Key takeaways
- Under the Contract Year 2027 Medicare final rule, clinical measures carry more weight, emphasizing outcomes over administrative metrics.
- To close care gaps and protect U.S. Centers for Medicare & Medicaid Services Star Ratings, plans must prioritize genuine member activation to help members overcome nonmedical drivers of health challenges.
- The 2027 ruling introduces the very first mental health measure, making it a direct clinical requirement.
- Consumer Assessment of Healthcare Providers and Systems and Health Outcomes Survey metrics now make up 44% of Star Ratings, making member engagement essential to grow revenue and quality bonus payments.
Health plans are under constant pressure and scrutiny to perform, delivering benefits that will make a difference in members’ lives. The U.S. Centers for Medicare & Medicaid Services’ (CMS) Contract Year 2027 Medicare Advantage and Part D Final Rule is adding even more fuel to the fire, with traditional benchmarks emphasizing care quality more than ever.
See what’s changing and how it directly impacts your quality measures. Pyx Health lays out how member activation works to close care gaps — and why your plan should respond now to protect Medicare Star Ratings and maintain your standing.
The volatility of a thinner measure set
In its most recent guidance, CMS removed 11 “topped out” administrative measures — such as adult BMI assessment and appeals timeliness — that form the basis of Star Ratings. The focus is shifting toward member action, giving outsized influence to a smaller criteria set to drive your final Star Rating, including:
- Diabetes care
- Colorectal screenings
- Behavioral health follow-ups
Driving actual member behavior
Stripping away administrative fluff lessens the margin for error. As CMS turns the page, plans can’t coast on efficiency metrics to buffer poor clinical performance. To make your Star Ratings soar, you must go the extra mile to get members actively invested in their health outcomes.
Eliminating barriers to close health care gaps
As the threshold to earn four and five stars tightens, up to 25% of contracts could see their ratings drop. To close care gaps and maintain trust, plans must address the nonmedical drivers of health (NMDOH) that interfere with health care access.
So many challenges come from nonclinical stressors, whether it’s taking the bus to afford groceries or avoiding a doctor visit to make rent. But if you can activate your members — especially the most vulnerable, such as Dual Eligible Special Needs Plans and Medicaid crossover populations — you can make real progress. The problem? Traditional mailers, texts and robocalls outreach often fall short. Think outside the box to break through to these members.
Overcoming engagement washing
Do you go the extra mile to provide meaningful member communication? While quick interactions, such as app messages or voicemails, can be helpful in specific circumstances, they often fall short of personalized relationship-building.
Support your members over the long term by steering away from engagement washing and toward member activation instead. By taking the time to build trust, you can open the door to identify barriers and empower individuals to take control of their health.
Addressing the new behavioral health requirement
Previous iterations of Medicare’s quality measures didn’t place mental health on equal footing with physical health. That’s changing in 2027 with a new depression screening and follow-up measure — the first behavioral health clinical requirement. It requires a 30-day follow-up, which is notoriously difficult to track. By integrating depression into Medicare Star Ratings, CMS is not only closing the loop on mental health but also practically requiring plans to adopt high-touch navigation models.
Closing clinical gaps also closes financial gaps
While plans previously viewed member activation as more of a bonus achievement, it has become a powerful revenue-generating opportunity. In fact, with Consumer Assessment of Healthcare Providers and Systems (CAHPS) and Health Outcomes Survey metrics now making up 44% of Star Ratings, member involvement and satisfaction just make financial sense.
Protecting your bottom line
With the shift toward action and outcomes, poor performance on any clinical quality measure could have a direct hit on a health plan's bottom line and rebate potential. Each of these is now triple weighted, so take the steps to improve your CAHPS and Star metrics — and protect your quality bonus payments — through digital health engagement and meaningful human interaction.
Elevating outcomes through meaningful connection
CMS reimagining its quality measures gives health plans a clear call to action: Upgrade your standards for care delivery. To succeed under the new benchmarks, you must prioritize genuine member activation over impersonal check-ins and paperwork. Pyx Health empowers you to motivate members and elevate all metrics.
We provide plans with the tools to address NMDOH needs by combining compassionate outreach and connection with technology-based resources. From app technology to connect with peer mentors to home-delivered food boxes, the vehicle to continuous member activation is parked right outside your door. Build trust with members to offer:
- Targeted health education
- Improved health literacy
- Consistent, reliable resources
Ready to get started? Contact Pyx Health today to learn how our empathetic care coordinators and integrated solutions can elevate your Medicare Star Ratings and health care outcomes.
