CMS Proposed Changes in Medicare Advantage: Key Updates, Tips, and Strategies for Star Ratings Success

The Biden administration’s final proposed rule for Medicare Advantage (MA), under the leadership of Chiquita Brooks-LaSure, delivers a sweeping set of modifications and new proposals. Some of these changes, particularly those addressing health equity, are already being labeled as “woke” by critics, likely including those aligned with the Trump administration. As we look ahead to potential political shifts, many wonder whether new, equity focused methodologies like the Health Equity Index (HEI) will survive long-term or be snuffed out within a year or two.

For plans, the message is clear: be nimble, prepared to pivot, and ready to act depending on what becomes codified. Equally important, this is an opportunity to submit comments on proposals that may not align with best practices or could unfairly disadvantage your plan.

Here’s what’s on the table:

Prior Authorization and Utilization Management

CMS aims to improve transparency and fairness in prior authorization practices and increase member awareness of appeal rights. Plans will also face new reporting requirements for initial coverage decisions and appeals.

• Star Ratings Insight: More awareness of appeal rights could mean more appeals, which will affect Part C timeliness and fairness measures. Plans not currently reporting these measures might find themselves suddenly included. It’s critical to have processes in place to handle increased volumes accurately and efficiently—at 2X weight each, these aren’t metrics to fall behind on.

Artificial Intelligence (AI)

CMS proposes that MA plans ensure equitable service delivery and avoid bias in AI tools, particularly those used for clinical decision-making.

Coverage of Anti-Obesity Medications

CMS is proposing coverage for anti-obesity medications, recognizing obesity as a chronic disease, but will exclude coverage for weight loss medications for those who are not obese.

• Star Ratings Insight: Expanding coverage for anti-obesity medications could exacerbate a current issue with GLP-1s prescribed for weight loss. Members without diabetes who are prescribed these medications are sometimes incorrectly included in Part D Star measures like diabetes adherence and SUPD (Statin Use in Persons with Diabetes), where two diabetes medication fills are enough to trigger inclusion.

If CMS moves forward with this coverage, plans must advocate for updated exclusionary criteria to prevent non-diabetic members from entering these measure denominators unfairly. Otherwise, adherence rates could tank—hurting Star Ratings unnecessarily.

Provider Directories on Medicare Plan Finder

CMS proposes requiring MA plans to make provider directories available on Medicare Plan Finder, including attestations of their accuracy and consistency. Directories would need to be updated promptly and remain searchable as provider information changes.

• Star Ratings Insight: Provider directories are already a significant challenge for plans to maintain accurately. Increased visibility on Medicare Plan Finder could lead to more member complaints if inaccuracies arise, which could negatively impact the 2x weighted Complaints about the Health Plan Star measure.
• Additionally, CMS has previously indicated interest in introducing a provider directory accuracy measure for Star Ratings in historic proposed rules. Plans should proactively strengthen their processes for updating and auditing provider directories to minimize errors, reduce complaints. Now is the time to make provider directory accuracy a priority—both to avoid immediate complaints and to future-proof against potential changes to Star Ratings.

Supplemental Benefits via Debit Cards

CMS proposes requiring transparency and alternative benefit access methods if card issues arise. Flashy marketing of dollar values tied to benefits would also be prohibited.

Medicare Prescription Payment Plan (M3P)

This voluntary program would allow members to spread annual drug costs across the year. CMS is proposing that members who don’t opt out would be auto-renewed.

Behavioral Health Access

CMS proposes $0 cost-sharing for opioid treatments, cost caps for inpatient psychiatric services, and alignment of behavioral health cost-sharing with traditional Medicare.

• Tip: These changes could support improved performance on two proposed Part D Star measures, potentially debuting in 2028: Initiation and Engagement of Substance Use Disorder Treatment (IET) and Initial Opioid Prescribing for Long Duration (IOP-LD). Plans should align outreach and provider education efforts now to prepare for these measures.

Star Ratings Updates

CMS’s proposed changes to Star Ratings introduce several significant updates and new measures, offering both challenges and opportunities for plans to refine strategies and improve performance. Here’s a breakdown of the key proposals and insights for plans looking to stay ahead.

New Measures

Initiation and Engagement of Substance Use Disorder Treatment (IET) – Part C

• Implementation: Proposed for the 2028 Star Ratings (2026 measurement year).
• Details: This composite measure evaluates initiation and engagement rates for substance use disorder (SUD) treatment. It has transitioned from a member-based approach to an episode-based approach, where each recovery attempt counts independently. Scores for initiation and engagement rates will be displayed separately, with an averaged composite score used for Star Ratings.
• Tip: Leverage behavioral health cost-sharing changes (if codified) to drive engagement. Build workflows to track multiple recovery attempts and enhance care coordination with behavioral health providers. Early preparation will be essential to accurately measure and report on engagement.

Initial Opioid Prescribing for Long Duration (IOP-LD) – Part D

• Implementation: Proposed for the 2028 Star Ratings (2026 measurement year).
• Details: This measure evaluates the percentage of Part D beneficiaries receiving an initial opioid prescription exceeding 7 cumulative days’ supply. It excludes beneficiaries with cancer, sickle cell disease, hospice, or palliative care.
• Tip: Develop strategies to educate providers on safe opioid prescribing practices. Integrate opioid safety edits and ensure pharmacy teams are equipped to address exceptions while adhering to guidelines. Member outreach on opioid safety and available alternatives may also support compliance. Work these best practices into your SNP care management HRA, ICPs and MOCs!

Revised Measures

Breast Cancer Screening (BCS)

• Changes: The age range for biennial mammography screening is expanding from 50-74 to 40-74, in alignment with updated U.S. Preventive Services Task Force (USPSTF) guidelines. The updated measure will appear in Star Ratings starting in 2029, with dual reporting of legacy and updated measures during the transition.
• Tip: Identify newly eligible members (ages 40-49) through data analytics and target them with outreach campaigns. Collaborate with providers to close gaps for this expanded population and prepare systems for dual reporting requirements. This includes ensuring readiness to collect and report data for both the legacy measure (50-74) and the updated measure (40-74) simultaneously during the transition period.
• Considerations for SNP and Dual Contracts: This change may have a greater impact on 100% SNP and Dual contracts, which often have a disproportionately high number of members under age 65. These members frequently face significant disabilities or chemical dependency challenges, pushing preventive care like mammography screenings to the back burner. Plans should analyze their data to assess performance for this younger age band and determine how the expansion might negatively impact them. If this disproportionality creates significant challenges, plans should consider submitting comments to CMS advocating for adjustments that reflect the unique needs of their populations.

Plan Makes Timely Decisions about Appeals

• Changes: CMS proposes eliminating the 5-day grace period for electronically submitted appeals (via secure portals) beginning January 1, 2025, impacting the 2026 measurement year and inclusion in the 2029 Star Ratings. Appeals submitted electronically will use the actual date and time of submission as the receipt date, even outside business hours. The 5-day grace period will remain in place for appeals submitted by mail.
• Impact on Plans: This change aligns with CMS’s focus on streamlining processes and increasing accountability for appeals. Plans will need to ensure that electronic submissions meet updated timeliness standards to avoid penalties.
• Tip: Plans should review their current appeal processes to ensure electronic submissions are handled promptly and accurately, particularly for cases submitted close to deadlines. Implementing system flags to monitor submission times and training staff on updated policies can help maintain compliance. Additionally, plans should consider internal audits to confirm alignment with CMS's new requirements, reducing the risk of performance dips tied to late or incomplete appeals.

 Health Equity Index (HEI)

• CMS proposes methodological adjustments to the HEI rewards (which incentivizes equity-focused efforts), including adjustments for contract consolidations, eligibility for D-SNP/I-SNP-only contracts, and penalties for data discrepancies.
• The Big Question: Will HEI last? Critics suggest it may not survive in its current form, with many predicting it could be deprioritized under a new administration. However, focusing on health equity is a strategic win for Star Ratings regardless of what happens to the HEI reward component. Underserved subsets of the population often drive lower performance on key measures, so improving outcomes for these groups directly boosts overall ratings while aligning with equity goals.
• Plans should use the current HEI framework to identify disparities in performance and address gaps, knowing these efforts will strengthen ratings across measures—whether HEI remains or not.

 Key Takeaways for Plans:

• Stay agile and ready to adapt. The proposed rule includes measures that could face political pushback and regulatory shifts.
• Use the comment period to highlight potential pitfalls, advocate for fairness, and align rules with real-world best practices.
• Build systems and workflows now that are flexible enough to pivot, ensuring you’re prepared for any scenario—whether these proposals stick or not.

Bottom Line: Do the right thing for the members you serve, and the Stars will align on their own! 😊