New members are enrolling, Star ratings are tightening, and CMS changes are reshaping how plans compete and perform. HLTHWorks helps plans move from reactive to ready—especially when every percentage point of quality and risk accuracy matters.

1. Star Ratings: The Rules Got Harder

• Cutpoints are rising, and CMS is measuring consistency, not luck.
• 2026 means no “easy wins”—plans must drive year-round performance with cross-functional accountability.
• Readiness Tip: Review your measure owners, refresh dashboards, and set early targets for CAHPS, HOS, and medication adherence.

2. Risk Adjustment: The v28 Reality Check

• The CMS-HCC v28 model reduces the lift from traditional conditions—particularly for diabetes, vascular, and mental health codes.
• With the impact curve flattening, accuracy and completeness matter more than ever.
• Readiness Tip: Focus second-pass coding on high-value chronic conditions and inpatient records; elevate provider documentation education now.

3. Member Complexity: Chronic Is the New Normal

• Over 70% of MA members have two or more chronic conditions, demanding stronger care coordination and data flow.
• Readiness Tip: Align care management, quality, and risk teams—shared metrics are the new competitive advantage.

4. Operational Alignment: One View of Performance

• Homegrown reporting and siloed measures are slowing execution.
• Readiness Tip: Build an enterprise “Performance Office” with unified data from HEDIS, Stars, and Risk Adjustment to make every decision ROI-driven.

5. Financial Impact: Every Measure Has a Dollar Sign

• Star and RAF performance directly influence premium, retention, and bonus pools.
• Readiness Tip: Connect your actuaries and quality teams—your Star plan is also your financial plan.

At HLTHWorks, we help health plans align vision, strategy, execution, and accountability to meet the moment. From risk adjustment model redesign to year-round Star execution and ECDS transformation, our experts help you win before the year starts.