Medicare Advantage (MA) plans continue to face mounting pressure to achieve high Star Ratings, comply with evolving CMS regulations, and deliver equitable, high-quality care. The 2025 Star Ratings averaged just 3.74 (weighted by enrollment), leaving many plans short of their quality and revenue goals. With ~$16 billion in quality bonuses on the line, performance in 2026 and beyond will determine who thrives in this increasingly competitive landscape.
InfoMC’s enterprise care management platform, Incedo, equips plans with the tools to bridge regulatory requirements, operational efficiency, and member outcomes. By aligning with CMS Final Rules (4201-F, 4205-F) and the Contract Year 2026 Proposed Rule (CMS-4208-P), Incedo helps MA plans improve Star Ratings, reduce compliance risk, and deliver person-centered care that members value.
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1. Star Ratings: From 2025 Results to 2026 Improvement
The 2025 Star Ratings, released in October 2024, evaluated plans across up to 40 measures, including HEDIS, CAHPS, and administrative performance metrics. Key takeaways included:
- Higher weight for member experience: CAHPS remains a dominant driver of overall ratings.
- Continued equity emphasis: Social risk factors and health disparities are increasingly tied to Star scoring.
- Financial implications: While ~70% of enrollees are in 4+ star plans, the decline in average scores highlights ongoing operational challenges.
Looking ahead, 2026 Star Ratings (to be released October 2025) will reflect 2024 performance data and prepare the ground for 2027 ratings that incorporate new measures tied to 2025 data collection.
How Incedo Helps
- Integrates medical, behavioral, and social data within a single care management record to improve HEDIS and CAHPS measures.
- Automates workflows that reduce complaints, enhance member engagement, and directly impact weighted measures.
2. Navigating CMS Regulations
Compliance with CMS regulations is no longer optional—it’s central to quality performance.
- CMS-4201-F (CY 2024): Mandates streamlined utilization management (UM) processes, including prior authorization timelines (72 hours urgent, 7 days standard), alignment with Medicare coverage criteria, and annual UM committee review.
- CMS-4205-F (CY 2025): Expands MTM eligibility, lowers D-SNP look-alike thresholds (70% in 2025, 60% in 2026), and caps agent/broker compensation.
- CMS-4208-P (CY 2026 Proposed Rule): Would introduce transparency requirements for AI/automation in UM, provider directory accuracy standards, insulin cost-sharing caps, and potential new Star measures focused on safety and equity.
- VBID Transition: The Value-Based Insurance Design (VBID) model sunsets at the end of 2025, requiring plans to transition benefits to Special Supplemental Benefits for the Chronically Ill (SSBCI) or other flexibilities.
How Incedo Helps
- Automates prior authorization workflows and maintains audit-ready documentation (ODAG/CDAG).
- Facilitates VBID-to-SSBCI transition through integrated chronic condition and SDOH data capture.
- Provides configurable rules engines and audit trails to ensure compliance with evolving CMS, NCQA, and state requirements.
3. Advancing Health Equity
CMS has made health equity a permanent fixture of Star Ratings through:
- Health Risk Assessments (HRAs) within 90 days of enrollment.
- Health-Related Social Needs (HRSN) screening and documentation.
- Health Equity Index (HEI) scoring that factors into overall ratings.
How Incedo Helps
- Captures HRSN, HRA, and SDOH data in structured, reportable formats.
- Enables interdisciplinary collaboration to address disparities and tailor interventions.
Supports CMS equity reporting and HEI compliance, strengthening Star performance.
4. Improving Member Experience
Member satisfaction, measured primarily through CAHPS, is a decisive factor in Star Ratings. Common friction points include utilization management challenges such as prior authorization delays, lack of transparency, and limited care coordination.
Starting in 2026, CMS will require public reporting of prior authorization metrics, with data collection already underway in 2025. Plans that fail to demonstrate timely access risk penalties and member dissatisfaction.
How Incedo Helps
- Streamlines PA processes to meet required timelines (72 hours urgent, 7 days standard).
- Facilitates real-time collaboration across providers and plans, reducing member abrasion.
- Tracks complaints and member feedback, enabling proactive service improvements.
5. Optimizing Care Coordination
Breaking down silos between medical, behavioral, and social services is essential for both compliance and outcomes. This is especially critical as CMS tightens oversight of D-SNP integration under CMS-4205-F.
How Incedo Helps
- Connects interdisciplinary teams, care managers, and community resources for whole-person care.
- Supports transitions of care and reduces readmissions with automated alerts and decision support.
Provides transparency and shared workflows to eliminate duplication and improve outcomes.
6. Preparing for 2026 and Beyond
With 2026 Star Ratings on the horizon and 2027 measurement already in motion, MA plans must act now:
- Data Collection: Capture 2025 data needed for new equity and safety measures.
- VBID Transition: Shift supplemental benefits to SSBCI before the 2025 sunset.
- Technology Readiness: Adopt platforms like Incedo that can scale with evolving CMS rules, including electronic prior authorization standards expected by 2027.
- AI Transparency: Prepare for oversight of AI/automation in utilization management (UM) decisions, ensuring auditability and fairness.
How Incedo Helps
- Scales MTM and equity tools to support upcoming Star measures.
- Tracks longitudinal data across care domains for future reporting.
- Provides configurable APIs to meet interoperability and ePA mandates.
Conclusion
Sustaining and improving Star Ratings requires more than incremental change—it demands integrated care management and utilization management, equity-driven strategies, and compliance built into daily operations.
Incedo empowers MA plans to:
- Coordinate holistic, whole-person care across medical, behavioral, and social domains.
- Automate compliance with CMS-4201-F, CMS-4205-F, and emerging 2026 requirements.
- Enhance member satisfaction by removing friction and streamlining processes.
- Leverage data to address disparities and improve outcomes.
Call to Action: Now is the time to prepare your operations for 2026 Star Ratings and beyond. Contact us or schedule a demo to explore how Incedo can help your plan stay ahead.
