What Health Plans Need to Do Now to Get Ahead on Medicare Star Ratings

Prepare Now for MY2026

Medicare Advantage (MA) now serves over half of all Medicare beneficiaries. As enrollment climbs, so does the pressure to perform. CMS Star Ratings aren’t just a benchmark — they drive Medicare Advantage quality bonus payments (QBP), member trust, and long-term competitiveness.

Yet recent changes to Part D measures are reshaping the rules. From adherence risk adjustment to equity-focused scoring and MTM measure expansion, the environment is more complex than ever. Newer polypharmacy measures also present challenges. Plans must go beyond traditional strategies.

In this post, we highlight key updates to measures that plans must prepare for — and explore the most effective strategies to address them. Health plans that act now to leverage AI, clinical expertise, and scalable technology will be best positioned to address risk at the member level—driving higher quality of care and stronger Star Ratings.

Why Medicare Star Ratings Are Stabilizing—But Challenges Remain

While Star Ratings for 2026 appear to have stabilized, the longer-term trend tells a different story. In 2025 and 2026, the enrollment-weighted average for MA-PD contracts held flat around 3.92 to 3.98 stars, but this marks a significant decline compared to 4.37 in 2022.

The downward trend is even more pronounced for stand-alone Part D (PDP) plans, which historically lag behind MA-PD performance. In 2025, the enrollment-weighted average rating dropped to just 3.06 stars — one of the lowest points on record. Plans continue to struggle, especially with the tougher Part D measures.

Why scores remain under pressure:

• Temporary COVID-era boosts to scores have ended.
• Performance thresholds are tighter, and cut points have risen.
• Bonus payment growth is slowing.

These shifts make it harder to maintain, let alone improve, Star Ratings performance. With increased financial strain on plans, it is now also more important than ever for them to demonstrate real-world improvements in quality and outcomes, especially for high-risk members. Technology-enabled strategies are essential for scaling interventions and closing gaps before they affect ratings.

Medication Adherence Measures Are Changing: How to Adapt and Improve Performance

Starting in Measurement Year (MY) 2026, CMS is introducing major updates to adherence scoring—reflecting member complexity through new risk adjustment and weighting rules.

• Sociodemographic Status (SDS) Risk Adjustment: Adherence scores will now account for sociodemographic factors like age, gender, low-income subsidy, disability status, and dual eligibility.
• Triple-Weighted to Single-Weighted Adherence Measures: For the 2026 measure year, the triple-weighted adherence measures will be temporarily reduced to single-weighted, but are expected to return to triple-weighted in 2027.
• IP/SNF Stay Removal (PDC impact): Days when members are hospitalized or in skilled nursing facilities will no longer be excluded from Proportion of Days Covered (PDC) calculations. These inpatient stays may contribute to lower PDC scores, since medications are administered through the facility.

These shifts create both challenges and opportunities. Plans that act now will gain an edge when 3x weighting returns.

To prepare, plans should:

• Use machine learning to predict and prioritize risk: Incorporate dual-eligible, low-income subsidy (LIS), and disability data, along with other clinical and social determinants of health (SDOH) data, to prioritize members most likely to fall below adherence thresholds.
• Apply AI to tailor interventions that address social risk: Identify social risk factor (SRF) driven barriers to adherence, such as those related to dual eligible, low income, and disabled members — and tailor interventions based on strategies proven to work for members with similar profiles.
• Proactively address members impacted by IP/SNF stays: Build workflows to monitor discharges and resolve medication gaps for members transitioning out of inpatient or skilled care.

EHO4all: Turning Health Equity into a Strategic Advantage

CMS has been preparing to replace the Reward Factor with the Health Equity Index (HEI) — a new scoring model designed to recognize plans that improve outcomes for members with social risk factors (SRFs), including dual-eligible individuals, those with low-income subsidy, or those who originally qualified for Medicare due to a disability.

In 2026, HEI will rebrand as Excellent Health Outcomes for All (EHO4all) and begin impacting Star Ratings in 2027 (based on MY2024–25 data). Unlike other measures, it only rewards improvement — there’s no penalty for underperformance.

Plans serving populations with a higher proportion of members with SRFs often face tougher adherence and engagement challenges. EHO4all gives those plans an opportunity to earn ratings boosts by investing in targeted, equitable interventions.

To succeed, plans need to:

• Track measure performance by SRF: Monitor outcomes for members with dual eligibility, low-income subsidy, and disability to ensure equitable care.
• Identify care gaps where performance among SRF members is lagging: Use data to pinpoint disparities in quality and outcomes.
• Personalize outreach to address SDOH barriers: Address challenges such as transportation, language barriers, and digital access through human-centered engagement.

Technology plays a critical role here. Arine’s AI-driven platform enables real-time identification of members with these social risk factors and empowers care teams to deliver tailored interventions that promote health equity.

MTM CMR Expansion: Why Now Is the Time to Scale Ahead of 2027 Scoring

CMS has made significant changes to the MTM Comprehensive Medication Review (CMR) measure. Eligibility criteria have expanded substantially — nearly doubling the number of members who now qualify. To allow time for adjustment, CMS paused this measure from contributing to Star Ratings, making it a display measure in MY2025 and 2026. While results will continue to be reported publicly, they will not impact plan scores during this period.

The increase in eligible members has made MTM one of the most challenging measures to succeed on, but it remains a critical touchpoint for engaging members and driving care. With scoring expected to resume in the 2027 measure year, plans need to use this time to refine internal processes, scale outreach, and ensure readiness for the broader member population in this measure.

The Path Forward: Smarter Quality and Cost Improvement

CMS isn’t just raising the bar — it’s redefining what quality improvement means. As CMS finalizes 2026 Star Ratings measure updates and methodology changes, health plans should use these signals to guide upcoming quality improvement strategies and technology investments. Member complexity, social risk, and a robust medication management strategy are now central to performance.

For Medicare Advantage performance strategies, success demands precision, personalization, and speed — all areas where AI and data-driven platforms like Arine excel. And while these initiatives aim to raise the quality of care, the best solutions also deliver meaningful improvement in total cost of care — ensuring long-term sustainability and measurable ROI for health plans.

Key Takeaways:

• Adherence measures will be single-weighted and risk-adjusted for sociodemographic status, and the exclusion of IP/SNF stays from adherence calculations will end. Given that it will return to triple-weighting in MY2027, it’s important to maintain strong performance on these measures.
• EHO4all (formerly known as the Health Equity Index) will reward plans that improve care for members with social risk factors, beginning with the 2027 Star Ratings.
• The MTM CMR measure has expanded eligibility and is a display measure through MY2026, with scoring expected to resume in MY2027, offering an opportune window for operational scaling in 2026.

Stay Ahead with Arine

Navigating CMS changes isn’t just about compliance — it’s about building a smarter, more resilient strategy. At Arine, we help your team focus where it matters most. Our platform identifies the members who will have the greatest impact on quality measures by drawing from diverse data sets, including social risk factors. We deliver intelligent interventions tailored to what’s proven to work for each member profile. And we provide real-time insights at the moments they matter most — enabling faster action to improve quality scores throughout the measurement year. Let’s talk about how you can outperform in the next phase of Star Ratings.

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