A New, Tougher Stars Era is Coming. Are MA Plans Ready?

CMS’ 2027 proposal marks one of the biggest remakes of the program—shifting from operational to clinical rigor, disadvantaging many plans (especially SNPs), and injecting new uncertainty into future revenue.

CMS’ Overhaul: Operational Measures Out, Clinical Intensity In

CMS’ draft MA & Part D rule (published Nov 25) proposes removing 12–14 operational/administrative measures beginning Measure Year 2027 / Star Year 2029 (with a few measures removed earlier). The removals shift Star “power” toward drug, HOS, and quality improvement measures by SY 2029 as well clinical measures after that.

Measures CMS Proposes to Eliminate

Key takeaway: CMS is stripping out nearly all operational measures, forcing plans into a more clinical-outcome-driven Stars landscape.

Shift in Star Weighting: Operational Drops to Zero

The changes above have the effect of transferring so-called Star power to drug, HOS survey, HEDIS clinical, and quality improvement measures. Below is the impact on relative weighting of measure groups toward the overall rating from Star Year 2026 (the just released Star year) vs. Star Year 2029 (the year all proposed changes will be in effect). Note that SNP-only plans have slightly different percentages but they are very close to these numbers.

Let’s look at this another way. The impact of CAHPS and HOS survey measures increases dramatically. These are not easily trackable as say HEDIS and drug measures are. You need to ensure the entire population is happy with their healthcare and outcomes in order to ensure excellent performance on these annual sample measures. This complicates consistent achievement as well as rating predictions for all plans. And moving these types of measures are muli-year.

The Surprise Reversal: EHO4all Paused, Reward Factor Returns

Key takeaway: Plans that invested in EHO4all may get zero benefit, while historically strong plans gain an advantage.

If the new rule is implemented as is, CMS will not implement EHO4all in SY 2027; instead, the Reward Factor will stay. If you look at how national, regional and smaller plans might or might not benefit from the change, we find:

• The larger regional plans benefit the most from restoring the Reward Factor as they tended to be the most consistent high performers.
• Most of the big national players have had some benefit from the Reward Factor in the past but not as much as the larger regional players. At the same, they are making heavy investments in Special Needs Plan (SNPs) and attracting dual eligibles. Meaning, they could perhaps go either way on this. But given their woes, they are likely satisfied with no more upheaval in Stars right now if the Reward Factor stays.
• Certain poorer performing national plans likely would have done better under the EHO4all, but that assumes they can serve dual eligibles better than they do today.
• The losers may be some of the smaller plans with high concentrations of dual eligibles and SNPs who have not traditionally scored well but counted on the EHO4all to move them up the Star scale.

• Winners: Plans already scoring high overall (consistent 4+ Star performers).
• Losers: Plans that heavily invested in EHO4all preparation for SY 2027.
• Risk: Timing of the reversal—one month before MY 2025 ends—may raise due-process challenges.

The real question about this change is whether plans are getting due process. There is a legitimate issue for plans to raise when the government proposes to zero out the EHO4all in a draft rule with just one month remaining in Measure Year 2025 and when the final rule will not be adopted until well after the measure year has concluded. Some plans would have a strong case in challenging the provision. After all, the original HEI proposal (the precursor to EHO4all) went through full rulemaking back in 2023. Plans had sufficient notice to prepare for the major change. They will not now.

New Measure Coming: Depression Screening & Follow-Up

Key takeaway: Universal Foundation measures continue to enter MA Stars, bringing more complex clinical requirements.
A new Depression Screening and Follow-Up measure will join the program in MY 2027/SY 2029.

CMS’ Estimated Impact on Star Ratings

Key takeaway: A quarter of plans drop; one in eight rise; most stay flat.

What’s Changing and When

The following synthesizes confirmed, proposed, and potential changes. Proposed items from the 2027 rule are bolded.

Measure Year 2025  (Star Year 2027)

Key takeaway: Major drug-safety measures arrive, HOS gets heavier, and COA measures reshuffle.

• Reward Factor retained; EHO4all not implemented (proposed).
• HOS Physical & Mental Health measures increase from 1× → 3× weights.
• COA Pain Assessment removed; COA Functional Status Assessment returns.
• Two difficult polypharmacy/drug safety measures begin:
  • COB (Concurrent Use of Opioids & Benzodiazepines)
  • Poly-ACH (Polypharmacy Anticholinergic)
• Diabetes Eye Exam loses chart review option (≈2-point performance hit).
• Statin Use in Diabetes gets new tolerance exclusion.
• Removal of MRP and MTM-CMR.

Measure Year 2026 (Star Year 2028)

Key takeaway: Adherence measures drop in weight and get risk adjustment—fundamentally changing performance dynamics.

• All three adherence measures drop 3× → 1× weight.
  • New risk adjustment based on age, sex, LIS/dual, disability.
  • Removal of inpatient/SNF adjustments.
• Statin Therapy (SPC) moved to Display due to specification changes; proposed elimination in MY 2026/SY 2028.
• Call Center measures proposed for removal in MY 2026/SY 2028.

Measure Year 2027  (Star Year 2029)

Key takeaway: Large measure removals and expansions further increase clinical difficulty.

• Breast Cancer Screening age drops to 40.
• CMS proposes eliminating: Appeals, SNP Care Mgmt, Complaints, Disenrollment, Price Accuracy, Eye Exam, CAHPS Service, CAHPS Quality.
• Depression Screening & Follow-Up added to Star (Display requirements will have been met).

Later Years

Key takeaway: Widespread ECDS conversions and more complex measures are coming.

• NCQA aims to convert all hybrid measures to ECDS by MY 2029 and non-hybrid by 2030.
• Several challenging measures (e.g., Blood Pressure, A1c, TOC, COA suite) slated for ECDS conversion.
• Substance use disorder measures likely to reappear in future proposals.
• Additional Universal Foundation measures possible (e.g., Immunizations, ADLs).
• Possible elimination of guardrails for cut points as well as possible elimination of improvement vs. no-improvement” scoring calculation for 4 and 4.5 Star plans.

The SNP Effect: Growing Enrollment, Lower Performance

Key takeaway: SNP growth and D-SNP carve-outs will structurally depress Star ratings for many contracts.

• SNPs now represent one-third of MA plans and 22% of all MA enrollment.
• D-SNP performance averages ≈0.3 points lower, with adherence measures more than double that impact.
• CAI helps but does not fully compensate for the performance gap.
• More plans shifting into D-SNP-heavy contracts may see declining Stars despite strong operations.

Bottom Line

If CMS finalizes its proposed framework, the Stars program becomes far more clinically demanding and far more difficult for plans with vulnerable populations.

• Billions in bonus payments are at risk.
• Plans must invest in faster data, better forecasting, and more scalable interventions.
• Success will hinge on the ability to identify gaps earlier and activate interventions at scale—especially for drug safety, adherence, and HOS.

If you want deeper commentary on all the changes and analysis about the implications, check out an accompanying article on The Healthcare Labyrinth. 

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Lilac’s Stars Management platform helps plans navigate these types of major changes to Stars.  We have the data models and analytics to easily understand the strategic implications of Stars program changes and agentic AI tools to make a plan’s member engagement in support of Stars more efficient and impactful. Reach out here to start a conversation with the Lilac team about how we can help your plan.