CMS Proposes Major Medicare Advantage and Part D Reforms for 2027, Streamlining Star Ratings and Drug Coverage Programs
核心洞察
The Centers for Medicare & Medicaid Services (搜索) released proposed 2027 rules for Medicare Advantage (搜索) and Part D programs, aiming to simplify the Star Ratings system by removing 12 performance measures and refocusing on clinical care outcomes.
Over 25% of the proposed changes address full implementation of Medicare Part D (搜索) redesign from the Inflation Reduction Act (搜索), including sunsetting the Coverage Gap Discount Program (搜索) and expanding the Manufacturer Discount Program (搜索).
CMS proposes broader use of risk adjustment data and seeks to modernize marketing oversight while reducing regulatory burden on healthcare organizations and improving beneficiary protections.
The Centers for Medicare & Medicaid Services (搜索) (CMS) has released its proposed Contract Year 2027 Policy and Technical Changes to the Medicare Advantage (搜索) Program, Medicare Prescription Drug Benefit Program, and Medicare Cost Plan Program, introducing significant reforms aimed at simplifying oversight while enhancing beneficiary protections and program efficiency.
Star Ratings System Overhaul
CMS proposes a comprehensive restructuring of the Star Ratings system, seeking to remove 12 performance measures to streamline evaluation criteria. The agency plans to eliminate seven measures focused on operational and administrative performance, three focused on the process of care, and two focused on patient care experience. This reduction aims to refocus the measure set on clinical care, outcomes, and patient experience measures where plans have not topped out performance.
The proposed changes align with the Make America Healthy Again initiative, with CMS believing that decreasing the number of measures will allow more focus on the measures that remain. Notably, CMS does not intend to move forward with the Health Equity Index rewards under the Star Ratings program and is seeking stakeholder input on the quality bonus payment system driven by Star Ratings.
Medicare Part D Redesign Implementation
Over 25% of the Proposed 2027 Rules address changes aimed at fully implementing the redesign of Medicare Part D (搜索) adopted in the Inflation Reduction Act (搜索) (IRA). The comprehensive reforms include formally sunsetting the Coverage Gap Discount Program (搜索) and further implementing the Manufacturer Discount Program (搜索).
Additional changes include clarifications regarding medical loss ratio calculations and modifications to amounts that accrue towards TrOOP (True Out-of-Pocket costs). Many of these proposed changes have been previously introduced through sub-regulatory guidance over recent years, with CMS now formalizing them through regulation.
Risk Adjustment Data Expansion
CMS proposes significant changes to the permissible uses for risk adjustment data, moving away from historically limited applications. The Proposed 2027 Rules propose to remove enumerated permitted uses and instead recognize CMS's ability to more broadly use and release data to government entities and external parties.
"CMS does not believe the statute restricts our use of risk adjustment data," the agency specifically states in the proposed rules. The changes would allow risk adjustment data to be released prior to reconciliation, representing a much broader approach than current regulations while maintaining beneficiary confidentiality protections.
Marketing and Communications Modernization
The proposed rules include changes to Medicare Advantage (搜索) and Part D marketing and communications regulations, alongside requests for information on modernizing oversight approaches. CMS proposes modifications to the definition of third-party marketing organizations (TPMOs) and updates rules regarding translations, enrollment verification, and testimonial usage.
The agency seeks stakeholder input on modernizing marketing oversight to reduce regulatory burden while ensuring beneficiaries continue receiving accurate information. CMS specifically aims to identify methods for taking appropriate actions against TPMO "bad actors" without hindering organizations operating appropriately.
Reporting Simplification Initiative
CMS is exploring comprehensive simplification of current Medicare reporting obligations, with considerations that would reduce burden on Medicare Advantage (搜索) organizations and Part D plan sponsors while also reducing agency administrative load. The agency cites examples of reporting obligations relating to provider networks, medical loss ratios, benefit utilization, and special needs plans' models of care.
The agency specifically seeks ways to streamline reporting through automated data sharing and different technology solutions that would make data import and utilization less burdensome for all parties involved.
Stakeholder Engagement and Future Direction
The Proposed 2027 Rules include a broad Request for Information regarding the future direction of the Medicare Advantage (搜索) program, with specific focus on risk adjustment and quality bonus payments. CMS seeks improvements targeting multiple program areas: data transparency, beneficiaries' ability to select optimal plans, overall quality enhancement, competition improvement, fraud reduction, waste and abuse prevention, and taxpayer savings generation.
The proposed changes come as CMS has faced multiple legal challenges in recent years, losing cases related to Star Ratings, marketing and communications rules adopted for 2025, and the risk adjustment extrapolation rule. The Proposed 2027 Rules broadly address all these regulatory areas that have been subject to legal scrutiny.
Interested parties must submit comments on the Proposed 2027 Rules by January 26, providing stakeholders with the opportunity to influence the final regulatory framework that will govern Medicare Advantage (搜索) and Part D programs.