Trump admin proposes Medicare Advantage ratings overhaul
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The Trump administration is proposing to scrap a dozen quality measures for Medicare Advantage plans and not move forward with a Biden administration plan to reward insurers that improve the health of low-income and disabled enrollees.
Why it matters: A proposal issued on Tuesday marked the Trump administration's first shot at putting its mark on the privatized Medicare program and delivered a mixed bag for top plans like UnitedHealth Group and CVS Health's Aetna.
Driving the news: The administration is taking aim at the star ratings that plans get based on performance metrics and determine whether they get bonus payments.
- Medicare is proposing to not implement a Biden-era change that was due to take effect in 2027 and would give plans extra incentives for improving health outcomes for low-income and disabled seniors. The administration would instead continue the current system, which rewards plans that achieve high and stable performance across measures.
- "This shift is part of a broader effort to refocus the Star Ratings on clinical care, outcomes, and patient experience," the Centers for Medicare and Medicaid Services wrote in the proposal.
- Medicare administrators estimate the star ratings changes would cost taxpayers about $13 billion between over a decade, or 0.15% of Medicare payments to private health plans during the time period.
CMS also is seeking feedback on future changes to the Medicare Advantage risk adjustment, which allows plans to get paid more for having sicker enrollees. Some insurers have been accused of "upcoding" — a practice of classifying patients as sicker in order to receive higher payments.
Between the lines: CMS is proposing to remove 12 quality measures, including two measures of how plans respond to appeals of claim denials.
- Average performance on the claim denial measures has increased from 2015 to 2025, with average performance now at or above 95%, CMS said.
- Medicare administrators are also proposing to remove measures of how many enrollees leave plans, customer service and health care quality.
- They want to add a measurement reflecting screening patients for depression and follow-up, which would go into effect for 2029 ratings.
Removing the 12 quality measures will generally reduce plans' star ratings, but dropping the health equity reward program could give them higher grades, CMS predicted.
Zoom out: The proposal also suggests making it easier for seniors to switch Medicare Advantage plans midyear if their doctor drops out of network.
