CMS Final Rule 2025: What To Know

The Centers for Medicare & Medicaid Services (CMS) has finalized updates to the Medicare Advantage (Part C) and Medicare Prescription Drug Benefit (Part D) Star Ratings program, as detailed in the document [CMS-4208-F]. These changes, effective June 3, 2025, with applicability for coverage beginning January 1, 2026, aim to enhance the evaluation of plan performance and quality.​ The Medicare Advantage changes impact the 34.4 million seniors enrolled in the upwards of 700+ Medicare contracts in 2025.

While the CMS Star Ratings program has mostly stayed at status quo, this is somewhat surprising given the last two years of health plan lawsuits on the ratings system. After much speculation that it would be removed, the Health Equity Index/Score has remained in the Final rule (although, it was called out and this provision may be addressed in future rulemaking). Additionally, CMS will continue to review regulations and policies in the Medicare program and make necessary and appropriate changes to ensure consistency with the Executive Order 14192, “Unleashing Prosperity Through Deregulation.”

This list also included annual health equity analysis of utilization management, requirements for Medicare Advantage (MA) plans to have culturally and linguistically appropriate services; and quality Improvement and health risk assessment focused on equity and Social Determinants of health (SDOH).

Key updates to the Star Ratings Program:

1. Introduction of new quality measures:

• Kidney Health for Patients with Diabetes: Measures the rate of kidney health evaluations in diabetic patients, promoting early detection of renal issues.
• Improving/Maintaining Physical and Mental Health: Focuses on beneficiaries’ self-reported physical and mental health statuses, encouraging plans to support overall well-being. ​
• Use of Multiple Anticholinergic Medications in Older Adults: Evaluates the prevalence of multiple anticholinergic prescriptions among seniors, linked to cognitive decline.​
• Concurrent Use of Opioids and Benzodiazepines: Assesses the percentage of members with overlapping prescriptions, addressing the heightened risk of adverse effects (MY2025/RY2027).
• Newly added: updated Breast Cancer Screening as a display measure for 2027 and 2028 Rating Years. Evaluation now includes biennial mammography screening for women aged 40-74 years at average risk of breast cancer. Learn more here.

2. Adjustment in measure weights:

• The weights for the patient experience, complaints, and access measures will be reduced from 4x to 2x in 2026.

3. Implementation of the Health Equity Index (HEI):

• Starting with the 2027 Star Ratings, the HEI will replace the current reward factor, emphasizing the importance of equitable healthcare delivery and aiming to reduce disparities among different demographic groups. Clarifications were provided on how these would be applied. Also, a name change was outlined to change “Health Equity Index” to “Excellent Health Outcomes for All” (EHO4all) index.

It has also been made clear by CMS that plans should not wait until the Plan Preview to flag data issues with Complaints Tracking Module (CTM), Appeals, or Part-D Patient Safety data.

Here are the key dates when data corrections must be received:

• May 30, 2025 – Last day to request review of 2024 CTM data
• June 30, 2025 – Last day to request review of 2024 appeals data
• (For 2027 reporting:) May 18, 2026 – Deadline for review of Part D Patient Safety data

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¹ CMS Final Rule: Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly (CMS-4208-F) | CMS

² CMS-4208-F 2025-06008.pdf

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