Overview: CMS’s CY 2027 proposed rule reshapes Stars by removing 12 measures, dropping the EHO4All/HEI reward, keeping the Reward Factor, and adding a Depression Screening & Follow‑Up measure while continuing to emphasize member experience. Meanwhile, the CY 2026 final rule tightens prior authorization/appeals guardrails and codifies IRA vaccine/insulin and Prescription Payment Plan (PPP) requirements. Below, we summarize the changes impacting payers and pharmacies, and outline strategies including ways Outcomes can help.
Changes to Star Ratings
What CMS proposes:
- MY2026/ SY2028: No major new methodology changes beyond those already released.
- MY2027/ SY2029: CMS proposes removing 12 measures and halting the Excellent Health Outcomes for All (EHO4All/HEI) reward, retaining the historical Reward Factor instead.
- CMS would add a new Part C “Depression Screening and Follow‑Up” measure starting with MY2027.
- CAHPS/HOS weight continues to rise, approaching 40% of total weight by 2029.
Payer Impact Summary:
Fewer “safety‑net” measures mean heavier reliance on clinical outcomes and experience. Payer simulations and budget scenarios should incorporate Quality Bonus Payments (QBP) volatility and Reward Factor retention. Press Ganey estimates as much as 25% of MA contracts could lose half a star under CMS modeling, translating to $1.3B in lost QBP if the removals are applied to current performance baselines. Milliman’s simulation of the 12 removals under current policy shows a 0.15 Star national average decline and predicts 158 contracts dropping by half a star.
Pharmacy Impact Summary:
With administrative measures exiting, pharmacies’ role in adherence, chronic condition management, follow‑up, and screenings grows in importance for plan partners.
How Outcomes can help:
Pharmacies play a critical role in closing care gaps consistently. Leveraging the Outcomes MTM/TIP engine enables targeting of more than 600 interventions across 50+ disease states, embedding gap closure directly into workflow and documenting results for Stars.
Member experience cannot be left to chance. Outcomes Patient Engagement tools allow deployment of pulse surveys and educational nudges, integrating responses into actionable follow-up tasks. Together, these strategies position payers and pharmacies to adapt quickly, protect revenue, and deliver measurable improvements in quality and satisfaction.
Member Protections & Prior Authorization / Appeals Guardrails
What CMS finalized for CY2026 (effective Jan 1, 2026):
- No retroactive denials of approved inpatient admissions except for obvious error or fraud; plans must honor the prior auth decision.
- D‑SNP timelines codified: Initial Health Risk Assessment (HRA) within 90 days of enrollment, and individualized care plan within 90 days after the HRA or enrollment (whichever is later) beginning CY2026.
Payer Impact Summary:
Medicare Advantage plans should prepare for tighter UM oversight under the CY2026 rule. Expect increased notice volume and stricter documentation standards, requiring alignment of coverage criteria and determination workflows to ensure compliance. For D‑SNPs, operational readiness is critical. Plans must adopt the 90‑day cadence for HRAs and individualized care plans now, while planning for integrated ID cards and integrated HRAs for applicable integrated programs starting in 2027.
Pharmacy Impact Summary:
Pharmacies will play a growing role in supporting compliance and care coordination under the new CMS rules. Accurate documentation is critical, and pharmacist findings such as medication lists, patient histories, and counseling notes increasingly serve as evidence for medical necessity and strengthen appeal packets for coverage determinations. Additionally, pharmacies can help streamline D‑SNP onboarding by assisting with HRA through proactive outreach and social‑needs screening, ensuring timely completion and improved member experience.
How Outcomes can help:
Outcomes helps health plans and pharmacy networks adapt to evolving regulations by strengthening data capture and member engagement. Our MTM/TIP workflows guide pharmacists through comprehensive documentation, bridging gaps in health plan records and supporting compliance for coverage determinations and appeals. Building on this foundation, our recently launched HRA solution leverages the trusted pharmacist-patient relationship to expand outreach and collect critical health and social data, while ensuring completion of assessments and improved care coordination.
Pharmacy Benefit Modernization & Part D Redesign
What CMS finalized/clarified:
- IRA codifications: No deductible and zero cost‑sharing for ACIP‑recommended adult vaccines under Part D and insulin cost‑sharing limits reaffirmed.
- Part D sponsors must offer enrollees the option to spread OOP drug costs via capped monthly payments under PPP.
Payer Impact Summary:
Participation in the PPP will require Medicare Advantage and Part D sponsors to integrate billing, accumulator, and portal systems to support monthly payment options. Real-time patient communication at the point of sale is essential to ensure members understand cost-smoothing features and avoid confusion or refund issues which could impact member experience. These operational changes demand strong coordination between benefit design, technology, and member engagement strategies.
Pharmacy Impact Summary:
Adult vaccine volumes are expected to rise alongside increased insulin counseling, making it essential to ensure billing and inventory processes align with IRA requirements. At the same time, pharmacists will field more questions about PPP options, requiring clear communication and coordination with health plans.
How Outcomes can help:
Our Vaccine Registry Reporting and medical billing features ensure accurate documentation and reimbursement for adult vaccines, including out-of-network routing when needed. To support PPP adoption, Outcomes can partner with payers to implement co-pay smoothing scripts and proactive education into workflows.
Quick References:
https://www.cms.gov/newsroom/fact-sheets/contract-year-2027-medicare-advantage-part-d-proposed-rule
https://info.pressganey.com/press-ganey-blog-healthcare-experience-insights/cms-stars-shake-up
https://www.milliman.com/en/insight/falling-star-rating-trajectory-2027-proposed-rule
