When the 2025 Medicare Advantage Star Ratings were announced, only 42% of plans with prescription drug coverage scored four or five stars, down from 68% in 2022. This marks the third consecutive year of decline of high-performance plans — turning up the heat for Medicare Advantage (MA) plans to adjust their strategies to protect performance.
Now, as health plans prepare their 2026 bids, leaders should consider incorporating novel incentive programs in these bids—incorporating tactics proven to work in patients with health complexities — to close gaps in care and support strong Health Equity Index performance.
Going on offense for Star Rating performance
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During the recent “CMS Bid Bootcamp” hosted by RISE, conversations focused on practical strategies for navigating the MA payment landscape and on HEDIS (the Healthcare Effectiveness Data and Information Set). In Stars Year 2026, HEDIS will become the highest-weighted Star measure category, comprising 26% of a Medicare Advantage plan’s Star Rating for 2027.
In addition to three new measures that will be added for Measurement Year 2026 — Kidney Health Evaluation for Patients with Diabetes, Improving or Maintaining Physical Health, and Improving or Maintaining Mental Health — HEDIS triple-weighted measures include:
- Diabetes care — Blood Sugar Controlled
- Medications Adherence for Diabetes Medications
- Medications Adherence for Cholesterol (Statins)
- Medications Adherence for Hypertension (RAS Antagonists)
- Controlling Blood Pressure
- Plan All-Cause Readmissions
This emphasis on preventive care and chronic condition management turns up pressure on health plans to adopt new approaches to member engagement and address care early and throughout the plan year. Low patient participation and adherence to programs for chronic care, complex care journeys, and wellness are major contributors to excessive healthcare costs and impact health plans’ ability to close gaps in care. Without a plan for successfully addressing the complexities of adherence, health plans will not receive the Health Equity Index reward factor.
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Experts project that most health plans will not receive the Health Equity Index reward factor, which rewards plans for reducing disparities in care among members with social risk factors. The Health Equity Index replaces the existing reward factor for Star Ratings year 2027, putting quality bonus payments at risk for high-performing Medicare Advantage plans. Many health plans could lose hundreds of millions of dollars in revenue if they do not receive this reward factor. Poor performance on this measure would also make it impossible for plans to achieve five stars.
Developing strategies for 2026 plan success and beyond
Health plans must earn a rating of four stars or higher to receive a 5% bonus, yet the average plan rating dropped to 4.04 in 2024, decreasing from 4.14 in 2023 — and this downward slide does not show signs of rebounding. Demonstrating strong performance in 2026 — and positioning a health plan to continue to perform well as the Star Rating system evolves over time — will depend on new, highly innovative approaches to member engagement grounded in science.
Here are three strategic actions health plan leaders should prioritize this year to enhance 2026 bids to secure stronger Star Rating performance.
1. Explore ways to incorporate gamification in member engagement. New research points to the power of financial incentives and personalized, tailored outreach in empowering disadvantaged patients to take control of their health. In recent health plan pilots, for example, this type of model has driven a 178% increase in primary care visits, a 264% increase in cervical cancer screenings, and a return on investment exceeding 700%. For Medicare Advantage plan leaders, who face the risk of decreased revenue and member satisfaction if plans struggle to close gaps in chronic care management, it’s time to consider why gamification holds strong appeal for disadvantaged patients.
In West Virginia, for example, a partnership between a managed care organization, federally qualified health centers, and a digital engagement specialist drove better health outcomes for high-risk, low-engagement members in a large health plan. Key to success: a personalized, omnichannel member engagement designed with the needs and preferences of this population in mind — including in partnership with organizations that already have established relationships with these patients. For patients with Type 2 diabetes, this resulted in:
- 74% completion of diabetes self-management program activities — a 48% improvement over the median adherence rate of similar app-based educational programs
- Significant reductions in A1c levels (10.5% to 8.5%, p<.001), weight (250 to 239 pounds; p<.001) and BMI (41 to 37 kg/m2; p<.001) throughout a 12-week program
- Higher rates of commitment toward better health, with 84% saying their motivation for improving outcomes had increased
By assessing the lessons learned in initiatives like this, Medicare Advantage plan leaders can develop their own gamification model and include this design in their 2026 bids. Use of omnichannel engagement, which a McKinsey & Company survey indicates is preferred among Medicare Advantage beneficiaries, should complement this model.
2. Apply a behavioral health science-based approach to member engagement. Engaging Medicare members in initiatives designed to strengthen treatment adherence and self-management of chronic conditions is notoriously difficult. Not only must program coordinators overcome layers of seeded distrust to demonstrate the value of member participation, but the on ramp for education, activity tracking and closing critical gaps in care is often unnecessarily complex. In fact, app-based health education programs have a median dropout rate of 50%, with many having rates up to 80%.
This is an area where behavioral economics can be a powerful tool for closing gaps in care for complex populations and disease cohorts. For instance, one way to establish trust among people for whom the healthcare system has left them feeling disempowered is by framing a conversation around healthy behaviors in a reciprocal way — “Here’s what you’re going to get out of this service. Here’s what we’re going to give you to help you improve your health.” This makes the “ask” very clear from the start. It also establishes trust, confidence and momentum for people to continue making strides on their complex care journey and highlights the value that members can expect.
It’s important to use clear, direct language in applying this approach. By communicating transparently, you can help cut through the barrier of mistrust that comes from being treated marginally by institutions and systems. Communicating often is also essential. Take the time to explain how a benefits program or incentive works—and do so as much as needed.
3. Use rewards to drive member engagement with Health Equity Index measures. Offer incentives for members to complete social risk factor surveys, sharing information around income, race and ethnicity, sexual orientation and more. Look for ways, too, to reward members for completing actions within their care plan that are linked to the Health Equity Index, such as completing screenings for breast cancer annual flu shots. Actions such as these increase the chances of receiving this reward in a year when many plans are not expected to do so.
By exploring these behavioral science-based, incentive-driven approaches to member engagement, Medicare Advantage plans can more effectively position themselves up for success under an evolving measurement system. They can also apply these techniques to chronic condition management outside the Star Ratings program. Such efforts position plans to more effectively improve health outcomes and reduce costs.
Photo: designer491, Getty Images
Matthew Swanson is CEO and co-founder of Reciprocity Health, Inc., a managed service that strengthens care plan adherence through an all-digital engagement platform and reward programs designed to meet the needs of complex care cohorts. Formerly, Swanson served as the founding director and chairman of the Delaware Center for Health Innovation, a non-profit organization dedicated to the implementation of Delaware's State Healthcare Innovation Plan and funded in part through a grant from the Center for Medicare & Medicaid Innovation. Through his work with Reciprocity Health, Swanson works at the intersection of behavioral economics and healthcare, seeking to fundamentally transform the Medicaid and Medicare markets.
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