SY2025 Data Insights

The Centers for Medicare & Medicaid Services (CMS) released the 2025 Star Ratings for Medicare Advantage plans on October 10th, 2024.

Following the dramatic impact of Tukey outlier deletion in Star Year 2024, Star Year 2025 didn’t face the uncertainties or shock in methodology, but instead we realized an upswing in cut points and knock-on effect of Tukey and compressed distribution of scores. The guardrails, restricting the majority of measure cut point movement (+/- 5 pts) was in place and had impacts on performance. In a year over year trend, the MA-PD contract enrollment weighted average Star rating decreased and faced one of the lowest levels in nearly a decade – shifting from 4.07 to 3.92.

The ratings also showed that 40% of MA-PD plans earned an overall rating of 4 stars or higher for Star Year 2025, down slightly from 42% in Star Year 2024. When weighted by enrollment, 62% of MA-PD enrollees are currently in 4+ Star plans for Star Year 2025 which is a significant drop to last year’s 74%.

Seven MAPD contracts earned 5 stars, marking them as highest quality "high performing" plans. CMS highlighted these plans on the Medicare Plan Finder website to help beneficiaries identify top-rated options. This is a stark reduction from the 38 5-star plans in 2024. MAPD plans with longer tenure also scored higher relative to newer plans, with five of the seven 5-Star plans being established programs for 10+ years. We’ve seen the number of 5-Star plans decrease steadily over the past few years, but with the removal of the reward factor starting in SY26 and the introduction of the health equity index, achieving that 5 Star mark will likely continue to prove more and more difficult.

Our team put together our SY2025 Insights and Analysis to begin to “tell the story” for SY2025. If you have any questions or are curious to speak about your plans Star Rating and how we can help improve.

Rating Swing Distribution from Prior Year¹

Graph Description:

• Compares Health Plans Overall Star Rating between SY2024 and SY2025.
• Only includes Local CCP, Regional CCP, PFFS and 1876 Cost. Excludes MSA, PDP, Employer Group.
• Excludes Contracts that did not have a Star Rating in SY2024 or did not have enough data available.

Distribution of Star Rating SY2024 and SY2025¹

Graph Description:

• Identified the total count of contract that received a Star Rating in Star Year 2024 and Star Year 2025 and shows the distribution over each year.
• Only includes Local CCP, Regional CCP, PFFS and 1876 Cost. Excludes MSA, PDP, Employer Group.
• Excluded any plans that were too new to be measured, not enough data available, or not applicable.

Distribution of Domain Level Performance

Using the data presented in the tables below, our team conducted a comprehensive analysis on the distribution of an overall plan ratings in correlation with a plan's performance in five domains: CAHPS, HEDIS, Pharmacy, Operations and HOS.

Key Highlights:

• The Operations domain demonstrated a more concentrated performance range for high-performing plans, with 75% of 4.0+ Star plans achieving a score of 4.0 or higher in the designated measures.
• In order to achieve 4.0+ Stars, plans were required to succeed in CAHPS. Of the 189 plans that received a 4.0+ star, 82% of them had a minimum CAHPS scoring average of 3.5 Stars.
• In line with CMS methodology weighting, HEDIS, Pharmacy, and HOS showed a more expected spread in overall health plan performance based on the domain's average rating.

In summary, the health plan operations domain stands out as a consistent and influential factor driving higher Star ratings for health plans. With the shift in weighting, away from the 4x in the member experience focused measures in operations (e.g., Members Choosing to Leave the Plan, Complaints, and TTY/FLI) how will performance be impacted for SY26? A strong focus on HEDIS and HOS will be required especially with the return of the two tripled weighted (x3) Improving/Maintaining Physical/Mental Health measures in HOS for SY2027.

As we enter the final stretch of the performance year SY2026, it is essential to place significant emphasis on the efforts of Q4. Health plans should arrange all available resources and make every effort, giving special attention to driving improvements in HEDIS performance. This Q4 push can act as an additional safeguard prior to the CAHPS survey distribution in March 2025. The MA marketplace faces many headwinds, including benefit reductions across many of the plans and how health plans communicate these changes broadly to their membership could have a significant impact on CAHPS results.

As we look ahead to the future of Stars and the “new normal” we continue to see tremendous value in investing in digital measurement transformation, electronic clinical data systems optimization, interoperability and health data exchanges. The industry will continue to shift this way and the health plans that invest now in this will end up being the biggest winners, long term.

Plan Count by Overall Rating & Average CAHPS Rating^1,2,3

Graph Description:

• ProspHire categorizes the CAHPS domain based on the following 9 measures: Annual Flu Vaccine, Getting Needed Care, Getting Appointments and Care Quickly, Customer Service, Care Coordination, Rating of Heath Care Quality, Rating of the Health Plan, Rating of the Drug Plan, Getting Needed Rx Drugs
• Measures that were noted by CMS as ‘Not enough data available’, ‘No data available’, ‘Plan too small to measure’ did not count in the domain calculation per plan due to CMS methodology of excluding those measures in the overall Star rating calculation.
• Totals will vary across graphics as some health plans may not have been able to score for some domain categories due to unavailable data as noted in item 2.

Plan Count by Overall Rating & Average HEDIS Rating^1,2,3

Graph Description:

• ProspHire categorizes the HEDIS domain based on the following 13 measures: Breast Cancer Screening, Colorectal Cancer Screening, Care for Older Adults - Medication Review, Care for Older Adults - Pain Assessment, Osteoporosis Management in Women who had a Fracture, Diabetes Care - Eye Exam, Diabetes Care - Blood Sugar Controlled, Controlling High Blood Pressure, Medication Reconciliation Post-Discharge, Plan All-Cause Readmissions, Statin Therapy for Patients with Cardiovascular Disease, Transitions of Care, Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions
• Measures that were noted by CMS as ‘Not enough data available’, ‘No data available’, ‘Plan too small to measure’ did not count in the domain calculation per plan due to CMS methodology of excluding those measures in the overall Star rating calculation.
• Totals will vary across graphics as some health plans may not have been able to score for some domain categories due to unavailable data as noted in item 2.

Plan Count by Overall Rating & Average Pharmacy Rating^1,2,3

Graph Description:

• ProspHire categorizes the Pharmacy domain based on the following 5 measures: Medication Adherence for Diabetes Medications, Medication Adherence for Hypertension (RAS antagonists), Medication Adherence for Cholesterol (Statins), MTM Program Completion Rate for CMR, Statin Use in Persons with Diabetes (SUPD)
• Measures that were noted by CMS as ‘Not enough data available’, ‘No data available’, ‘Plan too small to measure’ did not count in the domain calculation per plan due to CMS methodology of excluding those measures in the overall Star rating calculation.
• Totals will vary across graphics as some health plans may not have been able to score for some domain categories due to unavailable data as noted in item 2.

Plan Count by Overall Rating & Average Operations Rating^1,2,3

Graph Description:

• ProspHire categorizes the Operations domain based on the following 10 measures: Special Needs Plan (SNP) Care Management, Plan Makes Timely Decisions about Appeals, Reviewing Appeals Decisions, Call Center - Foreign Language Interpreter and TTY Availability, Complaints about the Health Plan, Complaints about the Drug Plan, Members Choosing to Leave the Plan – Part C and Part D, MPF Price Accuracy.
• Measures that were noted by CMS as ‘Not enough data available’, ‘No data available’, ‘Plan too small to measure’ did not count in the domain calculation per plan due to CMS methodology of excluding those measures in the overall Star rating calculation.
• Totals will vary across graphics as some health plans may not have been able to score for some domain categories due to unavailable data as noted in item 2.

Plan Count by Overall Rating & Average HOS Rating^1,2,3

Graph Description:

• ProspHire categorizes the Health Outcome Survey (HOS) domain based on the following 3 measures: Reducing the Risk of Falling, Improving Bladder Control, Monitoring Physical Activity
• Measures that were noted by CMS as ‘Not enough data available’, ‘No data available’, ‘Plan too small to measure’ did not count in the domain calculation per plan due to CMS methodology of excluding those measures in the overall Star rating calculation.
• Totals will vary across graphics as some health plans may not have been able to score for some domain categories due to unavailable data as noted in item 2.