the methodology used for calculating Star Ratings. Health plans should thoroughly review these documents to understand program requirements and how ratings are determined.
- Subscribe to CMS Email Updates: CMS offers email subscription services that deliver the latest news, announcements, and updates on the Star Ratings program directly to inboxes. Subscribing to these updates ensures timely access to information that can affect plan performance and compliance.
- Timeline Awareness: Health plans should note relevant dates and deadlines within the Star Ratings cycle, such as data submission deadlines, release dates for technical notes, and announcement dates for final Star Ratings. This awareness allows plans to prepare adequately and align their operations with program requirements.
8. Optimize Based on Numerical Targets
Understanding numerical targets and cut points is essential for developing an effective strategy to improve Star Ratings. Conducting a gap analysis between current performance and target scores helps prioritize improvement efforts and allocate resources efficiently.
Here are some tips to get started:
- Target Setting: Health plans should clearly define their desired Star Rating goals and translate them into specific numerical targets for each measure and domain. Plans must understand the weight assigned to each measure and its contribution to the overall Star Rating.
- Cut Point Analysis: Health plans should review projected cut points to understand the level of performance needed to reach their desired rating for each measure.
- Past Performance and Benchmarking: Analyzing past performance on Star Rating measures and benchmarking against high-performing plans can provide insights into areas for improvement and help set realistic targets.
- Address Areas with Low Performance: Identifying measures where the plan is performing below the desired Star Rating level allows for targeted interventions to improve scores. Analyzing data to understand the root causes of low performance is crucial for developing effective solutions.
- Consider Measures with Potential for Significant Improvement: Even if a plan is not currently achieving a 5-star rating on a particular measure, focusing on measures with a realistic opportunity for significant improvement can lead to substantial gains in the overall Star Rating.
The CMS Star Ratings system helps Medicare beneficiaries compare and choose health plans. Additionally, it drives quality improvement within the Medicare Advantage program. By leveraging these approaches, health plans can enhance their performance, achieve higher Star Ratings, and provide better care to their members.
Sources:
2025 Medicare Advantage and Part D Star Ratings
Medicare 2025 Part C & D Star Ratings Technical Notes
4 strategies to reach a 5-star CMS rating
5 Things Medicare Advantage Plans Can Do to Improve Their Star Ratings
7 Data-Driven Strategies to Improve Star Ratings
Cracking the Code to 2025 CMS Star Ratings
Five ways AI can improve your Star Ratings
How Care Management and Care Coordination Can Improve Star Ratings
How to Improve Medicare Advantage Star Ratings
Reaching for a High CMS Star Rating: Is It Possible Nowadays?
Improving Medicare Advantage Quality Measurement
Leveraging operational excellence: Enhancing Medicare Star Ratings through effective adaptation
How new strategies can help boost Medicare Advantage performance
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