LUGPA Policy Brief – Medicare Advantage Star Ratings and Proposed CMS Reforms

December 2025

The Medicare Advantage (MA) Star Ratings program evaluates plan quality on a 1–5 scale across up to 43 measures. These ratings drive bonus payments, shape benefit design, influence network participation, and ultimately affect patient access. With more than 33 million beneficiaries enrolled in MA, any change to the ratings methodology has direct implications for independent physician practices—including LUGPA groups.

On November 25, 2025, CMS released a proposed rule outlining major changes to the Star Ratings methodology for Contract Year 2027. Because MA plan bids and contracting strategies rely heavily on these ratings, updates to scoring, measure weighting, and clinical expectations may have significant downstream impacts on both practices and patients.

Key Proposed Changes to Star Ratings

• Adjustment to Health Equity Incentives

• CMS will not implement the previously planned 2027 Health Equity Index.
• Instead, existing incentives for strong and consistent performance across all measures will remain in place.

• Streamlining the Measure Set

• Twelve low-variation measures—such as customer service and appeals timeliness—would be removed to reduce administrative burden.
• A new clinical measure for depression screening and follow-up would be added beginning with the 2029 ratings cycle.

• Greater Flexibility for Beneficiaries

• CMS proposes allowing beneficiaries to switch plans mid-year when a contracted provider leaves the network—potentially reducing care disruptions.

• Ongoing Review of Coding and Risk Adjustment

• CMS is seeking input on strategies to curb coding intensity and strengthen the integrity of risk adjustment.
• Federal oversight bodies continue to scrutinize coding-related payment practices across MA plans.

Fiscal Impact: CMS estimates the proposed changes will increase MA program costs by $13 billion over 10 years.

Additional trends:

• Only 86 plans scored 4.5+ stars (down from 96 in 2022).
• Nonprofit plans continue to outperform for-profit plans (4.18 vs. 3.99 average).
• Major insurers—including Humana, UnitedHealth, and Centene—saw notable declines, affecting bonus payments and plan stability.
• Roughly 1% of beneficiaries remain in plans below 3 stars, which may face sanctions.
• Higher cut points and increased weighting of clinical measures (e.g., readmissions) contributed to lower scores.

For providers, these declines may influence contracting leverage, supplemental benefits, and patient access.

Implications for Independent Urology Practices

• Plan Stability and Patient Access

Falling ratings may prompt benefit reductions, narrower networks, or shifts in enrollment—potentially affecting continuity of care for urology patients.

• Contracting and Performance Expectations

Plans trying to improve scores may impose more rigorous expectations for quality reporting, documentation, and care coordination from contracted providers.

• Risk Adjustment and Coding Requirements

With increased scrutiny of coding intensity, practices may face tighter documentation standards, more frequent audits, and evolving policies affecting MA reimbursement flows.

• Reduced Care Disruptions

The proposal allowing mid-year plan switching when a provider leaves a network could help maintain continuity of care for patients treated by independent groups.

Bottom Line for LUGPA Practices

MA enrollment growth has leveled off as policymakers intensify oversight of coding, prior authorization, and program spending. CMS’s proposed updates aim to simplify the Star Ratings system, strengthen clinical measurement, and stabilize the program—but further reforms may require congressional action.

For LUGPA practices, tracking MA plan performance in local markets and maintaining strong, measurable quality metrics will be critical as plans prepare 2027 bids and adjust to the evolving Star Ratings framework.