CMS Announces Changes for the Star Rating Program

CMS announces changes for the Star Rating Program

In January, the Centers for Medicare and Medicaid Services (CMS) released the 2026 Medicare Advantage and Part D Announcement. In this year’s publication, CMS reviewed changes for the upcoming 2026 Star Ratings, discussed technical measure updates, and shared ideas for simplifying and refocusing the Star Rating program. This included feedback from a RAND-convened Technical Expert Panel (TEP) which reviewed the program. Overall, the TEP did not recommend drastic changes but did support rethinking the measures that are included.

Here are three themes that impact pharmacy care management services:

Adherence measures are evolving

For the 2028 Star Ratings (CY2026), the adherence measures will implement sociodemographic status adjustments based on beneficiary level characteristics and remove the SNF and inpatient stay adjustments. CMS reported the convened TEP recommendations included redesigning current measures to assess patient outcomes, specifically referencing the Part D medication adherence measures.

Constant evolution of adherence programs is needed to be ready for these changes. Programs that focus on overall patient outcomes and not just on prescription fills will continue to perform well irrespective of the direction CMS takes with these measures.

RxAnte program strategies focus on identifying members for outreach at the right time and focusing on more than just medication refills. Advanced analytics find cohorts of patients that might need a more targeted approach, and interventions are selected based on how likely a patient is to respond to that intervention. If analytics show one modality is not working, a different one is selected. Looking at the complete picture from measure performance to intervention success will be needed to evolve programs further.

Medication-sensitive measures remain important

Beginning with the 2027 Star Ratings (CY2025), there will be 2 new medication-related measures with the addition of Polypharmacy:  Use of ACH medication in Older Adults (Poly-ACH) and Concurrent Use of Opioids and Benzodiazepine (COB) to Star Ratings. CMS has also proposed adding Initial Opioid Prescribing for Long Duration to future Star Ratings.

For the 2026 Star Ratings, medication-sensitive measures will make up 42% of the overall Part D Summary score, and 14% of overall Part C and D scores. Designing programs to improve the performance on these measures is crucial to overall Star Rating success. RxAnte analytics have shown that many patients (9-31%) that qualify for these measure have 4 or more prescribers. Prescriber intervention on these measures will be an important component of performance improvement.

RxAnte has incorporated the medication overlap measures into our product suite including plan performance tools and within outreach platforms.

Driving excellent care is still a focus

Beginning with 2027 Star Ratings, the Health Equity Index (HEI) incentive will replace the reward factor. The most recent CMS publication shared the HEI incentive will be renamed the Excellent Health Outcomes for All (EHO4all) incentive to “better capture the goal of ensuring exceptional care for all enrollees” per CMS. It will assess how well a plan has performed across members that are LIS, dual eligible, or disabled over two years and compare that to the performance of other plans. The Advance Notice communication proposed adding geography (rural vs. urban) to the EHO4all factors is being considered. RxAnte analytics have shown a decrease in adherence rates for members that live in rural settings.

RxAnte developed a social risk factor (SRF) intervention that identifies patients with SRFs that have lower adherence rates. These patients are recommended to a specialized intervention which often includes a social need screening and goes beyond medication adherence. Evaluation results show this to be one of the most effective interventions in improving adherence rates across our programs.

What all this means

In the Advance Notice, CMS shared a strong focus on more evidence-based clinical measures that assess patient outcomes. Continuous innovation of Star Rating programs will be essential to remain successful. Programs that focus on overall patient outcomes will continue to be the most successful as the Star Rating program evolves.