Driving Star Ratings Success: 4 Strategies to Strengthen Plans in 2025PY and Beyond

The 2024 Star Ratings reveal was a tough pill to swallow for many Medicare Advantage (MA) health plans. Average ratings fell for the third year in a row with more than a third of the plans losing half a star or more in their ratings. The decline in ratings can be attributed to several factors. For one, Centers for Medicare and Medicaid Services (CMS) eliminated policies that artificially inflated ratings during the pandemic. For another, CMS altered the calculation of cut points by adopting the Tukey Outlier method, eliminating both the highest and lowest performers. The changes to cut points make it more challenging for plans to maintain their high Star Rating as well as improve their current rating.

Given the substantial $13 billion in MA bonus payments at stake in 2024MY, it is imperative that plans proactively assess the implications of ongoing updates and make essential process adjustments promptly.

• Strategize on enhancing HEDIS measures, which will play a more substantial role, contributing to 25% of a plan’s overall 2026 Star Rating (an increase from 17% in 2025).
• Address improvements in Health Outcomes Survey (HOS) scores given that these measures will have a 3X weight starting in 2025.
• Consider various changes proposed to operations, ratings methodology, and Dual Eligible Special Needs Plans (D-SNPs) outlined in the 2025 Medicare Advantage Rule.
• Design meaningful outreach efforts to engage underserved populations as CMS discards the traditional reward factor in favor of the Health Equity Index (HEI) for 2028 ratings.

Why member experience matters more than ever

Grounded in numerous quality metrics, the annual Star Ratings play a pivotal role in incentivizing healthcare plans to deliver high-quality care. Attaining high Star Ratings offers a significant enrollment advantage for plans, ranging from increased quality bonuses to extended period of enrollment. They also serve as a valuable tool for beneficiaries, aiding them in selecting plans that align with their specific healthcare needs.

MA plans with prescription drug coverage undergo assessment based on 40 individual measures and those without prescription drug coverage are evaluated on 30 measures. Key assessment measures include – Care Coordination, Call Center and Customer Service,  and Member Complaints, and Appeal Decisions – highlighting the important role member experience plays in determining Star Ratings.

At the same time, rising customer expectations for Amazon-like healthcare experiences is putting plans under further pressure to transform the member experience.

Driving differentiation through digital-first engagement

By integrating automation and analytics with the human touch, plans can craft individualized and smooth omnichannel experiences throughout the member journey. This approach allows plans to assist members through their preferred channels (such as email, voice, chat, or SMS), resulting in heightened member engagement and satisfaction.

In- and after call automation solutions, coupled with AI-driven workflows and knowledgebases, empower agents to deliver compassionate and customized interactions. Simultaneously, analytics solutions, encompassing speech and customer journey analytics, play a pivotal role in understanding customer history, needs, and behaviors. The insights contribute to an enhanced understanding of member segmentation and profiling, facilitating the seamless implementation of omnichannel outreach.

Employing a digital-first strategy across the following four key areas has the potential to significantly influence Stars Ratings.

1. Fill care gaps – The Getting Appointments and Care Quickly measure, a part of CAHPS, will now account for 32% of the Stars Scores (up from 22%).
   
   1. Harness an omnichannel communication strategy to efficiently reach individuals and seamlessly connect them to appropriate services.
   2. Target specific patient cohorts through proactive engagement that goes beyond traditional communication, delivering compassionate outreach and relevant education where needed. This guarantees that members at risk receive the necessary care, including timely health screenings and preventive measures, ultimately enhancing your HEDIS scores, star ratings, and quality objectives.
2. Address unique member needs – For MA members, especially those dealing with chronic conditions, plan satisfaction encompasses varied dimensions.
   
   1. Implement a digital-first patient engagement strategy to make it easy for potential beneficiaries to learn about your plan and differentiate your brand among potential members.
   2. Better understand the barriers to care, and provide personalized engagement – across appointments, medication adherence, management, and refills – to elevate plan satisfaction.
3. Enhance outreach with HEDIS data – Retrospective HEDIS data gathering, reporting, and submission puts your plan at a disadvantage.
   
   1. Establish a structured foundation to utilize in-year HEDIS data.
   2. Pinpoint areas of improvement, segment data, and apply predictive analytics to identify high-risk members and build meaningful outreach that improves scores.
   3. Utilize various communication channels such as email, texting, outbound calls, and mail to enhance reach.
   4. Also, consider incorporating Social Determinants of Health (SDoH) data into predictive models to gauge a member’s responsiveness to specific communication methods and improve their effectiveness.
4. Empower agents through technology and training:
   
   1. Ensure your contact center associates have what they need to work effectively and efficiently. AI-driven training, knowledgebases, and workflows equip agents with the right information at the right time, enabling them to deliver personalized and empathetic member support.
   2. Utilize speech analytics to better understand member needs, identify process gaps, and provide targeted coaching to improve agent performance.

Partnering for success

During the recent Annual Enrollment Period (AEP), Medicare Advantage (MA) enrollment Dominant industry players with strong 2024 Stars Ratings – Aetna and Humana – experienced the most growth, indicating a strong correlation between Star performance and enrollment.

The growing share of MA business (MA members now constitute over 50% of all Medicare beneficiaries) presents a unique opportunity for plans to improve their Star scores and accelerate revenues. Collaborating with an agile customer experience management (CXM) partner can help plans adapt quickly in the near term while maintaining a long term perspective. ResultsCX’s CMS Task Force helps multiple MA health plans achieve this delicate balancing act by blending omnichannel engagement with empathetic human touch. Our technology-driven solutions are geared to meet the specific needs of the Medicare population, helping plans elevate their member satisfaction as well as Star performance.