On Wednesday morning at The 16th Annual HEDIS® & Quality Improvement Summit in Baltimore, attendees settled in for a fireside chat on Stars policy with the midterm results less than a day old. Mark Newsom, President and Founder of Health Evaluations, LLC, opened the 45-minute conversation with what the new Congress means for Medicare Advantage before moving to the Clover Health ruling and the future of Star Ratings. Melissa Newton Smith, Founder and Senior Advisor at Newton Smith Group, moderated.
Newsom brought an unusual vantage point to the stage. He served three tours inside CMS across four administrations, starting on the team behind the Medicare Modernization Act, which created Medicare Advantage and the Part D benefit, and most recently as Deputy Director of the Medicare Drug Benefit Group, the division responsible for administering Star Ratings. His private sector roles include operational and policy work at Coventry and CVS Health/Aetna and serving as Vice President of Public Policy at Humana.
A new Congress and a bipartisan appetite for MA reform
Democrats won majorities in both chambers on November 3, in what Newsom described as the largest congressional swing since the Nixon era. Neither chamber holds a veto-proof majority, so he expects two years of divided government, with Congress and the administration each holding a check on the other. CMS, the agency setting MA payment, audit and Star Ratings policy, stays under the current administration through January 2029.
Newsom sees appetite in both parties for a significant MA legislative package, and he expects the package to take shape in the new Congress, which convenes January 3, 2027, rather than in the lame duck session. Risk adjustment and payment policy sit at the top of his list, followed by prior authorization reform, which has support across both parties and both chambers. The Improving Seniors' Timely Access to Care Act, which cleared the House Ways and Means Committee unanimously in July, is one example of bipartisan prior authorization work already in motion, though any bill not enacted by January 3 needs to be reintroduced.
For Stars teams, Newsom expects quality policy to ride inside broader legislation rather than lead the debate. He also expects Congress to look at MA spending as a source of offsets for other health priorities, and he put a specific range on the reduction to quality bonus payments he considers most likely, describing a trim to the bonus rather than an end to quality incentives.
He flagged an ongoing discussion about harmonizing quality measures between MA and traditional Medicare, including MIPS and ACO programs, so beneficiaries compare coverage options on the same terms. Because the work is technical, he expects Congress to lean on CMS, contractors such as RAND and measure developers for the details. He described NCQA's standing on Capitol Hill as strong, with little pressure on the core HEDIS® portfolio, while Part D measures face more legal and regulatory pressure along with congressional interest in protecting them in statute. Inside CMS, he expects day-to-day policy development to stay with career technical teams regardless of leadership changes at HHS.
What the Clover ruling did to the measure set
The conversation then turned to Clover Health's case, heard in the U.S. District Court for the Southern District of Georgia, well outside the venues where MA litigation usually lands. The court ruled against CMS on 20 Star Ratings measures in two groups of ten. The first group fell because the technical specifications had not gone through notice-and-comment rulemaking under the Administrative Procedure Act, and the second fell because the measures did not exist in the 2003 statutory text referencing HEDIS®, the Health Outcomes Survey (HOS) and CAHPS.
CMS had long read the 2003 reference as describing types of measures, with HEDIS® standing for clinical data, CAHPS for member experience surveys and HOS for longitudinal outcomes surveys. The court read the reference as a list of what existed in 2003. Newsom explained what the narrower reading means for measures built since, including digital quality measures, ECDS and FHIR-based data, and why requiring rulemaking for every technical specification would swell CMS's annual rule into a document thousands of pages long. He tied the rulings on Part D, PDE-based and administrative measures, including the Complaint Tracking Module and appeals measures, to the measure removals in the CY 2027 final rule.
Why cut points keep moving
Newsom traced Star Ratings back to their start as an informational tool for beneficiaries comparing plans on Medicare Plan Compare. Financial incentives arrived later through the ACA-era demonstration, partly to soften benchmark reductions, and over time the four-star threshold took on enough financial weight to shape benefit design, service areas and product mix for plans across the market.
He spent time on the Tukey outlier deletion and clustering methods behind cut points, which leave plans working toward targets set after the measurement year has closed. His alternative was a fixed target. "In sports, you know what it takes to score a touchdown," he said, arguing for goals tied to population change rather than year-over-year competition. Moving to fixed or predetermined cut points would require rulemaking, and he estimated a runway of two to three years before such a change takes effect.
Data flows feed the ratings
MA enrollment has grown from roughly 15 percent of Medicare beneficiaries in the program's early years to more than half today, and Newsom noted CMS staffing and contractor infrastructure did not grow alongside. He described recurring issues in MARx, the Drug Data Processing System and the Encounter Data Processing System, along with data exchanges with the Social Security Administration and states, and explained how errors in those systems flow into administrative Star Ratings metrics built on transaction data.
Where plans fit in the conversation with CMS
The final stretch focused on how plans engage CMS on Stars policy. With 165 parent organizations in the MA market, Newsom argued individual plans carry more weight than they assume, and he laid out who inside a plan belongs in those conversations, how plans share technical detail without exposing proprietary strategy and why timing matters more than most teams realize. His point about Plan Preview 2 was among the most practical of the session. He also described the federal research data sets available through ResDAC and how plans put them to work for benchmarking and market entry decisions.
Attendees left with a clear picture of three forces, the courts, Congress and CMS, each reshaping Star Ratings on its own timeline heading into the 2027 through 2029 ratings years.
Stars program changes, the lawsuits following Clover and quality improvement strategy anchor The RISE Star Ratings Master Class, December 14-16 at the Fairmont Scottsdale Princess in Scottsdale, Arizona, including hands-on Stars Math and Cutpoint Hackathon workshops.
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