CY 2027 Star Ratings, HEDIS & Quality FAQ

Because the bar moved more than you did. For the draft 2027 Star Ratings, half of all cut points rose, almost entirely on HEDIS measures: Kidney Health Evaluation moved 7 to 10 points, Colorectal Cancer Screening 4 to 11 points, Controlling Blood Pressure 4 to 5 points. A practice that held a 72% blood pressure control rate may now sit below the threshold the plan needs from its network. Plan incentive contracts are written against those thresholds, so the same performance pays less.

What stopped mattering are administrative measures you never controlled: call center, appeals, complaints, disenrollment, and two CAHPS items. What is left is clinical and lands in your exam room: Controlling Blood Pressure, Diabetes glycemic control, Kidney Health Evaluation, Eye Exam (chart review no longer counts), breast and colorectal screening, three medication adherence measures, and the new Functional Status Assessment, Polypharmacy, and Opioid-Benzodiazepine measures. The two HOS survey measures, Improving or Maintaining Physical Health and Mental Health, now weigh 3x, and Depression Screening and Follow-Up arrives for the 2029 ratings.

For measurement year 2026, the three Part D adherence measures (diabetes medications, RAS antagonists, statins) add sociodemographic risk adjustment and drop the inpatient and SNF stay adjustments. A practice with a low-income or dual-eligible panel will be judged against an adjusted expectation, which helps. But the adjustment removes the excuse: a plan can no longer accept poor adherence in your panel as a patient-mix problem, and it will bring adherence targets into your contract. These measures return to 3x weight in the 2029 ratings.

The HOS physical and mental health measures now weigh 3x, are fielded by mail and phone only, and compare a patient's own answers two years apart. CAHPS is web, mail, then phone. Neither survey has a workflow you can chart, but both are driven by things you do control: whether the patient feels their chronic conditions are managed, whether they got timely appointments and clear answers, whether someone followed up after a hospital stay, and whether they could communicate in their language.

For the plan, a half-star drop below 4 stars removes the 5% quality bonus and reduces the rebate share from 65% to 50% of the bid-benchmark difference; the average bonus in 2026 is $381 per enrollee in individual plans, and only 68% of enrollees are in bonus-status plans, down from 75%. Plans pass that through as withholds, tighter incentive tiers, and benefit cuts that push members to switch. For a capitated practice on a percent-of-premium deal, the plan's lost bonus is your lost premium base.

NCQA is retiring chart-sample (hybrid) reporting: Statin Therapy measures went ECDS-only in MY2026, Controlling Blood Pressure and Blood Pressure Control for Diabetes move to ECDS in MY2028, Glycemic Status, Transitions of Care, and Care for Older Adults in MY2029, with fully digital HEDIS by MY2030. In plain terms, a blood pressure written in a progress note will stop counting; only a structured, coded value transmitted electronically will. Social need screening moves from the G0136 code to LOINC-coded results in MY2027.

LEAD (Long-term Enhanced ACO Design) runs PY2027 through PY2036 with a 3% quality withhold on the benchmark for every ACO, earned back on performance; unearned withhold funds a High Performers Pool. The measure set keeps five REACH measures (risk-standardized all-condition readmissions, unplanned admissions for patients with multiple chronic conditions, days at home for patients with complex chronic conditions, timely follow-up after acute exacerbations, and CAHPS) and adds two MSSP eCQMs: Controlling High Blood Pressure and Diabetes glycemic status above 9%. The eCQMs are optional in 2027 and 2028, pay-for-reporting in 2029 and 2030, and pay-for-performance from 2031 through 2036. The score is up to 10 points per measure, adjusted by a continuous improvement and sustained exceptional performance multiplier, plus an eCQM reporting adjustment (up to 2.5 points in the first two years) and a Prevention and Quality Plan adjustment (up to 5 points in 2027 and 2028, up to 10 afterward). HOS is not in the set; CAHPS is. The REACH health equity benchmark adjustment and health equity plan do not carry over.

Every LEAD ACO must adopt a Prevention and Quality Plan on one of three tracks: cardiovascular disease, falls, or nutrition. The plan is worth up to 5 quality points in 2027 and 2028 and up to 10 from 2029, which is a meaningful share of a score built on 10 points per measure. Benefit enhancements support each track: medical nutrition therapy for prediabetes and hyperlipidemia (new for Global ACOs in 2027), the chronic disease prevention reward (healthy food up to $150), and the RISE to Age in Place falls-prevention episode under CARA from 2028 (up to $2,500 in home interventions over three to six months).

Applications closed May 17, 2026; CMS said it would notify selected ACOs by early summer and, as of September 2026, has not published a participant list. The deadline to resolve TIN overlap between MSSP and LEAD rosters was September 8, 2026 (a TIN cannot sit in both). The optional implementation period runs September 15 to December 31, 2026 with no alignment, payment, or risk, and PY2027 begins January 1, 2027. CARA target-price reports arrive in Q2 2027 and the first CARA performance year is 2028. CMS anticipates future application windows but has not announced dates.

Under the CY 2027 PFS proposed rule, APP Plus shrinks to eight measures for PY2027: five clinical measures reportable as eCQM, MIPS CQM, Medicare CQM, or the new Medicare eCQM option, CAHPS for MIPS (now web, mail, and phone), and two administrative claims measures; Quality ID 305 (SUD treatment) and 493 (Adult Immunization Status) are removed. MIPS CQMs are extended with the reporting incentive, all Medicare CQMs move to flat benchmarks, and CEHRT can be met through three pathways. The 40th-percentile performance threshold still gates shared savings. FHIR-based reporting is expected to be mandatory around 2030, so the data plumbing you build now has to last.

Controlling Blood Pressure and diabetes glycemic control are LEAD eCQMs, MSSP APP Plus measures, Star measures, and HEDIS measures. Breast and colorectal screening and depression screening are in APP Plus and Stars (Depression Screening and Follow-Up joins Stars for the 2029 ratings). CAHPS is in LEAD, MSSP, and Stars. Readmissions and follow-up after exacerbation are LEAD claims measures and the drivers of the 3x-weighted HOS results plans are graded on. NCQA is retiring chart-sample reporting for blood pressure in MY2028 and glycemic status in MY2029, so structured capture is the common requirement.

LEAD uses a prospective model derived from CMS-HCC V28 with a symmetric 3% cap on risk score growth (4% for High Needs beneficiaries), and CMS will phase in AI-inferred risk adjustment from 2028 to 2031. MA plans can no longer count unlinked chart-review diagnoses in 2027, and every contract gets a RADV audit. Both programs now reward the same thing: accurate, encounter-based documentation of conditions that are actually present, captured in structured data at a real visit.

With eleven administrative measures leaving, plans have fewer levers they control from a call center and more that sit in your practices: blood pressure and glycemic control, kidney evaluation, screenings, three risk-adjusted adherence measures, functional status, polypharmacy, and the 3x-weighted HOS measures. Cut points on HEDIS measures rose in both the 2026 and draft 2027 ratings. Expect 2027 contracts to raise thresholds, add adherence and HOS-driver gates, and tie more of the deal to hitting them. Plans that fall below 4 stars lose the 5% bonus and drop from a 65% to a 50% rebate share, and they renegotiate downward.

Stars is graded on a curve, Tukey deletion keeps removing the lowest contracts before cut points are set, and roughly 10% of 2026 enrollees were in products that were discontinued, which mechanically raises the average. In LEAD, a fixed ten-year benchmark and first-dollar losses raise the cost of a practice that stands still. The practices that move the network are usually the bottom third, and their problems are workflow problems: unseen patients, unstructured data, no follow-up after discharge, and no owner for the gap list.

Improving or Maintaining Physical Health and Mental Health compare a member's own answers two years apart, case-mix adjusted; LEAD's days at home and unplanned admission measures are claims-based. The drivers are the same: whether functional decline, pain, falls, and depression were identified and managed, and whether the patient stayed out of the hospital and the SNF.

For the 2028 Star Ratings (MY2026) the three adherence measures are risk-adjusted for sociodemographic factors, lose the inpatient/SNF adjustment, and drop to 1x weight for one year; in the 2029 ratings they return to 3x. Plans will treat MY2026 as the reset year. Networks with large dual-eligible and low-income panels benefit from the adjustment only if their actual fill rates keep pace, and the same medication management supports LEAD's cardiovascular Prevention and Quality Plan track.

Only the work that pays through the measures. CMS estimates the Star changes add about $18.6 billion in bonus payments over ten years and projects roughly a quarter of contracts down a half star. The cancelled reward and the absent LEAD adjustment remove bonuses for serving dual, low-income, and disabled members well, but risk-adjusted adherence, blood pressure and glycemic control in those panels, and survey drivers in multilingual communities still decide the rating and the withhold. LEAD's High Needs designation, with its own benchmark and 4% cap, is where that population's cost and quality now sit.

Half of the draft 2027 cut points tightened; Kidney Health Evaluation and the respecified Colorectal Cancer Screening moved 7 to 11 points because neither is guardrail-protected as a new measure. In 2026, 57% to 60% of cut points rose. Tukey deletion removes the lowest contracts before clustering, plan exits removed about 10% of enrollees from the pool, and CMS is exploring a percentile-based method from MY2027. The bar will move again next year. A rating strategy built on maintaining performance is a strategy for losing a half star.

What you can move from the plan: Part D adherence outreach (though the measures are risk-adjusted from MY2026 and your practices influence fills), CAHPS access and coordination items, and the operations behind the survey experience. What now depends on providers: blood pressure and glycemic control, kidney evaluation, eye exam (chart review no longer counts), breast and colorectal screening, functional status assessment, polypharmacy and opioid-benzodiazepine deprescribing, depression screening from MY2027, and the 3x-weighted HOS measures, which are driven by whether chronic conditions and functional decline were managed in primary care. With the administrative measures gone, the provider-dependent share of your rating is the majority.

Unlinked chart-review diagnoses no longer count toward risk scores in 2027, and NCQA is retiring hybrid reporting: statin measures in MY2026, blood pressure in MY2028, glycemic status and Care for Older Adults in MY2029, fully digital by MY2030. Both changes reward the same thing: structured, coded data captured at a real encounter and transmitted electronically. Supplemental data feeds from practices become your primary HEDIS source, and their quality becomes your rating.

Only the ones that pay through the measures. The reward that would have replaced the reward factor is gone, but the risk-adjusted adherence measures, the survey measures in multilingual communities, and blood pressure and glycemic control in dual and low-income panels still decide the rating. CMS also removed the equity analysis requirement for utilization management committees. The money now follows outcomes in those populations, not the program label.

The 2027 ratings use a cohort surveyed in 2024 and 2026; the 2028 ratings use a cohort surveyed in 2025 and 2027. What your network does in the second half of 2026 and in 2027 shows up in ratings two years out. The measures reward members who stay at the same physical and mental health level or improve, adjusted for case mix, which means preventing functional decline, managing pain and depression, preventing falls, and keeping members out of the hospital.

A drop below 4 stars removes the 5% quality bonus and cuts the rebate share from 65% to 50%; a drop below 3.5 cuts rebates further. The average bonus is $381 per enrollee in individual plans and $466 in employer plans, and only 68% of enrollees are in bonus-status plans in 2026, the lowest since 2018. Analysts describe a half-star swing at a large insurer as hundreds of millions of dollars a year. Every remaining measure with rising cut points sits in the practice, which is where the next dollar of Star investment returns the most.

Customer Service and Rating of Health Care Quality leave for the 2029 ratings; Getting Needed Care, Getting Appointments and Care Quickly, Care Coordination, Rating of Health Plan, and Rating of Drug Plan remain at 2x. The survey runs web, mail, then phone, and case-mix was re-estimated for 2027. The items that remain are about access and coordination, which are practice behaviors: timely appointments, results explained, specialists' information in the chart, follow-up after a visit.