New Model for How Plans Must Operate
Every few years, CMS issues a rule (or rules) that change requirements – sometimes drastically.
However, it’s not often that CMS signals a philosophical shift. The CY2027 proposals are one of those moments.
Behind the technical updates is a clear message:
Medicare Advantage must move closer to actual clinical value and farther from administrative throughput.
Measures that reward documentation (which can be a complex and expensive process) rather than health change (which can be even more expensive and complex) are being reduced.
Processes that once insulated plans from volatility are being reshaped, and incentives are being rebalanced to favor organizations that can demonstrate real improvement in member outcomes.
The next two years allow plans time to adapt, but the direction of travel is clear.
So, what does this all mean for Medicare Advantage plans? Let’s explore…
Stars: A Return to Meaningful Variation and Real Influence
CMS is resetting the purpose of Star ratings by removing 12 process measures and reducing weight on metrics without meaningful performance differences.
The program is refocused on outcomes that represent true plan impact: control of chronic disease, follow-up after behavioral health needs, access, experience, and preventive care that actually happens.
With an emphasis on “actually happens”.
“CMS estimates that these changes would not impact overall ratings for 62% of contracts.
Overall ratings would increase by a half star for 13% of contracts, decrease by a half star for 25% of contracts, and decrease by one star for one contract.
Additionally, 5% of contracts would gain quality bonus payments, while 4% would lose quality bonus payments.”
This shift eliminates much of the “noise” that made Stars a game of operations rather than a reflection of members’ health experience.
It places pressure on plans to influence what happens in clinical settings and not just in supplemental workflows after a member visit.
The following quality measures are being eliminated and may negatively impact Star Ratings if health plans continue prioritizing them:
- Diabetes Care – Eye Exam
- Statin Therapy for Patients with Cardiovascular Disease
- Special Needs Plan (SNP) Care Management
The takeaway: In this new model, plans must shape care, not paperwork.
The Compliance-Operations Gap
CMS’s proposed Special Enrollment Period tied to provider terminations introduces something Medicare Advantage has tried to avoid – real-time churn risk.
On average, MA members churn at roughly 10% year over year (YoY); this increases the pressure level.
If a provider leaves the network, the member now has the right to leave as well…right?
This reframes provider stability as part of member stability and positions communication efficiency and efficacy as a competitive differentiator.
Plans that understand how members interact with their providers, and which members are most sensitive to change, will be better positioned to protect continuity of care and avoid unnecessary/avoidable turnover.
Plans without that visibility will experience a spike in unplanned disruption.
This represents a subtle but important shift: network management is no longer an internal contracting issue or even just a CMS compliance check box. It is a member experience issue.
Risk Adjustment Is Quickly Moving Toward Clinical Evidence
Chart reviews and supplemental data will no longer be a strategic backbone for risk adjustment.
CMS wants primary-source clinical documentation, EMR-level evidence, and real-time capture, not retrospective reconstruction of care.
Through the RFIs, CMS is signaling the next evolution of risk adjustment:
- Less reliance on coding intensity
- More reliance on clinically validated diagnoses, backed up by appropriate documentation
- More interest in EMR data, labs, notes, and functional measures
- Desire to create a level playing field between large incumbents and newer plans
Few topics in MA have been as distorted over time as risk adjustment.
What began as a tool for risk stratification eventually became a tool for revenue recovery.
CMS is now pulling RA back into its original clinical role.
This approach rewards plans that understand real clinical activity in real-time (or near-real time), not months later.
It also rewards solutions that can connect the dots between risk, quality, and member stability as those domains are increasingly inseparable.
In a clinical evidence–driven risk model, RAF will move more sharply year-to-year.
Plans must strengthen prospective risk forecasting to maintain financial stability.
Behavioral Health Moves From Programmatic to Foundational
As an example, the addition of Depression Screening + Follow-Up is the first indication of something larger:
CMS is embedding behavioral health into the core of MA performance.
Chronic disease control, medication adherence, and preventive care are already intertwined with behavioral needs.
Now the measurement system is catching up.
In practice, this will force plans to treat behavioral health integration as basic infrastructure, not as a specialty program.
It will require closer collaboration with primary care, better visibility into screenings and follow-ups, and an understanding of members’ behavioral barriers to completing care.
This also marks a shift away from measuring what was ordered and toward measuring what occurred.
The Competitive Landscape Will Reset
Breaking down silos isn’t a middle-management project. It requires leadership understanding and support.
Leaders need to grasp the resource implications of RADV audits—not just financial resources, but human capacity, cross-functional coordination, and time. They need to understand how many moving pieces exist and how those pieces must work together seamlessly.
When leadership understands this complexity, they can make informed decisions about policies, staffing, technology investments, and organizational design that support integrated audit response rather than perpetuating silos.
The Competitive Landscape Will Reset
Taken together, these changes reshape how plans will compete:
- With fewer process measures, scoring becomes harder.
- With outcomes weighted more heavily, variation will be more meaningful.
- With risk adjustment grounded in clinical activity, retrospective strategies will diminish. Prospective will rule the day.
- With member churn tied to provider events, network strategy becomes a retention strategy.
- With behavioral health woven into core metrics, integration becomes essential.
The plans that succeed will not necessarily be the largest or the most resourced.
They will be the ones that can adapt quickly—those with connected data, aligned clinical and operational strategies, and the ability to recognize member needs early.
How Plans Should Think About CY2027 Now
This moment calls for more than compliance checklists.
It calls for a rethinking of how MA programs are structured, staffed, and measured.
Prepare for Member Volatility
Plans should develop the ability to identify members most likely to churn when their provider relationship is disrupted and understand which of those churn events carry the greatest clinical and financial consequence.
Shorten the Distance Between Care and Awareness
Claims data alone cannot support a measurement system designed around real care.
Plans will need to use EMR data, unstructured notes, and clinical evidence to close the latency gap and understand what occurred when it occurred.
Align Risk and Quality Around Outcomes, Not Processes
Future performance depends on seeing the member holistically: their chronic conditions, quality gaps, behavioral health needs, and continuity of care.
Strategies built in isolation will underperform.
Build Provider Engagement Models That Prioritize Impact, Not Volume
Provider Workflow Enablement Becomes the Central Strategy.
Plans will need Prospective member-level prioritization to intervene where it matters most.
Not all gaps carry equal weight in Stars or risk. Not every member is equally sensitive to disruption. Knowing the difference will define the winners.
Plans will need to support providers with:
- Point-of-care documentation alerts
- Integrated EMR workflows (not portals)
- Clinical evidence suggestions
- Gap visibility inside the visit workflow
- Real-time feedback loops
- Streamlined chart submission pathways
Success will depend on whether providers can document correctly the first time—not whether the plan can fix it later.
The integration of risk adjustment, quality, behavioral health signals, and EMR-sourced clinical evidence is not a “nice to have” anymore.
It is the foundation.
The shift toward digital quality measurement (dQMs) by 2027–2028 will force plans to unify clinical, claims, EMR, and social data into a single longitudinal member record.
As CMS moves toward models that require real-world clinical visibility, connected member insights, and early detection of instability, we are aligned with both the spirit and the letter of the proposals.
CY2027 is not just a policy update.
It is a blueprint for a more clinically grounded Medicare Advantage system.
It rewards plans that can understand their members earlier, act more precisely, and measure impact more honestly.
And it challenges all of us to build a model that reflects what matters most: Whether members actually get the right care, at the right time, in a way that meaningfully improves their health.
