Last updated: November 2026
As IHS uses the term, a Medicare Advantage Star Ratings improvement program is a plan's own operating structure for raising a contract's Star Rating: a named owner for every measure, a root-cause review of each measure that lost ground, and a monthly review. It rests on how CMS builds the ratings under 42 CFR 422.160 through 422.166, which CMS uses to determine quality bonus payment (QBP) status and rebate retention allowances, among other purposes. Integral Healthcare Solutions (IHS) is a consulting firm. It drafts the measure-owner map, root-cause worksheets, workplan and monthly review structure, and your staff own the clinical and operational interventions.
This is program development work, one of three IHS practice lines with accreditation consulting and compliance services.
What are Medicare Advantage Star Ratings?
Star Ratings are the 5-star quality ratings CMS assigns to Medicare Advantage contracts. The regulation fixes how ratings are built, not how to improve them. We checked these sections against the eCFR text built November 4, 2026 (Title 42 last amended October 8, 2026), on November 5, 2026. This page reads 42 CFR Part 422 only, not the Part D rules in Part 423.
What are the ratings used for?
Section 422.160(b) lists three purposes. One is comparative information on plan quality and performance for beneficiaries making enrollment and coverage decisions. Another is "To provide quality ratings on a 5-star rating system to be used in determining quality bonus payment (QBP) status and in determining rebate retention allowances." The third is compliance oversight of MA plans, where appropriate and possible to use data of the type described in 422.162(c) (42 CFR 422.160).
Where do the yearly measures come from?
"CMS lists the measures used for a particular Star Rating each year in the Technical Notes or similar guidance document with publication of the Star Ratings." (42 CFR 422.164, section (a)). CMS also reviews the quality of the data behind a measure before using the data to score and rate performance or in calculating a Star Rating (section (b)).
CMS reduces a HEDIS measure to 1 star when audited data are submitted to NCQA with a designation of biased rate (BR) based on an auditor's review, or nonreport (NR) (section (g)(1)(i)). Section (g) also covers reductions tied to data validation results.
How long are new measures on the display page?
"New measures added to the Part C Star Ratings program will be on the display page on www.cms.gov for a minimum of 2 years prior to becoming a Star Ratings measure." (section (c)(3)). "A measure will remain on the display page for longer than 2 years if CMS finds reliability or validity issues with the measure specification." (section (c)(4)).
How does CMS set a star level for a measure?
"CMS will determine cut points for the assignment of a Star Rating for each numeric measure score by applying either a clustering or a relative distribution and significance testing methodology." (42 CFR 422.166, section (a)(1)). For non-CAHPS measures: "Effective for the Star Ratings issued in October 2022 and subsequent years, CMS will add a guardrail so that the measure-threshold-specific cut points for non-CAHPS measures do not increase or decrease more than the value of the cap from 1 year to the next." The cap: "The cap is equal to 5 percentage points for measures having a 0 to 100 scale (absolute percentage cap) or 5 percent of the restricted range for measures not having a 0 to 100 scale (restricted range cap)." (section (a)(2)(i)). New measures that have been in the Part C and D Star Rating program for 3 years or less have no guardrail for their first 3 years in the program. IHS inference: cut points come from current data, so a plan's target can move within the cap.
How much does each kind of measure weigh?
Section 422.166(e)(1) assigns weights by category, subject to (e)(2) and a Puerto Rico rule for Part D adherence measures in (e)(3).
| Measure category | Weight |
|---|---|
| Improvement measures | 5 |
| Outcome and intermediate outcome measures | 3 |
| Patient experience and complaint measures | 2 starting with the 2026 Star Ratings (4 through the 2025 Star Ratings) |
| Access measures | 2 starting with the 2026 Star Ratings (4 through the 2025 Star Ratings) |
| Process measures | 1 |
Under section (e)(2), new measures weigh 1 in their first year in the program, and substantively updated measures weigh 1 in their first year returning after being on the display page; later years use the category weight.
How does the improvement measure work?
CMS compares each measure's score for the current year to the immediately preceding year (42 CFR 422.164, section (f)), and calculates an improvement score only for contracts with numeric measure scores for both years in at least half of the measures identified for use. Under 42 CFR 422.166 section (g)(1), if a contract's highest rating is 4 stars or more without the improvement measure(s) and with all applicable adjustments (CAI and the reward factor), CMS compares the rating with and without them and uses the higher. If it is less than 4 stars without them, the rating is calculated with them. The highest rating is the overall rating for an MA-PD contract and the Part C summary rating for an MA-only contract.
Who needs it and what triggers it
Typical triggers for an improvement program:
- A contract's rating drops, or a measure weighted 3 or 5 loses ground.
- QBP status or rebate retention is at risk under 422.160(b)(2).
- A new measure is nearing the end of its display period under 422.164(c)(3).
- Part C or Part D summary ratings of 2.5 or lower in all 3 years mark a contract with a low performing icon, if it has a Part C or Part D rating for all 3 years (422.166(h)(1)(ii)(A)).
- Patient experience, complaint and access weights fell from 4 to 2 starting with the 2026 Star Ratings, so older owner priorities may not fit.
How IHS helps
Dr. Thomas G. Goddard, the IHS founder and former URAC Chief Operating Officer and General Counsel, leads the work, and your staff run the program. These steps are IHS method, not CMS requirements:
- Pull the current Technical Notes and list every measure for your contract, with its category weight and the owner you name for it.
- Build the measure-owner map: who is accountable for the data, the intervention and the report.
- Rank measures by weight and by the gap to the prior year.
- Write a root-cause worksheet for each measure that lost ground, separating data causes from care and operations causes.
- Draft the workplan, the monthly review structure (agenda, owner evidence, escalation path) and the governance documents that make it standing.
What you supply. Your quality, pharmacy, member experience and operations staff own the interventions. You supply your data and measure reports. Counsel and actuaries handle payment effects.
The real limit. IHS does not predict CMS cut points or ratings, and it does not run clinical interventions. We did not open the current-year Technical Notes for this page, so your measure list comes from CMS, not from IHS.
What to have ready
- The Technical Notes for your rating year (42 CFR 422.164, section (a)).
- Your contract's star level, the measure scores behind it, each measure's category and its owner (42 CFR 422.166, section (e)).
- Data quality evidence, including HEDIS audit designations and data validation results (422.164(b) and (g)).
- Prior-year scores, because the improvement measure compares them with the current year (422.164(f)).
- The CMS display page list of measures coming into the ratings (422.164(c)(3) and (c)(4)).
- CAHPS results, response volumes and reliability (422.166(a)(3)).
- Plan preview materials: CMS has two plan preview periods before each Star Ratings release, in which MA organizations can preview preliminary Star Ratings data in HPMS (422.166(h)(2)).
The free introductory call turns that list into a workplan.
How it compares
The table records what the regulation fixes and what the plan controls, and recommends neither.
| Topic | Fixed by the regulation | Controlled by the plan |
|---|---|---|
| Measures and weights | CMS lists measures yearly; weights follow category | Which owner is named for each measure |
| Cut points | Clustering or relative distribution, with a guardrail cap | How the plan tracks its trend |
| Data | CMS reviews data quality and reduces some measures to 1 star | Data capture, submission and reporting |
IHS structure sits in the right-hand column. This page does not claim that URAC or NCQA accreditation changes a Star Rating.
What it costs
No CMS fee attaches to a Star Ratings improvement program in the sections we opened. IHS scopes each engagement after a free introductory call, and this page carries no IHS figure. Owners will also spend staff time on the review, and the interventions are plan operating costs outside any consulting scope.
What this is not
- It does not predict or improve a CMS rating on its own; plan staff carry out the interventions.
- It is not legal or actuarial advice.
- IHS does not contact or file with CMS. The plan's staff submit its own data.
Frequently asked questions
What are Medicare Advantage Star Ratings used for?
CMS uses them for comparative information for beneficiaries, for determining quality bonus payment (QBP) status and rebate retention allowances, and for compliance oversight where appropriate and possible to use data of the type described in 422.162(c) (42 CFR 422.160, section (b)).
How does CMS set the cut points for a star level?
It applies either a clustering or a relative distribution and significance testing methodology to each numeric measure score (42 CFR 422.166, section (a)(1)).
What is the cut point guardrail, and what is the cap?
For the Star Ratings issued in October 2022 and subsequent years, non-CAHPS cut points may not increase or decrease more than the cap from 1 year to the next. The cap is 5 percentage points on a 0 to 100 scale, or 5 percent of the restricted range otherwise (42 CFR 422.166, section (a)(2)(i)). New measures in the program for 3 years or less have no guardrail for their first 3 years.
How long are new measures on the display page before they count?
A minimum of 2 years, and longer if CMS finds reliability or validity issues with the measure specification (42 CFR 422.164, section (c)(3) and (c)(4)).
What is the reliability floor for CAHPS measures?
For CAHPS measures, CMS combines the relative percentile distribution with significance testing and accounts for the reliability of scores from survey data, and no measure Star Rating is produced if the reliability of a CAHPS measure is less than 0.60 (42 CFR 422.166, section (a)(3)).
How does the improvement measure affect a contract's rating?
A contract whose highest rating is less than 4 stars without the improvement measure and with all applicable adjustments (CAI and the reward factor) is rated with it. At 4 stars or more on that test, CMS compares the rating with and without it and uses the higher (42 CFR 422.166, section (g)(1)).
Who should own each measure, and how should a plan run a monthly Stars review?
The sections we opened do not say, so this is IHS method. Each measure gets a named owner for the data, the intervention and the report, and a monthly review has a fixed agenda, owner evidence, dated actions and an escalation path. IHS drafts the structure, and your leaders confirm it.
What does IHS draft, and what do plan staff own?
IHS drafts the measure-owner map, root-cause worksheets, workplan, review structure and governance documents. Plan staff own the interventions, the data and the filings. IHS scopes each engagement after a free introductory call.