Learnings from the Field – Medicare Advantage Plan Preview 1

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Plan Preview 1 has concluded for Medicare Advantage (MA) Stars and operational teams at health plans. We are all now anxiously awaiting Plan Preview 2, where we get Centers for Medicare and Medicaid Services (CMS) cut points, measure ratings, improvement ratings, and overall ratings. We have seen three years in a row – 2023, 2024, and 2025 – of declining overall Star ratings. Will the trend continue or will there be a rebound?

Before Plan Preview 1’s learnings get clouded by Plan Preview 2 results, we thought it would be good to summarize our main findings in terms of working with clients. In an earlier blog, we summarized how Plan Preview 1 and 2 work and what we believe are best practices to ensure the best performance. You can find that here: https://lilacsoftware.com/in-depth-primer-for-plan-preview-2025/ 

 

The importance of planning and dialogue

We cannot emphasize enough how important it is to think about Plan Preview as a nearly 9-month process. Begin early in the closeout period of January to June of the following year to identify data anomalies and inconsistencies between your view and CMS’s data. Heck, the best of you will start this 21 months in advance by having processes that analyze the data beginning in month one of each measure year. 

In some cases, your chance to impact changes closes during the first half of the year following the measure year. A good example is getting in your PDEs for drug measurement and reporting data issues to Acumen on exclusions, the denominator, the numerator, and attainment rates. And pay particular attention to the need to update your data analysis often during the 1H closeout period. Examples here are PDE reports, Acumen reports, Maximus appeals completion, complaints completion, disenrollment updates, and more. 

An ongoing dialogue with CMS on data issues and inconsistencies establishes great credibility. It shows the care you as a plan take in terms of operations, transparency, and accuracy. CMS is quite suspicious of a plan throwing a data issue or inconsistency at them deep into the Plan Preview 1 week. You are sure to get better consideration with planning and ongoing dialogue.

And most important, after Plan Preview 1, data issues or inconsistencies are almost never won by plans. Getting everything reported by the Wednesday deadline each year is key, preferably with notice to CMS well in advance.

 

Don’t be afraid to push back on CMS

Last, many plans struggle with the idea of pushing back on CMS. It is a bit like biting the hand that feeds you. But here are a few truths: (1) CMS and its vendors do make mistakes; (2) CMS runs a good Stars program, but it is not without problems – a certain paucity of data and insights, a certain inflexibility of government to new ways of thinking (I know, I have been a part of it.); (3) the mammoth task of evaluating every contract, every measure, and every year when regulations and the Stars road map are changing; and (4) notwithstanding number 2, CMS is a professional organization willing to partner and hear concerns. Ultimately, not pushing back puts you at a disadvantage vs. other plans. 

More to the point, plans can win when they push back. While it wins more than it loses, CMS has lost some high-profile lawsuits of late regarding Stars. As well, CMS invites you to report data and calculation issues and plans do win during that process. Take for example appeals won by Lilac’s clients this year.

  • Challenges to call center findings.
  • Challenges to appeals cases and calculations.
  • Challenges to CTM classifications and assignment.
  • Disaster impacts to measure values and ratings.
  • Acumen patient safety report calculations and data recognitions.

 

Plan Preview 1 learnings

Here are some other learnings from this year’s Plan Preview 1.

CAHPS Measures: While ratings are calculated during Plan Preview 2, make sure you review CMS data related to the application of disaster impacts and proactively report any discrepancies to CMS in Plan Preview 1. More specifically, for a plan impacted by the LA Wildfires (25% or more of membership impacted), they can take the better of CAHPS scores from SY 2025 (2024 survey) or SY 2026 (2025 survey). This is a little different than the normal better of allowance across all measures besides Call Center. If a survey was not conducted this year, you get the CAHPS measure ratings for the 2024 survey. But CMS notified plans that if a 2025 survey was run, you will be credited for the better of the 2024 or 2025 survey ratings. 

Leave/Disenrollment Measures: There is a new rule that removes from the Leave calculation disenrollments to various integrated and some aligned but coordinated Special Needs Plans. Note in the SY 2026 Plan Preview 1 Tech Notes that CMS has included this new exclusion even before the effective date of the new monthly Special Enrollment Period provision as of 1/1/2025. Few plans are aware of this. It is important to check the CMS calculation and ensure a member who did disenroll into an eligible SNP is not counted against you. Begin using this new exclusion to calculate monthly disenrollment in MY 2025.

Complaints Measures: Make sure you scrub for any misclassifications, removal of all CMS Issues, other cases you think are CMS issues not classified as so, and cases that may actually be properly assigned to a different plan. 

Appeals measures: Pay attention to the classification of cases (yours and Maximus’) because different case types have different timeframes now. This could lead to miscalculations of timeliness. Be aggressive on analyzing both timeliness and reviewing errors by Maximus. Errors are not uncommon and are best addressed month by month and documented.

TTY/Foreign Language Measures: We see many mistakes by the CMS vendor here. While CMS is hesitant to change findings due to ongoing legal suits, appeals can be won with careful analysis and justification, inclusion of detailed data, and persistence. Challenging may require checking detailed call logs and recordings and supplying this data.

Drug Measures: We see huge value in ongoing reconciliation of plan data and what is reported by Acumen in the patient safety reports. Sometimes discrepancies in numerators, denominators, and attainment rates in measures may tie to a significant data lag between more current plan data and CMS’ claims and eligibility cutoffs. Track these to make sure Acumen eventually updates a value. Pay particular attention to both claims-based and enrollment flag exclusions. 

There too simply could be lack of recognition of certain data a plan sees that Acumen does not. Document it and report it to Acumen. A handful of members could impact values and lead to higher ratings. 

Plans too need to watch to ensure Acumen is using the most updated NDCs and when its NDCs are refreshed you get credit back in time in the measure year.

 

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Lilac Software offers a cloud-hosted, data aggregation and analytics solution for health plans’ most complex problems. Our Star Performance Management Platform gives unprecedented insight into all aspects of the Medicare Advantage Star program, including individual measure performance, best practice remediations for all measures, and forecasting of aggregate scores and revenue.

Lilac’s platform has dedicated reporting and functionality to help manage the toughest Star measures. Reach out to us via the form in this link to learn how we can help your plan perform better in these critical areas.