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Sharalee is the senior director of population health at Vatica Health.

Health plans experienced some of the most significant Star score drops in recent history. The average enrollment-weighted Star rating for MA-PD plans decreased from 4.07 in 2024 to 3.92 in 2025. Only seven MA-PD plans hold the coveted 5-Star rating. The declining performance is primarily due to model changes and an increase in cut points. 

According to a whitepaper by the Wakely Consulting Group, this decline translates to an estimated $4-5 billion loss in quality bonus payments for health plans in 2026, increasing the urgency to make adjustments. The impact was further exacerbated by a 15% rise in cut point thresholds from 2024 to 2025, as reported by the Centers for Medicare & Medicaid Services (CMS).   

Model changes were primarily driven by updates to the CMS Star ratings methodology. One key effect is the recalibration of performance metrics. In 2025, CMS implemented a revised weighting system that places greater emphasis on clinical outcomes and member experience, reducing the influence of process measures by approximately 20%, according to the 2025 CMS Technical Notes. 

In response, plans are hard at work. Remediation strategies include employing new solutions and technology, segmenting membership to provide better focus and collaborating with their provider networks.  

But one important lever is sometimes overlooked. Accurate risk adjustment is foundational to ensuring that Star ratings reflect true quality, rather than differences in member health. Accuracy ensures CMS appropriately compensates plans for managing complex populations, rewarding those that deliver superior care despite higher patient acuity.   

For example, clinical measures such as hospital readmissions and care for those with diabetes can be skewed for plans serving less healthy populations. A plan with a high proportion of diabetic members might see a 10% higher readmission rate compared to the national average, unfairly lowering its Star score without proper risk adjustment. For certain Part D measures such as medication adherence for diabetes, hypertension and cholesterol, plans serving more complex or higher risk populations might appear to perform worse. Risk adjustment can mitigate disadvantages for those serving sicker beneficiaries.  

The oversight regarding risk adjustment’s role in Star scores is likely due in part to the fact that this responsibility generally falls under the finance department while quality is under the purview of the clinical team in most health plan organizational structures.  

Whose job is it? 

Boosting Star scores requires a team effort. Quality must be the priority for everyone: risk adjustment, quality, care management, provider relations, analytics, P & L leadership, even customer service. For example, analytics teams can identify at risk populations, while care managers ensure followup.  A cross-functional team is best positioned to pull every available lever to boost risk adjustment accuracy and Star scores.   

The good news is that significant synergies exist when the focus is on both quality and risk adjustment. Interactions with members should focus on addressing and documenting existing conditions as well as closing care gaps. Here are some of the benefits: 

• Efficiency for both the health plan and providers when outreach activities and office visits aim to identify risk-adjustable diagnoses as well as close care gaps. 

• Decreased provider abrasion when the health plan contacts the provider just once with a comprehensive list of relevant conditions and open care gaps. 

• Decreased member abrasion when the health plan supports the PCP with accurate data and care management services. Members benefit from an effective, efficient visit that addresses their health concerns and provides resources such as disease management programs and support to address social determinants of health.  

• Driving additional outcomes when the health plan conducts just one comprehensive outreach to the provider, the provider can be prepared to address all conditions and care gaps during the patient visit. That’s likely to result in greater member satisfaction. The Stars member satisfaction measures can be challenging for plans to impact; this is one way plans can have a positive effect.  

Don’t go it alone 

One of the biggest challenges health plans face in this effort is data: gathering accurate information and sharing it with providers in an actionable format. Resources like Vatica Health’s proprietary platform provide actionable insights by combining clinical data with claims data, helping plans and providers address care gaps efficiently. Unlike most tech-only solutions for risk adjustment, Vatica employs clinicians who review data gathered from the EMR, health plan and other relevant sources. This process ensures only relevant diagnoses and care caps are presented to providers.  

The result? Accurate risk adjustment for health plans, improved performance with HEDIS and Star measures, less administrative burden for providers and better outcomes for members. Find more information about Vatica’s resources here.