The Future of Medicare Advantage Stars: Why Health Plans Should Prepare for More Than a Recalculation

Medicare Advantage organizations are entering one of the most uncertain strategic planning cycles in recent years. While Stars release and bid planning always have an intensity and baseline of assumptions, this year teams are being pushed even further as CMS recalculates Star Ratings and Quality Bonus Payments (QBPs) following the Clover Health decision.  The pressure to make multi-year decisions regarding bids, quality investments, care management programs, and product strategy without knowing what the future composition of the Stars program will ultimately look like is weighing on the industry already pressured by rising medical expense, increased operational and financial scrutiny, and wavering public sentiment. The ruling has brought into sharp focus a broader strategic challenge: how to make long-term investment decisions when the rules governing quality performance may themselves be in flux.

While much of the industry’s attention has centered on which organizations may benefit from the recalculations with the hold harmless provision in place only creating additional revenue based on improvement, the more consequential issue is what the ruling reveals about the future of the Stars program itself. For years, plans have built quality strategies, operational infrastructure, and financial forecasts around a relatively stable set of measures and methodologies – we’d typically get a few measure changes with each update. But the Clover decision? It has the potential to completely reshape the landscape.

Unlike many previous Stars program changes, the court’s decision was not based on the methodology used to calculate the measures. Rather, it challenged CMS’ authority to include certain measures in the program at all. This distinction is important because it may not be easily addressed through traditional rulemaking alone.

At the same time, CMS has stopped short of providing definitive guidance on how the affected measures will be treated in future years. As a result, Medicare Advantage organizations are left navigating several critical questions:

• Will the affected Part D measures return to the Stars program?
• How will CMS address the Part C administrative measures impacted by the ruling?
• If measures are removed permanently, how will weighting be redistributed across the remaining Stars portfolio?
• What are the implications for future Quality Bonus Payments, bid assumptions, and quality improvement investments?

The direct impact of the ruling may ultimately prove less significant than its second-order effects. Organizations may revisit quality investment priorities, reevaluate pharmacy-focused interventions, reconsider vendor relationships, and adjust assumptions embedded within future bids and financial forecasts. In that sense, the ruling’s greatest influence may not be the ratings recalculations themselves, but the strategic decisions it catalyzes across the Medicare Advantage landscape.

While uncertainty remains, health plans cannot afford to take a wait-and-see approach. Organizations are actively making decisions regarding bids, quality investments, care management programs, pharmacy strategy, and product design. The most successful plans will use this period to evaluate multiple future scenarios and prepare accordingly.

Based on our work with Medicare Advantage organizations, we believe there are four areas every health plan should be evaluating now.

1. Model Potential Future-State Stars Scenarios

The first priority is to quantify how different regulatory outcomes could affect Stars performance at the contract level. Many Medicare Advantage organizations have built their quality strategies around a relatively stable set of measures, weights, and precise improvement levers.

Rather than relying on a single projected Stars outcome, health plans should conduct structured scenario analyses that evaluate multiple regulatory and financial pathways. At a minimum, organizations should model what it looks like if all measures are removed. Compare that to your existing models and evaluate what this means for your scores and future revenue

Use the modeling to answer these questions at a minimum:

• How might recalculated ratings influence expectations at the H-contract level?
• What would these potential future Stars changes alter for your bid assumptions or revenue projections?
• What are the implications for pharmacy strategy and investment that have historically been tied to Part D performance?
• If measure weighting shifts, are there opportunities to redirect investment toward care management, population health, or other medical benefit programs with broader strategic value?
• How could different Stars scenarios influence product strategy, benefit richness, and market competitiveness?

The objective is not to predict CMS’ next move, but to understand where performance is most vulnerable, where it is most resilient, and how different regulatory scenarios could affect both quality and financial performance.

For some organizations, this analysis may validate current priorities. For others, it may reveal that measures historically viewed as secondary become increasingly important under future methodologies. Either way, it enables leaders to make investment decisions based on analysis rather than assumptions.

2. Reassess Existing Programs and Intervention Strategies

Periods of regulatory uncertainty create an opportunity, and in many cases a necessity, to revisit long-standing assumptions about where quality improvement resources are deployed.

Over the past decade, many Medicare Advantage organizations have built intervention strategies, vendor relationships, staffing models, and member engagement programs around specific Stars measures and weighting methodologies. If those structures change, plans should evaluate whether current investments remain aligned with the performance drivers most likely to matter in the years ahead

Organizations should consider several important questions:

• Where are the most significant performance gaps across HEDIS, CAHPS, and HOS?
• Which programs create measurable value regardless of future Stars methodology changes?
• Which interventions were developed primarily to improve the affected Part D measures?
• If those measures do not return, how can you leverage existing resources and staffing to refocus?

For organizations that have made substantial investments in pharmacy-focused Stars programs, these questions are particularly important – and so is caution in making any major decisions when considering scaling down any programs. If future Stars methodologies place greater emphasis on clinical outcomes, member experience, functional status, or care coordination, plans may need to reassess whether existing investments are aligned with future performance opportunities.

The objective is not to reduce investment in quality improvement. Rather, it is to ensure that investments are directed toward capabilities that create sustainable value across multiple measures, populations, and regulatory scenarios. Organizations that use this period to critically evaluate their intervention portfolios will be better positioned to adapt regardless of how the Stars program evolves.

3. Develop Contingency Plans Around High-Opportunity Measures

While uncertainty remains regarding the future composition of the Stars program, not all measures carry the same strategic significance. Certain measures are likely to remain closely aligned with CMS’ broader objectives around quality, outcomes, member experience, and cost containment, regardless of future regulatory adjustments.

As a result, health plans should focus on strengthening capabilities in areas that are likely to remain durable drivers of both Stars performance and organizational success. These might include:

Rather than building contingency plans around individual measures alone, organizations should focus on developing the underlying capabilities that drive performance across multiple domains. In many cases, the same investments that improve member outcomes, experience, and care coordination today will remain valuable regardless of how future Stars methodologies are ultimately structured.

From Measure Optimization to Capability Building

The Clover ruling is often discussed in terms of measures, weighting, and Star Ratings. However, the more important question may be whether health plans have built sustainable organizational capabilities or simply optimized for the current version of the Stars program. The organizations best positioned for long-term success will focus less on optimizing individual measures and more on building capabilities that create value across multiple measures, populations, and regulatory environments.

Organizational Capability	Questions to Address
Care Coordination	How do you manage transitions of care across the continuum? Where can you strength the process to prevent complications and readmissions?
Chronic Disease Management	Are you leveraging every opportunity and data source to obtain results for A1c and BP readings? Are you addressing upstream causes of outcomes?
Member Engagement	How do you take ownership of survey results with real operational changes? Are you getting feedback on what needs to change from the right places?
Provider Performance Management	Do you put resources toward providers that are willing and able to improve? Are you making it easy to get credit for care gap performance? Are you coordinating quality discussions with medical management?
Population Health Analytics	Do your systems enable value-based care performance management? Have you recently evaluated your risk stratification as populations behaviors are shifting?
Care Management Infrastructure	How connected are your Care Management and Quality teams? Does Care Management regularly see Quality data to take action or are you waiting too long between discussions?

Care coordination, chronic disease management, member engagement, provider performance management, analytics, and population health infrastructure create value that extends far beyond any individual measure or ratings year. These capabilities improve outcomes, strengthen member experience, support financial performance, and position organizations to adapt as regulatory requirements evolve.

Viewed through this lens, the Clover ruling is not simply a question of whether certain measures return to the Stars program. It is a test of how adaptable a health plan’s quality strategy truly is. Organizations that have built durable capabilities will be better positioned to navigate future changes, regardless of how CMS ultimately restructures the program.

At COPE Health Solutions, we help Medicare Advantage organizations translate this philosophy into action. Through Stars analytics, population health strategy, care management transformation, quality improvement, and value-based care enablement, we help plans strengthen the operational and analytical foundations that drive sustainable performance across a range of regulatory and market scenarios.

Preparing for What Comes Next

The Clover ruling has introduced a degree of uncertainty that extends far beyond a single ratings cycle. While future CMS guidance will undoubtedly provide greater clarity, organizations should resist the temptation to postpone strategic decisions until every question has been answered.

The organizations best positioned for success will be those that use this period to deepen their understanding of performance drivers, reassess long-standing assumptions, and build flexibility into their Stars, financial, and population health strategies.

Regardless of how CMS ultimately addresses the affected measures, the underlying determinants of success remain largely unchanged. Organizations that excel in care coordination, chronic disease management, member experience, provider engagement, and operational execution will continue to be well positioned to succeed in an increasingly competitive Medicare Advantage market.

The Clover ruling may ultimately be remembered less for the recalculations it produced for a single Stars year than for the strategic questions it forced organizations to confront. In an environment where regulatory certainty is increasingly difficult to predict, the ability to evaluate risk, adapt investments, and align organizational priorities may become as important as performance on any individual measure. The plans that emerge strongest from this period may not be those that benefited most from the immediate recalculation. They will be the organizations that used this moment to reassess long-held assumptions, strengthen core capabilities, and build the strategic flexibility required to succeed regardless of how the Stars program evolves.