As health plans approach the final stretch of the year, the focus turns to maximizing performance in Medicare Advantage Star Ratings while laying the groundwork for sustained success in 2026. Several themes and tactical strategies stand out for leaders who want to make meaningful progress in the months ahead.
The Importance of Data Precision
Data quality remains the foundation of Star performance. Plans should prioritize rigorous validation of HEDIS, pharmacy, and CMS-reported data, since even small corrections can yield measurable gains. Year-round data audits are essential, with attention to discrepancies in appeals, disenrollment flags, and LIS/CAI classifications. Incremental fixes—such as reconciling lab or pharmacy records—add up to meaningful score improvements.
Tackling Drug Measures Head-On
Drug adherence measures continue to be the single largest challenge, with widespread underperformance. Leaders recommend three areas of focus:
- Medication adherence: Prioritize members hovering near the 80% threshold to preserve or lift ratings.
- Statin use: Work directly with providers to ensure appropriate prescriptions, especially for diabetes and cardiovascular patients.
- New measures (COB and Poly-ACH): Take a risk-based approach to identify members likely to become non-compliant early, since retroactive interventions are often too late.
Engaging Members Through CAHPS and HOS
Member experience surveys have outsized influence on Star ratings. Plans can improve performance by:
- Promoting survey awareness compliantly at every member touchpoint.
- Oversampling to stabilize long-term results.
- Proactively engaging with “middle-of-the-road” members (those rating plans 7–8 out of 10), who can be moved more effectively than the most dissatisfied members.
- Using AI-enabled outreach and creative engagement strategies to detect depression, isolation, or dissatisfaction before they appear in survey results.
Health Risk Assessments (HRAs) in SNP and D-SNP Plans
With SNP enrollment now approaching a quarter of all Medicare Advantage members, HRA completion has become both a compliance necessity and a growth driver. Plans should:
- Track HRA due dates meticulously and forecast completion rates.
- Use labor calculators to plan staffing and overtime needs.
- Leverage a mix of staff, provider partners, and AI tools for outreach and completion.
- Recognize that provider-administered HRAs, when aligned with CMS domains, can count toward compliance.
Navigating Complex Care Measures
Event-based measures such as Post-Discharge Readmissions (PCR), Transitions of Care (TRC), and Follow-Up after Mental Illness (FMC) remain among the toughest to manage. Successful strategies include:
- Addressing them holistically, since poor performance in one often correlates with another.
- Strengthening admission, discharge, and ED notification systems to support proactive patient engagement.
- Conducting retrospective reviews at the provider-group level to identify high-impact opportunities.
- Focusing disease management efforts on major drivers such as CHF and diabetes, while tracking hospital-acquired conditions like sepsis.
A Precision Approach to Resource Allocation
Star ratings are often a “game of inches.” Rather than spreading resources thin, plans should apply precision analytics to target interventions where they can make the greatest difference. This means tailoring outreach and support to members most likely to shift ratings, rather than relying solely on broad-brush strategies.
The Path Forward
The months ahead represent both a challenge and an opportunity. By doubling down on data quality, sharpening focus on medication adherence, investing in member engagement, and adopting a precision mindset, plans can not only strengthen their current-year scores but also set the stage for durable improvements in 2026 and beyond.
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Interested in learning how your plan’s end of year initiatives can benefit from Lilac’s powerful analytics and agentic AI solutions? Reach out here to start a conversation with the Lilac team.
