倒退中的星级：解读2025年的衰落

MILLIMANWHITE PAPER StarRatings in Retrograde:Decoding the2025Decline Hayley Rogers, FSA, MAAAMatthew H. Smith,FSA,MAAA The 2025 Medicare Advantage Star Ratings release represents acontinuingtransformation for the quality program, requiring health plans to fundamentallyreassess their strategies as they navigate this new landscape. On October 10, 2024, the Centers for Medicare and Medicaid Services (CMS) released the 2025 Star Ratings forMedicare Advantage (MA) contracts, along with detailed measure and methodology files supporting these ratings.1This release contained significant Star Rating declines for many plans.This edition of our Star Rating seriesdiscusses the declining StarRatings for Medicare Advantage Prescription Drug (MA-PD) contracts2and explores thefactors contributing to the lower ratings andassociatedrevenue implications. Impact on members and drivers The member-weighted averageStar Rating for MA-PD contracts has fallen to 3.92 in 2025and the percentage ofmembers in 5.0-Star contracts fell to 1.8%, the lowestpointsincethe end of the Star Rating demonstrationperiod in 2015. For the first time, the member-weighted average quality bonus payments(QBPs) for numerically rated contractswerebelow 3.5%,the payment level that new or low-enrollment contracts receive. This is led by narrowingperformance gaps between large and small enrollment contracts.While125contracts serving7.5millionbeneficiariesimproved by at least 0.5 stars,a much larger cohort–206 contracts serving16.1millionbeneficiaries—experienced areductionof at least 0.5 stars.3The largesteighteen contracts, with over 300,000 members each (44% of total MAPD membership), together saw 57% ofStar Rating declines.Contractswith decliningStar Ratingshadahigherpercentage(43%)of members withsocial risk factors(SRFs)4compared to improvingcontracts(30%).Thecontracts being consolidated haveanSRF percentage of 66%, while the contracts they are merging intohave an average SRF of 29%, which could improve their maximum rewards under the upcoming Health EquityIndex (HEI) system.Ongoing Tukey Outlier removals in non-CAHPS measures contributed to the decline inStar Ratings. Legalchallenges Several largeMedicare Advantageorganizations (MAOs)have filed legal challenges against the 2025 StarRatings, building on precedents set in the 2024 Star Rating litigation.56This new wave of litigationby MAOs goesbeyondCMS’methodology toalsoaddress thereliability andtransparencyof the Star Rating cut points, rounding,andtheCall Center measures. The 2025 Star Ratingdecline The overall member-weighted average Star Rating for MA-PD contractsdecreasedfrom 4.07 in 2024 to 3.92 in 2025, representing the lowestMA-PD average Star Rating since 2015. For PDP contracts, the overallaverage Star Rating decreased from 3.34 to 3.06, marking the lowestaverage Star Rating for PDPs since 2014. This white paper referencesmeasure year (MY), StarRatings year (SY),andpaymentyear (PY). For example, a 2025Star Rating (2025SY) influencesthe revenue in 2026 (2026PY)andisbased on measure year2023 (2023MY). CONTRACT SHIFTS AND MARKET RESTRUCTURING Contract-level analysis reveals broad deterioration inStar Ratings, withreductionssignificantly outnumberingincreases.Figure 1 shows thetransition between the 2024 and 2025Star Ratings forthe MA-PDcontracts7.While 125 contracts achieved at least a 0.5 Star increase(112of thesecontractsexpectcorresponding revenue increases for2026PY), 206 contracts experienced a 0.5 Star or greater decrease(175facerevenue reductions). Thetotal number of rated contracts decreased by 24, reflecting significant market restructuring: Newlyrated:44 contracts moved fromnew/lowenrollmentstatus to rated status, averaging 3.4StarsDroppedrating:10 previously rated contracts dropped tonew/lowenrollmentstatus, having averaged 3.6StarsConsolidated:18 contracts were consolidated into existing contracts, averaging 3.5 StarsTerminated:40 contracts were terminated, with an average rating of3.0 Stars This market restructuring has important implications forcontracts in thefuture. The 68 departing contracts (throughconsolidation, termination, or transition tolowenrollment status) showed notably weaker performance than newentrants. Among departing contracts, only 13 achieved four or more Stars, while 15wererated at or below 2.5 Stars.The 44 newly rated contracts showed somewhat better performance, with 14 achieving 4+ Stars and7rating at orbelow 2.5 Stars. Looking ahead, this trend appears likely to continue. Only 30 new contracts joined the MA-PD marketas neworlowenrollment contracts, far below the 70 contract terminations and 19 consolidations. With fewernew entrants andlimited contract growth into rated status, the market will likely continue consolidating. While the MA-PD marketcontinues to grow in total membership and MedicareAdvantagemarket shareas a percentage of total Medicareeligibility9, the shrinking number of contracts could create additional upward pressure