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Boost Medicare Star Ratings: A Strategic Game Plan for Health Plans

by Shannon Smith, Assistant VP of Clinical Success at Zyter|TruCare 07/15/2025 Leave a Comment

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Boost Medicare Star Ratings: A Strategic Game Plan for Health Plans
Shannon Smith, Assistant VP of Clinical Success at Zyter|TruCare

 As they navigate complex times, health insurers have their eye on two important financial indicators. And both are moving in the wrong direction. Costs are on the rise while Medicare Star Ratings are on the decline.

Separate but related, the two trends converge on the same idea: health plans need to enable higher quality care at a lower price.

If it sounds like a Herculean feat, that’s because it is. But some health plans are making it happen.

While some of the cost pressures—for example, the price of new drugs—cannot be quickly or easily mitigated, others can be.

This includes health plans’ Star Ratings, a system developed by the Centers for Medicare & Medicaid Services (CMS) to evaluate and compare the quality of Medicare Advantage (Part C) and Medicare Part D prescription drug plans.

Far more than a simple measure of plan quality, the ratings are a primary determinant of health plan revenue, profitability, and market competitiveness. A single star can mean the difference between financial losses and hundreds of millions of dollars in bonus payments, increased enrollment, and enhanced market share.

CMS has been leaning on health plans to use more advanced technology. Using analytics, automation, and AI to boost Star Ratings is a way to do just that, and is something that will benefit not only health plans, but their members.

Why Are Ratings Trending Downward?

CMS has implemented stricter standards for assessing Medicare Advantage plans, which is one reason some insurers have seen their Star Ratings drop. This year, for example, with tougher criteria in place for customer satisfaction, chronic care management and other metrics, Humana’s largest Medicare Advantage plan saw its rating decrease from 4.5 to 3.5 stars.

Insurers are also dealing with higher healthcare costs and more demands from seniors. This utilization surge stretches the budget and can impact overall performance and Star Ratings.

Labor shortages have also affected Star Ratings, as has health plans’ imperfect reporting of health outcomes – sometimes because of their use of outdated technologies for this purpose.

But health plans can turn the tide on this trend. They can deploy the right technologies to capture and report outcomes, as well as maintain a consistent quality of coverage that boosts their Star Ratings — and the bottom line.

A Star Rating Game Plan

As Star Ratings are derived from examining various operations within a health plan, and because every plan has its own unique challenges, insurers will need to come up with their own tailored program to boost their ratings. But below are several techniques that many plans may find useful:

Use Data Analytics: Insurers can use predictive modeling and real-time data to drive:

  • Cut-point analysis: Determine performance thresholds needed to achieve target star levels.
  • Benchmarking: Compare performance against top-rated plans to identify improvement opportunities.
  • Root-cause analysis: Investigate underperformance in specific measures (for example, low cancer screening rates).

Improve Member Engagement: Improve satisfaction and outcomes through personalized outreach via:

  • Digital tools: Deploy telehealth platforms and health portals for remote care access.
  • Human-centered communication: Use motivational interviewing and culturally tailored messaging to address barriers like medication nonadherence and other social determinants of health.
  • Gap closure documentation: Ensure all preventive services (for example, annual wellness visits) are accurately recorded in claims data.

Focus on chronic condition management and target high-impact clinical areas:

  • Diabetes care: Improve HbA1c testing and eye exam rates through reminders and provider partnerships.
  • Medication adherence: Deploy automated refill reminders and 90-day mail-order prescriptions.
  • Preventive care: Increase screenings (for example, mammograms) via targeted outreach campaigns.

The Role of AI and Automation

The newest and most sophisticated technologies have a role to play for health plans looking to increase Star Ratings. Use cases for AI and automation include:

Identifying and Addressing Care Gaps: AI-driven workflow automation identifies members needing preventive screenings, chronic care management, or medication adherence support. 

Optimizing Prior Authorization with Intelligent Workflows: AI-powered prior auth platforms auto-approve routine requests using clinical guidelines, reducing delays. Machine learning can predict high-risk cases needing manual review, improving turnaround time for critical treatments. Real-time provider alerts notify clinicians of missing documentation, reducing administrative burden.

Making Care More Equitable: Generative AI identifies underserved populations by analyzing social determinants of health. Tailored outreach campaigns can use multilingual AI chatbots to engage members in culturally relevant ways. Equity-focused dashboards can track performance for dual-eligible or low-income subgroups to meet CMS Health Equity Index requirements.

Streamlining Care Coordination: AI care management platforms can predict readmission risks using EHR data, enabling targeted post-discharge interventions. Automated care plans sync with provider workflows to ensure follow-ups for chronic conditions like heart failure. Real-time data sharing between providers and plans can reduce duplicate tests and medication errors.

Modeling Proactive Interventions: Risk stratification models can be used to identify members likely to develop chronic conditions, enabling early outreach. Financial impact analysis can quantify how closing specific gaps will affect Star Ratings. Scenario planning can simulate the impact of CMS methodology changes.

Beset by financial and other pressures, many health plans have seen their Star Ratings take a costly dip. But this doesn’t have to be a long-term trend. By following the guidance of CMS—and using advanced technologies to shore up operations—health plans can once again see their stars on the rise.


About Shannon Smith

Shannon Smith is the Assistant Vice President of Clinical Success at Zyter|TruCare, where she leads efforts to enhance customer engagements and optimize the implementation of clinical solutions. With a background in clinical informatics and years of experience as an ICU nurse, she bridges the gap between clinical expertise and technology to drive meaningful improvements in healthcare delivery.

Prior to her current role, Shannon served as the Senior Director of Clinical & Business Success, Delivery Success. She played a pivotal role in ensuring seamless clinical workflows and supporting organizations in navigating complex healthcare challenges. Her experience as a Senior Clinical Systems Specialist at Centene Corporation further refined her ability to translate clinical needs into actionable technology-driven solutions.

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