Medicare Program; Contract Year 2027 and Certain Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, and Medicare Cost Plan Program

CMS develops and publicly posts a 5-star rating system for Part C,\83\ more commonly referred to as Medicare Advantage (MA), and Part D plans as part of its responsibility to disseminate comparative information, including information about quality, to beneficiaries under sections 1851(d) and 1860D-1(c) of the Act. The Part C and D Star Ratings system is used to determine quality bonus payment (QBP) ratings for MA plans under section 1853(o) of the Act and the amount of MA beneficiary rebates under section 1854(b) of the Act. We use multiple data sources based on the collection of different types of quality data under section 1852(e) of the Act to measure the quality and performance of contracts, such as CMS administrative data, surveys of enrollees, and information provided directly from health and drug plans. CMS regulations, including Sec. Sec. 417.472(j) and (k), 422.152(b), 423.153(c), and 423.156, require plans to report on quality improvement and quality assurance and to provide data that help beneficiaries

compare plans. The methodology for the Star Ratings system for the MA/ Part C and Part D programs is codified at Sec. Sec. 422.160 through 422.166 and 423.180 through 423.186, respectively, and we have specified the measures used in setting Star Ratings through rulemaking. In addition, the cost plan regulation at Sec. 417.472(k) requires cost contracts to be subject to the Parts 422 and 423 MA and Part D Prescription Drug Program Quality Rating System. As a result, the regulatory changes proposed here will apply to the quality ratings for MA plans and cost plans.

\83\ We generally use “Part C” to refer to the quality measures and ratings system that apply to MA plans and cost plans.

We have continued to identify enhancements to the Star Ratings program to ensure it is aligned with the CMS Quality Strategy as that Strategy \84\ evolves over time to increase the health and wellbeing of enrollees. In this final rule, we are finalizing most of the changes proposed to simplify and refocus the areas included in the Star Ratings, including changes to the measure set, with the exception of the proposal to remove the Diabetes Care--Eye Exam measure from the Star Ratings. We also are finalizing our proposal to not move forward with the implementation of the Health Equity Index reward and to continue to include the historical reward factor in the Star Ratings methodology. We are finalizing adding additional information about the data available to MA organizations and Part D sponsors during the plan preview periods before each Star Ratings release. We also solicited comments in the Contract Year 2027 proposed rule on ways to further simplify and modify the Star Ratings program to further drive improved quality of care, and whether there are ways to streamline the timeline from measure development to implementation. In this rule we are also finalizing a technical clarification proposed in the Medicare and Medicaid Programs; Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly proposed rule, which appeared in the Federal Register on December 10, 2024, to provide details about how the enrollment- weighted measure score is calculated when a consumed or surviving contract is missing data for a measure. We also solicited additional feedback related to Star Ratings in the Request for Information on Future Directions in Medicare Advantage in section 6 of the Contract Year 2027 proposed rule.

\84\ https://www.cms.gov/medicare/quality/meaningful-measures-initiative/cms-quality-strategy.

B. Adding, Updating, and Removing Measures (Sec. Sec. 422.164 and 423.184)

In the “Medicare Program; Contract Year 2019 Policy and Technical Changes to the Medicare Advantage, Medicare Cost Plan, Medicare Fee- for-Service, the Medicare Prescription Drug Benefit Programs, and the PACE Program” final rule which appeared in the Federal Register on April 16, 2018 (83 FR 16532) (“Contract Year 2019 final rule”), we stated we are committed to continuing to improve the Part C and D Star Ratings system and anticipated that over time measures would be added, updated, and removed. We also specified at Sec. Sec. 422.164(d) and 423.184(d) rules for measure updates based on whether they are substantive or non-substantive. The regulations, at paragraph (d)(1), list examples of non-substantive updates. (See also 83 FR 16534 through 16537.) Due to the regular updates and revisions made to measures, CMS does not codify a list in regulation text of the measures (and their specifications) adopted for the Part C and D Star Ratings program. CMS lists the measures used for the Star Ratings each year in the Medicare Part C & D Star Ratings Technical Notes or similar guidance issued with publication of the Star Ratings.

The regulations at Sec. Sec. 422.164 and 423.184 specify the criteria and procedures for adding, updating, and removing measures for the Part C and D Star Ratings program. As has been historically operationalized and as described at 83 FR 16533, measure removals are proposed and finalized through rulemaking unless they meet the requirements at Sec. Sec. 422.164(e)(1) and 423.184(e)(1), which allow for measure removals through the process described for changes in and adoption of payment and risk adjustment policies in section 1853(b) of the Act. This subregulatory process for measure removal was codified at Sec. Sec. 422.164(e)(1) and 423.184(e)(1) to allow CMS to remove measures quickly, and without separate rulemaking, in certain circumstances where it is appropriate and necessary to do so. We proposed language at Sec. Sec. 422.164(e)(3) and 423.184(e)(3) to clarify our existing policy that removal of measures for any other reasons not stated in paragraph (e)(1) will be proposed and finalized through rulemaking. We also proposed language at Sec. Sec. 422.164(e)(2) and 423.184(e)(2) to clarify that removals for the reasons stated in paragraph (e)(1) will either be announced through the process described for changes in and adoption of payment and risk adjustment policies in section 1853(b) of the Act or proposed and finalized through rulemaking. This language would reflect that where one of the bases for measure removal identified in paragraph (e)(1) applies, we would pursue removal using the process that allows for the most expedient notice to MA organizations and Part D sponsors at that time. For example, if a measure steward announces a measure retirement, we would use the process described for changes in and adoption of payment and risk adjustment policies in section 1853(b) of the Act or rulemaking depending on the timing of the announcement so that we can provide this information as quickly as possible to MA organizations and Part D sponsors.

We received several comments on our proposal to clarify existing policies and procedures on measure removal. A discussion of these comments follows, along with our responses and final decision.

Comment: All commenters expressed support for the proposed language to clarify the process of measure removal.

Response: We appreciate the support received for the proposed clarification and thank the commenters for their feedback.

Comment: A few commenters emphasized the importance of transparency and the value of stakeholder engagement as part of the comment process for measure removal, particularly for high-impact clinical measures, including those affecting common chronic conditions.

Response: We agree with these commenters and highlight here that removals for the reasons stated in Sec. Sec. 422.164(e)(1) and 423.184(e)(1) will either be announced through the process described for changes in and adoption of payment and risk adjustment policies in section 1853(b) of the Act (that is, the annual Advance Notice and Rate Announcement) or proposed and finalized through rulemaking. We intend to use whichever process allows for the most expedient notification to MA organizations and Part D sponsors. We appreciate the value of robust stakeholder engagement and note that stakeholders will continue to have an opportunity to provide input regarding measure removals.

Comment: Another commenter urged CMS to ensure that MA enrollees are not harmed by any measure removal and that the needs of enrollees and their providers take priority in decision-making concerning MA and Part D.

Response: CMS monitors the Part C and D Star Ratings and display page

measures for quality improvement, relevance, and necessity. CMS publishes display measures on www.cms.gov each year, including measures that have been transitioned from the Star Ratings, new measures that are tested before inclusion in the Star Ratings, or measures displayed for informational purposes only. This listing of measures is separate and distinct from CMS's Part C and D Star Ratings. If CMS identifies the need to remove a measure from the Part C and D Star Ratings program for any of the reasons stated in Sec. Sec. 422.164(e)(1) and 423.184(e)(1), measure removal will be announced in a timely manner either through the process described for changes in and adoption of payment and risk adjustment policies in section 1853(b) of the Act or proposed and finalized through rulemaking. CMS will consider public input on measure removals, including any impact on enrollees and providers.

After consideration of the comments received and for the reasons outlined in the Contract Year 2027 proposed rule and our response to comments, we are finalizing the proposal at Sec. Sec. 422.164(e)(2), 422.164(e)(3), 423.184(e)(2), and 423.184(e)(3) without modification. Since this codification is consistent with current practice and policy, it will apply immediately on the effective date of the final rule and to the 2027 Star Ratings. 1. Removing Measures

As the Part C and D Star Rating program continues to evolve and align with the measures included in the Universal Foundation,\85\ a strategy to align measures across the agency's quality and value-based care goals, we proposed to simplify and refocus the measure set on clinical care, outcomes, and patient experience of care measures where performance is not topped out and where there is more variation in performance across contracts. Reducing the number of measures would increase the focus on the remaining measures, including those consistent with the Make America Healthy Again (MAHA) initiative, such as Reducing the Risk of Falling and Monitoring Physical Activity. Additionally, reducing the number of measures is consistent with recommendations from MedPAC \86\ and other interested parties that CMS consider having fewer measures in the Part C and D Star Ratings program. This is also consistent with the Universal Foundation which attempts, among other things, to focus attention on measures that are meaningful for the health of broad segments of the population and to reduce provider burden by streamlining and aligning measures--in other words, to focus the measure set on clinical care, outcomes, and patient experience of care measures. We initially solicited feedback on simplifying and refocusing the measure set in the Advance Notice of Methodological Changes for Calendar Year (CY) 2026 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies (“2026 Rate Announcement”),\87\ as well as from the Star Ratings Technical Expert Panel (TEP) in October 2024.\88\

\85\ https://www.cms.gov/medicare/quality/cms-national-quality-strategy/aligning-quality-measures-across-cms-universal-foundation.

\86\ Replacing the Medicare Advantage quality bonus program-- MedPAC.

\87\ https://www.cms.gov/files/document/2026-advance-notice.pdf.

\88\ https://www.rand.org/pubs/conf_proceedings/CFA3973-1.html.

Although the TEP recommended keeping the measure set as large as possible to avoid the ratings being influenced by a single measure, the TEP did support rethinking the measures included. Overall, the TEP supported measures from the current Healthcare Effectiveness Data and Information Set (HEDIS), Consumer Assessment of Healthcare Providers and Systems (CAHPS), Health Outcomes Survey (HOS), and some of the operational measures. Suggestions included the following: adding more evidence-based, clinical outcomes measures or redesigning current measures to assess patient outcomes (such as medication adherence); considering relevance, reliability, and the small denominator for some measures; considering “gameability,” attribution issues, provider burden, and the sensitivity of measures to small changes; and considering measures focused on trust enrollees have in the plan and network issues.

After taking into consideration feedback from the TEP and from interested parties that commented on the Advance Notice of Methodological Changes for Calendar Year (CY) 2026 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies,\89\ we proposed to remove seven Star Ratings measures focused on operational and administrative performance, three additional measures focused on process of care, and two additional measures focused on patient experience of care. There is a balance between streamlining the measure set and continuing to include enough measures to assess performance across the range of health care quality and to avoid contracts “teaching to the test” or focusing performance improvement efforts on a limited number of measured areas. We aim to achieve this balance by proposing initially to remove measures focused on operational and administrative performance, along with some additional process and patient experience of care measures with high performance and less variability across contracts, while retaining many measures focused on clinical care, outcomes, and patient experience and continuing to see where we can add additional outcomes measures in the future.

\89\ See pages 107-110 at https://www.cms.gov/files/document/2026-announcement.pdf for a summary of comments.

There are various measures currently in the Part C and D Star Ratings measure set that focus on operational performance or on completion of required administrative processes. While these measures have been invaluable to CMS's efforts to monitor and improve plan performance and compliance in critical operational areas, many of these measures may be better suited as measures to monitor plan performance and compliance rather than as quality measures in the Part C and D Star Ratings program, especially since ratings for many of these measures are sensitive to small changes in performance because they have smaller denominators, such that small changes in the numerator can have a large impact on the measure Star Rating. Additionally, we have seen improvement on these measures since the inception of the Part C and D Star Ratings program, and MA organization and Part D sponsor performance rates are consistently fairly high.

We also proposed to remove three additional process measures (Diabetes Care--Eye Exam, Statin Therapy for Patients with Cardiovascular Disease, and Members Choosing to Leave the Plan) and two patient experience of care measures (Customer Service and Rating of Health Care Quality) to further streamline the Star Ratings measure set. We want to focus more on clinical care, outcomes, and patient experience of care measures where performance is not topped out and where there is more variability in performance across contracts. This is where there is more room for improvement and measures where we see MA organization and Part D sponsors need more incentives to perform well. Additionally, when there is little variation in performance across contracts for a measure, this does not provide meaningful information to beneficiaries or their caregivers when choosing a plan. One purpose of providing quality and performance information is to highlight differences in

performance across contracts that can impact the care and services provided by the plan. Reducing the number of operational and administrative measures and removing some additional process and patient experience of care measures would also increase the relative weight of the outcome measures in the summary and overall ratings.

We proposed to remove the 12 measures in Table 3 beginning with the Star Ratings year shown in the table for each measure. As stated in the Contract Year 2027 proposed rule, we expect that removing these measures would result in an overall decrease in ratings since performance on many of these measures is very high; however, we also expect that the proposed removal of the Health Equity Index (HEI; also called Excellent Health Outcomes for All) reward along with keeping the historical reward factor, discussed in more detail in section V.D. of this final rule, would generally increase ratings. We provide the estimated combined impact of the final Star Ratings policies in section XI.C.6. of this final rule.

CMS is also considering removing additional measures in the future as we continue to simplify and refocus the program. Removal of any additional measures would need to be proposed and finalized through rulemaking. [GRAPHIC] [TIFF OMITTED] TR06AP26.032

We solicited feedback on all of the potential measure removals discussed in the Contract Year 2027 proposed rule, including feedback on the timing of measure removals and received many comments. A discussion of general measure removal comments, along with our responses follows. Comments about specific measures and our responses are summarized below each specific measure discussion.

Comment: Some commenters supported streamlining and refocusing the Star Ratings measure set. These commenters supported a focus on clinical care, outcomes, and patient experience.

Response: We thank these commenters for their support.

Comment: Some commenters were concerned that removing measures will reduce oversight and transparency of plan performance. Several commenters recommended that the measures continue to be reported on the display page. Some commenters were also concerned about the potential loss of quality gains if the measures are removed.

Response: CMS agrees that continued transparency and oversight are important when measures are removed from Star Ratings. Thus, CMS will continue to publicly report removed measures on the display page, which are displayed separately on cms.gov and not on Medicare Plan Finder, and will continue to monitor plan performance through its existing oversight and compliance activities. Where CMS identifies that an MA organization has failed to comply with the terms of its contract, we will continue to take appropriate compliance actions per 42 CFR 422.504(m)(3) and publicly post warning letters and corrective action plan requests (CAPs). If an organization receives too many compliance actions, CMS may deny applications for new contracts or service area expansions under 42 CFR 422.502(b)(1) for failure to perform in accordance with CMS contractual requirements. This approach preserves oversight of plans and transparency for beneficiaries and other interested parties while allowing the Star Ratings program to focus on measures that more meaningfully differentiate performance across contracts.

Comment: Some commenters expressed concern about removing administrative measures and noted that it may distort competition in MA by disproportionately harming smaller or regional plans and SNPs, and increase revenue volatility. They cautioned that outcomes-based measures alone are often harder for plans to control, and that administrative measures provide a stabilizing counterbalance within the Star Ratings system.

Response: CMS appreciates commenters' perspectives regarding the potential programmatic impacts of removing administrative measures from the Star Ratings program. CMS recognizes that outcomes-based measures can be more challenging for plans and that administrative measure scores have historically remained stable within the Star Ratings system given the high performance across all contracts. However, measures included in Star Ratings should meaningfully differentiate performance across contracts. Measures with little variation across contracts do not provide meaningful comparative information for potential enrollees when choosing a plan. CMS will continue to evaluate the mix of measures included in the Star Ratings program and its impact on plans of varying sizes. With regard to smaller plans or SNPs, in simulations of the impact of the proposed changes, we did not find that there were disproportionate impacts to these types of plans (see the Impact of Proposed and Finalized Changes section for more details).

Comment: Some commenters supported simplification of the Star Ratings, but cautioned against wholesale removal of measures without replacement. They recommended that if measures are removed from Star Ratings, CMS should consider beneficiary impacts and maintain robust, transparent compliance monitoring, enhanced CAHPS

questions, or public reporting to preserve accountability. Many of these commenters emphasized that the removed measures should still be publicly reported, even if CMS restructures how they are measured or incentivized.

Response: CMS appreciates commenters' support for simplifying the Star Ratings program while maintaining accountability. CMS agrees that continued transparency and oversight are important when measures are removed from Star Ratings. Thus, CMS will publicly report removed measures on the display page and will continue to monitor plan performance through its existing oversight and compliance activities. This approach preserves transparency for beneficiaries and other interested parties while allowing the Star Ratings program to focus on measures that more meaningfully differentiate performance across contracts.

Comment: A commenter stated that as CMS makes changes to the Star Ratings including proposing to eliminate the HEI reward, and adding and removing measures, CMS should ensure that changes are communicated to beneficiaries in an accessible way, including with State Health Insurance Assistance Programs (SHIPs) assistance. The commenter also stated that educational and training materials should be provided to SHIP counselors to help them understand and interpret the changes.

Response: We agree it is important for beneficiaries to understand the Star Ratings and we are considering how to best present the Star Ratings to make it easier for beneficiaries to understand. For example, we are reviewing how the ratings are presented on the Medicare Plan Finder website.

Comment: Some commenters raised concerns about Star Ratings volatility, destabilizing the Star Ratings system, and downstream impacts to QBPs if CMS removes multiple administrative measures at the same time. These commenters also raised concerns about making the remaining measure set smaller and more sensitive to single-measure changes. Some commenters were concerned about removing too many measures too fast and recommended a phased approach for removal of measures. Commenters also raised concerns about program disruption, which they believe will undermine the predictability and stability of the program and impact beneficiary experience.

Response: CMS does not agree that removal of measures destabilizes the Star Ratings program. The measures we proposed for removal have topped out (i.e., have very high performance across all contracts such that cut points for the measure are very close together and do not reflect meaningful differences in performance), are duplicative, or no longer provide meaningful differentiation across plans. Retaining such measures reduces the impact of measures that better distinguish differences in plan quality and performance. Removing these measures in a timely manner strengthens the Star Ratings program and supports informed beneficiary choice.

Comment: A couple of commenters recommended changing measure specifications or redesigning measures rather than removing measures. Other commenters proposed alternative approaches to deal with a “topped-out” measure apart from removing it from Star Ratings, including increasing the cut points, penalizing contracts if performance is not maintained, creating a composite measure of operational performance, and reassessing whether or how high-scoring measures should impact payment.

Response: As discussed in the Contract Year 2027 proposed rule, the Part C and D Star Ratings program continues to evolve and align with the measures included in the Universal Foundation. As such, we proposed simplifying and refocusing the measure set to focus on measures of clinical care, outcomes, and patient experience where performance is not topped out and where there is more variation in performance across contracts. Reducing the number of measures would increase the focus on the remaining measures, including those consistent with the MAHA initiative. Our proposal aimed to strike a balance between streamlining the measure set and maintaining enough measures to assess performance across the range of health care quality.

Comment: A commenter expressed concern that the removal of measures will create a substantial shift in how the measures are weighted, stating that 44 percent of the weighting would shift to member survey results for CAHPS and HOS. The commenter stated that these surveys are often unduly influenced by factors such as timing of the survey, memory recall bias, and survey fatigue. The commenter also stated that there is randomness, unpredictability, and volatility inherent in survey measures and how they are scored does not correlate to actual plan performance.

Response: We appreciate the commenter's concern regarding the potential impact of removing certain measures on the weighting of remaining measures, including the increased contribution of CAHPS and HOS survey measures. We disagree that these survey measures are unduly volatile or fail to reflect actual plan performance.

CAHPS and HOS are standardized, validated instruments designed to capture beneficiary experience and health outcomes. CMS employs multiple methodological safeguards, including standardized survey administration, large sample sizes, and case-mix adjustment to ensure reliable information that is comparable across contracts.

CAHPS and HOS measures provide information that complements clinical and administrative measures. Incorporating beneficiary- reported measures also aligns with CMS's commitment to evaluating beneficiaries' experiences of care and ensures that quality measurement reflects aspects of care that are best assessed by beneficiaries themselves. Accordingly, we find that the weighting of CAHPS and HOS measures remains appropriate.

Comment: A commenter stated that administrative measures were within plan control rather than health care provider control and should be retained. Another commenter recommended that CMS evaluate measures based on the degree of plan-level control and overlap with existing incentives in order to help prioritize measures where Star Ratings are most likely to produce improvements.

Response: CMS does not agree that non-administrative measures are not within plan control. The measures included in the Star Ratings are evaluated at the contract level and reflect the collective performance of the organization, including the organization's provider network. For each of its contracts, MA organizations are responsible for establishing provider networks, designing benefits, furnishing care management and care coordination services, and implementing quality improvement strategies to support measure performance.

Comment: A commenter supported the idea of simplifying the measure set in concept but did not support the proposal because of the associated increase in Medicare spending. The commenter stated that if CMS streamlines the measure set in future rulemaking, it should do so in a way that does not add cost.

Response: As we stated in the Contract Year 2027 proposed rule, we expect that removing these measures would result in an overall decrease in ratings since performance on many of these measures is very high; however, we also expect that not implementing the HEI reward, along with keeping the

historical reward factor, would generally increase ratings. While the combination of these two proposals results in net costs, the measure removal proposal on its own would result in savings.

Comment: A couple of commenters raised concerns about the ability of I-SNPs to have data for enough measures to receive an overall Star Rating. A commenter also stated that the measures proposed for removal are in areas where these plans typically perform well, noting that their removal would magnify the impact of the remaining measures which the commenter believes are not well-suited for long-term care populations.

Response: We appreciate this commenter's concerns about I-SNPs having data for enough measures to qualify for an overall rating. We will continue to monitor this and will consider what additional measures may be available for I-SNP only contracts. With regard to I- SNPs performing well on the measures proposed for removal, we note that this is also true of plans more broadly because performance on many of the measures is very high.

Comment: A commenter raised concerns that removing too many operational and administrative measures may weaken the program's ability to capture aspects of performance that are most relevant to beneficiaries, and that removing the measures may shift focus away from day-to-day experiences that shape beneficiary satisfaction and trust. Another commenter disagreed that the measures proposed for removal are not meaningful to beneficiaries.

Response: CMS will continue to closely monitor any measure removed from Star Ratings through existing oversight and compliance activities and will publicly report these measures on the display page. This approach preserves transparency for beneficiaries and other interested parties while allowing the Star Ratings program to focus on measures that more meaningfully differentiate performance across contracts.

Comment: A commenter stated that some measures that appear topped out are actually influenced by gaming among plans.

Response: We appreciate the commenter's concern. CMS is not aware of evidence of widespread gaming across Star Ratings measures. However, CMS agrees that measures that are vulnerable to manipulation or no longer meaningfully differentiate plan performance are not appropriate for continued inclusion in the Star Ratings.

Comment: A commenter recommended using statistical tests of variation over time to determine whether a measure should be removed and implementing a cap in the number of measures removed in a year.

Response: CMS appreciates this comment; however, we have evaluated performance on the measures proposed for removal and find that it is appropriate to remove them now in line with our goal of streamlining and refocusing the measure set. a. Plan Makes Timely Decisions about Appeals (Part C) and Reviewing Appeals Decisions (Part C)

We proposed removing the Plan Makes Timely Decisions about Appeals (Part C) and Reviewing Appeals Decisions (Part C) measures because average performance on these measures has increased from 90 to 96 percent and 88 to 95 percent from the 2015 to 2025 Star Ratings, respectively. There is also not a lot of variation across the vast majority of contracts on these measures and the measures can have small denominators for some contracts, both of which can lead to shifts in ratings as a result of small changes in the numerator. Since the appeals process is critical to monitor as it impacts access to care, CMS would continue to monitor plan performance and issue compliance actions based on appeals data as needed and would continue to monitor access issues through the CAHPS survey measures.

We solicited comment on removing the appeals measures from the 2029 Star Ratings. A discussion of Part C appeals measure removal comments, along with our responses follows.

Comment: Many commenters opposed removing appeals-related measures from the Star Ratings, emphasizing that these measures are essential indicators of access to care. They argued that appeals measures capture utilization management problems, including inappropriate denials, delays in post-acute care, and failure to process or forward appeals appropriately. Other commenters stressed that these measures are not merely administrative but directly tied to care continuity, discharge planning, transitions of care, and prevention of avoidable complications, hospitalizations, or functional decline. Several commenters emphasized that Star Ratings are the primary enforcement and accountability mechanism for the appeals measures within MA. They stated that because Star Ratings drive financial bonuses, enrollment growth, and marketing advantages, they significantly influence plan behavior. Some commenters also noted that appeals measures included in Star Ratings create tangible incentives for plans to reduce inappropriate denials, process appeals correctly, and comply with beneficiary protection requirements. Removing these measures would, in their view, erode accountability and shift reliance to oversight mechanisms that may lack sufficient resources or enforcement power.

Some commenters raised concerns about vulnerable populations, including individuals with complex medical needs, dually eligible individuals, and patients requiring specialized or time-sensitive care such as cancer treatment, post-acute services, or chronic disease management. For these populations, delays in appeals decisions can lead to irreversible harm. These commenters argued that maintaining appeals measures is especially important to ensure these groups are not disproportionately disadvantaged.

Response: CMS appreciates the thoughtful comments regarding the removal of appeals-related measures from the Star Ratings. We agree that the appeals process is a critical beneficiary protection and plays an important role in ensuring access to medically necessary care for all enrollees. Appeal rights are a core component of MA requirements, and plans remain fully accountable for appropriately administering the appeals process for all enrollees, regardless of whether specific appeals measures are included in the Star Ratings.

While CMS is removing the appeals-related measures from the Star Ratings, this action does not diminish plans' obligations under existing regulations at 42 CFR part 422, subpart M to comply with appeals requirements, including timely, accurate, and complete processing of appeals. CMS will continue to actively monitor plans' appeals adjudication through multiple oversight mechanisms, including audits, monitoring activities, and compliance actions. Where CMS identifies noncompliance, we will take appropriate compliance actions per 42 CFR 422.504(m)(3), publicly post warning letters and corrective action plan requests (CAPs), and if an organization receives too many compliance actions may deny applications for new contracts or service area expansions under 42 CFR 422.502(b)(1) for failure to perform in accordance with CMS contractual requirements.

CMS recognizes commenters' concerns that appeals measures reflect issues related to utilization management, inappropriate denials, and

care delays, and that failures in appeals processing can affect care continuity, discharge planning, and transitions of care. CMS also acknowledges the particular importance of an effective appeals process for vulnerable populations, including individuals with complex medical needs, dually eligible individuals, and those requiring specialized or time-sensitive care. Plans are expected to appropriately administer the appeals process for all enrollees, including these populations, as part of their fundamental responsibility to provide access to covered benefits.

Although Star Ratings serve as one mechanism to promote accountability, they are not the sole means by which CMS ensures compliance with MA requirements. CMS will continue to use its full range of oversight and compliance authorities to hold plans accountable for appeals-related failures and to protect beneficiaries' access to care. Appeals are not optional administrative functions; they are a core responsibility of MA plans, and CMS expects plans to administer appeals processes appropriately, consistently, and in compliance with all applicable requirements.

Comment: Some commenters supported removal of the appeals measures, citing methodological concerns such as disproportionate impact on smaller plans due to a smaller number of appeals and the lack of a volume adjustment. Other commenters supported removing the measures because they are operational, topped out, or poorly differentiated across contracts. These commenters argued the measures no longer meaningfully reflect quality, can be excessively burdensome, and are better suited for compliance monitoring than Star Ratings. These commenters supported shifting the Star Ratings program's focus toward clinical outcomes and value-based measures, with appeals oversight handled through audits, CAHPS surveys, or internal CMS monitoring instead of financial incentives.

Response: We appreciate commenters' support for the removal of the appeals-related measures from the Star Ratings program. CMS agrees that these measures no longer meaningfully differentiate performance across contracts due to consistently high performance levels and limited variation, and can be burdensome in that small changes in performance can have an impact on ratings given the measures are topped out. Consistent with commenters' feedback, CMS agrees that these appeals measures are better suited for compliance and program oversight rather than inclusion in Star Ratings as quality measures tied to financial incentives. Appeals processes remain an important safeguard for beneficiaries; however, CMS will conduct oversight of these activities through other monitoring efforts. By removing these measures from Star Ratings, CMS intends to refocus the program on measures that more effectively assess clinical care and beneficiary experience, while continuing to ensure robust oversight of appeals processes through other established channels.

Comment: Some commenters suggested that removing appeals measures from Star Ratings could disadvantage smaller, regional, or single-state plans that often excel in member experience, while benefiting large national plans. Other commenters argued that the appeals measures create uneven operational burden and do not reliably differentiate plan performance, particularly for plans near minimum thresholds.

Response: CMS has found that the appeals measures generally have high performance across all types of contracts which limits their ability to meaningfully distinguish differences in plan performance across contracts, regardless of plan size. For a measure to be useful for a beneficiary choosing a contract, it needs to have variation across contracts to be able to highlight differences in performance. Nevertheless, it will be critical to still calculate, monitor, and publicly report these measures since appeals processing is critical for the success of the MA program. As a reminder, CMS calculates the scores for the appeals measures from data contained in the Independent Review Entity (IRE) data system; thus, there is no burden to plans in these calculations.

Comment: Some commenters stated that high performance on appeals measures may be misleading rather than proof that the measures are no longer needed. Commenters described plan practices that artificially inflate performance, such as overturning denials early to avoid independent review, mislabeling valid beneficiary appeals as provider disputes, or improperly asserting that certain denials are not appealable. These tactics can block access to the IRE and obscure inappropriate denials from CMS oversight.

Response: We appreciate commenters'concerns that high performance on the appeals measures may not accurately reflect beneficiary protections and that tying these measures to Star Ratings may create incentives for plans to focus on appeals measure performance rather than meaningful access to the appeals process. CMS strongly objects to inappropriate practices by plans, such as overturning denials to avoid independent review or misclassifying appeals that can obscure access issues and limit visibility into inappropriate denials. Due to concerns regarding gaming, CMS implemented scaled reductions for the appeals measures to try to ensure all requisite appeals are sent to the IRE. By moving the appeals measures to the display page, CMS intends to reduce incentives to game measure performance while maintaining transparency into plans' appeals performance for beneficiaries and other interested parties. CMS will continue to monitor appeals and address inappropriate denials outside of the Star Ratings and QBP programs and hold plans accountable through compliance strategies as described in the section about general comments regarding measure removals.

Comment: Some commenters expressed concern that plans may deny more services, knowing fewer denials will be challenged or scrutinized. This would increase administrative costs for providers, delay care, and undermine CMS's goals of value-based care and program integrity. A few commenters emphasized that the “Reviewing Appeals Decisions” measure is particularly important for ensuring that plans do not shield indefensible denials from independent oversight.

Response: CMS shares commenters' concerns about inappropriate service denials and agrees that it is important to continue close oversight of plan appeals processing. While CMS is removing the appeals measures from the Star Ratings program, CMS will continue to monitor appeals through program audits and other oversight and compliance activities and will publicly report these measures on the display page. Removing these operational measures from the Star Ratings reduces administrative burden for CMS in the calculation of the ratings and allows the Star Ratings program to focus on measures with greater variation across contracts.

Comment: Several commenters argued that improved performance over time should be viewed as evidence that these measures are working, not as justification for elimination. These commenters suggested that sustained increases in appeals timeliness and review scores are attributed to the incentives created by Star Ratings. These commenters suggested that removing the appeals measures risks reversing years of progress and sending a signal that timely, fair appeals are no

longer a priority, even as utilization management and prior authorization remain major sources of access barriers. These commenters emphasized that removing the appeals measures would reduce plans' focus on appeals timeliness and accuracy, likely leading to backsliding, longer delays, and increased inappropriate denials. Several commenters emphasized that when financial and reputational incentives are removed, plans tend to redirect resources away from appeals processing.

Other commenters stressed that the high or “topped-out” performance on these measures reflects the success of the Star Ratings program rather than evidence that oversight is no longer needed. Commenters also noted recent declines in performance and persistent outliers at the contract level, arguing these trends show it is premature to remove the measures.

Response: CMS appreciates commenters' views that improved and sustained performance on the appeals measures reflects the effectiveness of the Star Ratings program and the incentives it creates. CMS agrees that timely and accurate appeals processing remains an important beneficiary protection and that continued oversight is necessary. However, the consistently high performance and limited differentiation across contracts indicate that these measures no longer function effectively as Star Ratings quality measures. We have not seen a decline in measure scores over the past year. For the 2026 Star Ratings, Plan Makes Timely Decisions about Appeals had an average score of 98%, and Reviewing Appeals Decisions had an average score of 97%, up from 96% and 95%, respectively, from the prior year.

While CMS is removing the appeals measures from Star Ratings, this does not diminish the importance of appeals timeliness or accuracy nor does it mean that CMS will stop calculating these measures. CMS will continue to closely monitor appeals processing and will publicly report these measures on the display page. Existing MA oversight processes such as program audits and contract monitoring will also continue to apply to the appeals processing measures. This approach maintains accountability and transparency while allowing the Star Ratings program to focus on measures that better differentiate performance.

Comment: A number of commenters urged refinement rather than removal of these measures from Star Ratings to help improve differentiation across contracts. Some commenters focused on methodological and data issues, acknowledging CMS's concerns about small denominators and limited variation. Other commenters recommended standardizing IRE determinations.

Response: CMS appreciates commenters' thoughtful suggestions to refine the appeals measures to improve differentiation across contracts. We will take these comments into consideration if we make future changes to these measures after moving them to the display page. The process of standardizing how the IRE makes decisions is outside the scope of the Star Ratings program.

Comment: Several commenters advocated for expanded public reporting and transparency if CMS proceeds with removal of the appeals measures, including requiring plans to publish annual reports on appeals timeliness, independent review outcomes, and overturned denial rates with stratification by service type. Other commenters suggested that CAHPS surveys and compliance monitoring cannot replace appeals measures in Star Ratings. While CAHPS provides valuable high-level patient experience data, commenters expressed it is lagged and lacks the operational specificity needed to detect real-time access barriers or improper plan practices.

Response: CMS appreciates commenters' recommendations regarding expanded transparency and public reporting following removal of the appeals measures from Star Ratings. CMS agrees that transparency remains important and will continue to publicly report appeals-related measures on the display page, while maintaining oversight and compliance through various monitoring activities. While CMS acknowledges commenters' views regarding limitations of CAHPS surveys for identifying real-time operational issues, CMS will use a combination of public reporting and existing oversight mechanisms to provide appropriate visibility into appeals processing.

After considering the comments we received and for the reasons outlined in the Contract Year 2027 proposed rule and our responses to the comments, we are finalizing the removal of the Plan Makes Timely Decisions about Appeals (Part C) and Reviewing Appeals Decisions (Part C) measures beginning with the 2029 Star Ratings. b. Special Needs Plan (SNP) Care Management (Part C)

We proposed removing the SNP Care Management (Part C) measure as part of our effort to increase the focus on patient experience and outcome measures. This administrative-focused process measure indicates how often a contract completed the required health risk assessment. The goal of this assessment is to then use the results to help enrollees get the care they need. CMS is ultimately interested in whether enrollees receive needed care as indicated by this assessment and not only whether the assessment is completed. We proposed removing this measure since the current measure does not provide any information about whether enrollees received care as indicated by their assessments. We would move this measure to the display page.

We solicited comment on removing the SNP Care Management measure from the 2029 Star Ratings. A discussion of SNP Care Management measure removal comments, along with our responses follows.

Comment: Some commenters supported the removal of the SNP Care Management measure, primarily because it is an administrative measure that tracks the percentage of members with a completed a Health Risk Assessment (HRA), as opposed to a more meaningful clinical outcome measure. Several other commenters simply appreciated the simplification of the Star Ratings measures, or recommended monitoring care management through other mechanisms.

Response: We appreciate the support for removing the SNP Care Management measure.

Comment: A number of commenters opposed removal of this measure since they were concerned that removal would reduce plan oversight and they claimed there is already underutilization of HRAs. Several commenters were specifically concerned about how proposed Star Ratings changes would impact SNP contracts, concerned that the removal would have a negative impact on dually eligible individuals as well as I-SNP enrollees, who are typically sicker and have more complex care needs. There were also concerns expressed about specific groups, such as those with kidney disease; commenters emphasized the importance of ensuring access to services for all vulnerable populations.

Response: CMS recognizes that HRAs are an important tool for providers and care teams in determining enrollee needs and ensuring access to appropriate services, particularly for vulnerable populations, including individuals with chronic or complex conditions such as kidney disease. The removal of the SNP Care Management measure from Star Ratings is not intended to reduce the use or importance of HRAs, nor to diminish

the quality of care delivered to SNP enrollees.

The removal of this measure from Star Ratings does not eliminate the requirement for SNPs to conduct HRAs at 42 CFR 422.101(f)(1)(i) and (ii). HRAs remain a required component of SNP model of care requirements and are critical for identifying enrollees' clinical, functional, and cognitive needs, as well as for informing individualized care planning and ongoing care management. Additionally, the SNP Care Management measure will remain available on the display page so performance information will continue to be publicly reported.

Comment: Some commenters suggested ways to modify the current measure. For example, CMS could work with SNPs and other stakeholders to develop a more meaningful measure, including a measure about whether the care identified in the HRA was provided. Other suggestions included expanding the SNP Care Management measure to all MA members and reporting at the geographic level. Another commenter expressed the need for clearer alignment between the NCQA Model of Care accreditation process and any future measures in this area.

Response: We appreciate the suggestions regarding changes to the SNP Care Management measure. We will take these suggestions into consideration for any future updates to this measure after moving it to the display page. We agree that it would be useful to measure whether care was provided since currently the measure just notes whether an HRA was completed and not if the information collected was used to develop and deliver a care plan.

After considering the comments we received and for the reasons outlined in the Contract Year 2027 proposed rule and our responses to the comments, we are finalizing the removal of the SNP Care Management measure beginning with the 2029 Star Ratings. c. Call Center--Foreign Language Interpreter and TTY Availability (Part C and D)

We proposed removing the Call Center--Foreign Language Interpreter and TTY Availability (Part C and D) measures. Average performance on these measures in the 2025 Star Ratings was very high at 94 percent on the Part C measure, and 94 percent for MA-PD contracts and 97 percent for PDP contracts on the Part D measure. Additionally, there is not a lot of variation across the vast majority of contracts on these measures, and the measures have relatively small denominators, both of which can lead to shifts in ratings as a result of small changes in the numerator. If these measures were removed, CMS would continue to monitor plan performance and issue compliance actions, and the Star Ratings would continue to capture similar issues related to customer service through the CAHPS survey measures.

We solicited comment on removing the Call Center measures from the 2028 Star Ratings. A discussion of Call Center measure removal comments, along with our responses follows.

Comment: Some commenters supported the removal of the call center measures, noting that their continued inclusion in the Star Ratings system does not meaningfully distinguish plan quality or drive further improvement. Other commenters supported removal since performance is topped out. Some commenters noted the reduction in administrative burden with the removal of these measures and that the current high- performance rates indicate that these measures may no longer be necessary. A few commenters agreed that the focus of Star Ratings should shift to measures that more directly impact clinical outcomes and patient experience. A commenter mentioned that these measures should be removed due to litigation around these measures and volatility in scores due to small denominators.

Response: We appreciate the support for removing the Part C and D Call Center--Foreign Language Interpreter and TTY Availability measures.

Comment: A number of commenters opposed the removal of these measures, stating that they are essential for ensuring meaningful language access and communication for non-native English speakers and those with disabilities. Some of these commenters emphasized the importance of maintaining measures that assess beneficiary experience with plan operations and policy. They stated that removing these measures could reduce oversight and accountability, ultimately harming beneficiary outcomes.

Response: CMS agrees that it is critical to continue to monitor performance on these measures to ensure that enrollees who speak languages other than English and those that are hearing impaired have access to plan call centers. CMS plans to move these measures to the display page so information on performance will still be publicly available. We will also closely monitor performance, issue compliance actions per 42 CFR 422.504(m)(3) and 423.505(n)(3), publicly post warning letters and corrective action plan requests (CAPs), and if an organization receives too many compliance actions may deny applications for new contracts or service area expansions under 42 CFR 422.502(b)(1) and 423.503(b)(1) for failure to perform in accordance with CMS contractual requirements.

Comment: A handful of commenters highlighted the potential negative impact on dually eligible individuals and I-SNP enrollees, who are often sicker and have more complex care needs. They emphasized the importance of maintaining transparency and accountability for measures that ensure access to services for these vulnerable populations.

Response: We agree that it is important to continue to monitor performance on these measures for all contracts, including those that serve vulnerable populations. We will be adding these measures to the display page so we can continue to monitor and make publicly available information about how contracts perform.

Comment: Some commenters requested that CMS provide information on how it will continue to monitor and ensure compliance with language access and TTY requirements if the measures are removed. They urged CMS to maintain robust monitoring and transparency to safeguard beneficiaries' access to these critical services. Some commenters suggested moving these measures to the display page. Some commenters stressed the importance of ensuring equitable access to healthcare services for non-native English speakers and individuals with disabilities.

Response: CMS agrees that monitoring compliance with language access and TTY requirements is critical and is committed to continuing to monitor performance and utilize compliance processes per 42 CFR 422.504(m)(3) and 423.505(n)(3) in this area. We are planning to move these measures to the display page and will continue to carefully review performance and issue compliance actions as needed if we do see poor performance on these measures.

Comment: Some commenters urged CMS to consider alternative approaches to measuring performance that preserve accountability and support meaningful access to language and communication services. A few commenters suggested modifying the call center measures to address concerns about small sample sizes rather than removing them entirely. Other commenters offered specific recommendations for making changes to the call center measures, such as using a multi-year approach for scoring, setting revised minimum denominator rules, or combining Part C

and D measures into a single measure to improve stability and consistency. Other commenters suggested that CMS consider regional language prevalence and contract-level demographic composition when assessing language access. A commenter suggested breaking contracts into groups based on size and demographics to provide a more accurate assessment of a plan's ability to support all of its members. Other commenters suggested calling the current member line versus the prospective member line or calling outside of the annual and open enrollment periods.

Response: We appreciate the suggestions for potential future changes to the Part C and D Call Center--Foreign Language Interpreter and TTY Availability measures, but making changes to measure specifications is out of scope for this final rule. We will take these suggestions into consideration for any future updates to these measures following moving them to the display page.

After considering the comments we received and for the reasons outlined in the Contract Year 2027 proposed rule and our responses to the comments, we are finalizing the removal of the call center measures beginning with the 2028 Star Ratings. d. Complaints About the Health/Drug Plan (Part C and D)

We proposed removing the Complaints about the Health/Drug Plan (Part C and D) measure. We stated that this measure demonstrated exceptionally high performance with limited variation across contracts. Average performance on this measure was high at 0.23 percent for MA-PD contracts and 0.04 percent for PDP contracts in the 2025 Star Ratings (lower scores are better). The volume of complaints has significantly decreased since this measure was first introduced, and there is also minimal variation in performance across contracts. CMS would continue to monitor plan performance and issue compliance actions as needed, and the Star Ratings would continue to capture similar issues related to access to care and patient experience through the CAHPS survey measures.

We solicited comment on removing the complaints measure from the 2029 Star Ratings. A discussion of the complaints measure removal comments, along with our responses, follows.

Comment: The majority of commenters opposed the removal of the Complaints about the Health/Drug Plan (“complaints measure”) from the Star Ratings. Many commenters expressed concern that removal would weaken a key accountability mechanism and incentive for plan sponsors to address issues impacting beneficiaries and providers, and stated the measure is a transparent indicator of plan performance and insight into beneficiary experience and access to care. Several commenters believed that the complaints measure was not just an administrative process measure but a beneficiary protection measure, and the complaints process reflects the final recourse for beneficiaries when the plan does not meet their needs.

A couple of commenters stated that oversight and quality incentives are not mutually exclusive, but complement each other, as a reason to retain the measure in the Star Ratings. Some cited CMS's changes to ensure uniform entry of provider complaints into the Complaints Tracking Module (CTM), and marketing and oversight reforms, as more reasons to keep the measure. Some commenters defended the complaints data as important information regarding providers' experience with plans' utilization management tools. Some commenters stated the complaints process fosters cooperation between plans and providers to resolve beneficiary issues or emphasized the complaints measure included direct feedback from beneficiaries and providers.

Other commenters said that uniformly high performance is evidence of success and the measure's effectiveness in incentivizing plans to improve their processes, rather than a justification for elimination. Commenters expressed concern that CMS was removing a measure they do well in, is within the plans' control, or that acted as a deterrent to non-compliant behavior by plans.

A few commenters believed that removing the complaints measure would weaken a key incentive for plans to maintain adequate staffing, systems, and operational capacity to resolve complaints effectively. One commenter stated that plans may be less likely to take proactive actions to address beneficiary and provider issues if the complaints measure is removed from the Star Ratings, which could unintentionally increase burdens on beneficiaries, providers, and CMS.

Response: We appreciate the thoughtful comments regarding the importance of the complaints measure for plan accountability and beneficiary protection. We acknowledge that it has historically served as an important tool for monitoring plan performance and promoting member-centered customer service. However, the high performance across contracts and minimal variation indicate that this measure no longer effectively differentiates plan quality in the Star Ratings system. The Star Ratings program is most effective when it focuses on measures where meaningful performance differences exist that can inform beneficiary choice and drive continued improvement.

Removal of this measure from Star Ratings does not eliminate CMS's oversight of complaints or our commitment to beneficiary protections. It also does not diminish plans' accountability for researching and resolving complaints, which may include coordination with beneficiaries, providers, or others.

CMS developed the CTM in the Health Plan Management System (HPMS) to track complaints received by CMS from beneficiaries, providers, and their representatives regarding specific MA organizations, Cost Plans, and Part D sponsors. Complaints are recorded in the CTM and assigned to the appropriate plan. Data may be populated into the CTM from various sources, such as 1-800-MEDICARE, CMS staff or contractors, Medicare Ombudsman, SHIPs, the Medicare.gov online complaint form for beneficiaries at https://www.medicare.gov/my/medicare-complaint, or the provider complaint form (regarding MA organizations) at https://www.cms.gov/medicare/health-drug-plans/provider-complaints-form.

As required under the contract provisions established at 42 CFR 422.504(a)(15) and 423.505(b)(22), plans are required to address and resolve the complaints received by CMS against them in the CTM. Plans must adhere to the timelines to resolve complaints in compliance with 42 CFR 422.125 and 423.129. The January 6, 2025 HPMS memorandum, Updated Complaints Tracking Module Standard Operating Procedures, provides information to sponsors on handling, resolving, and documenting complaints. Given the time-sensitive nature of many of the complaints, plans should continuously access, view, respond, and resolve the complaint(s) assigned to their organization in the CTM. CMS expects plans to enter periodic casework notes, including initial and subsequent contacts, developments, or research.

Furthermore, requirements for resolution of complaints received in the CTM do not override requirements related to the handling of appeals and grievances set forth in 42 CFR part 422 subpart M (which apply to cost plans as well as MA organizations per Sec. 417.600) and Part 423 subpart M, for Part D sponsors. Rather, CTM requirements

supplement the appeals and grievance requirements by specifying how organizations must handle complaints received by CMS in the CTM and passed along to the plan. In accordance with the regulations at 42 CFR 422.564 and 423.564, plans must provide meaningful procedures for the timely hearing and resolving of enrollee grievances. As such, beneficiaries are encouraged first to contact their plan directly to file a complaint (i.e., grievance). See the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeal Guidance \90\ for information about grievance procedures.

\90\ Available at: https://www.cms.gov/medicare/appeals-grievances/managed-care.

CMS will continue to closely monitor complaint trends, and how complaints were resolved in CTM casework notes, to ensure that plans maintain appropriate grievance and complaint processes regardless of whether this measure is included in Star Ratings, and CMS will continue to review plan practices for compliance. The complaints provide early warning signs of problems through feedback from beneficiaries and providers, and CMS will continue to calculate complaint rates and resolution timeliness to identify plan outliers for corrective action as necessary.

Comment: Several commenters supported the removal of the complaints measure, agreeing that performance has reached high levels with minimal variation among plans and that complaints are better suited for compliance oversight. A commenter stated that the measure is heavily influenced by factors outside of the plan control, and another pointed out that the measure is prone to manipulation. A couple of commenters agreed that the complaints measure is duplicative of CAHPS measurement. A commenter felt that the measure has systemic biases, and that biases due to plan design or geography could inflate performance.

Response: CMS appreciates the support for removal of the complaints measure from the Star Ratings to focus on measures with meaningful variation, which is consistent with recommendations from the Medicare Payment Advisory Commission (MedPAC) \91\ and our broader goals of reducing administrative burden while maintaining focus on outcome- oriented quality measures.

\91\ Replacing the Medicare Advantage quality bonus program-- MedPAC available at: https://www.medpac.gov/wp-content/uploads/import_data/scrape_files/docs/default-source/reports/jun20_ch3_reporttocongress_sec.pdf.

Comment: Multiple commenters asserted that CAHPS survey measures capture general satisfaction but not specific or real-time feedback about operational issues like the complaints measure. Commenters stated CAHPS and complaints data are complementary rather than duplicative. A few commenters noted that the CAHPS survey-based measures rely on sampling and member recall, but the complaints measures capture direct beneficiary feedback from all beneficiaries. A commenter pointed out that the breadth and specificity of the CTM complaint categories highlights that the CTM captures issues are not reflected in CAHPS. Another commenter stated that measuring access to care and patient experience through the CAHPS survey measures is not meaningful because survey results are not actionable (like complaints are), as questions are broad and ambiguous. A commenter did not want CMS to solely rely on CAHPS survey measures as an indicator of beneficiary experience.

Response: We acknowledge that CAHPS survey measures and complaint data capture feedback on member experience and access to care in different ways. However, the complaints measure no longer supports the purpose of the Star Ratings program, which is to differentiate plan performance in areas where meaningful variation exists. As noted in the response directly above, CMS will continue to monitor complaint data outside of Star Ratings and use this real-time, actionable information for compliance and oversight purposes. This approach allows us to maintain robust oversight while focusing the Star Ratings program on measures that effectively differentiate plan quality. Several measures will remain in the Star Ratings that capture beneficiary satisfaction, care coordination, and quality of care.

Comment: Several commenters recommended delaying the removal of the complaints measure to allow for further evaluation of its impact on plan behavior and beneficiary protection. Some commenters suggested that CMS should implement enhanced monitoring or alternative accountability mechanisms before removing the measure from Star Ratings.

Response: We have carefully considered the timing of this change and find that implementing the removal beginning with the 2029 Star Ratings (based on 2027 measurement year data) provides adequate notice to plans and stakeholders to prepare for the change.

CMS will continue to monitor complaint data and maintain robust oversight mechanisms outside of the Star Ratings program. We do not find that delaying implementation is necessary given the historically low complaints volume and the continued availability of other accountability tools.

Comment: Some commenters suggested changes to the CTM measure specifications. For example, some commenters recommended CMS exclude certain complaints, such as duplicates or provider complaints from the measure; reflect root cause of beneficiary complaints; remove Tukey outlier deletion when calculating this measure's cut points; calculate complaint rates by geographic area instead of by contract; create a new measure solely based on provider complaints or a measure that places a higher weight on provider complaints; or distinguish complaints about inpatient admissions, denials, and post-acute care delays from general customer service issues.

Response: We appreciate the suggestions and will consider them for future measure development or internal oversight metrics.

Comment: Some commenters urged CMS to make CTM complaint data more publicly accessible, including the substance of complaints and plan responses or total complaints stratified by complaint type, to help showcase true beneficiary experience and assist prospective enrollees in comparing plans.

Response: We appreciate these suggestions and recognize the value of transparency in helping beneficiaries make informed enrollment decisions. We will continue to evaluate opportunities to enhance the transparency and accessibility of complaint data while balancing privacy considerations and administrative feasibility.

However, these transparency efforts are separate from the Star Ratings program and do not affect our decision to remove the complaints measure from Star Ratings because of its limited value as a quality measure in light of the lack of variability across contracts.

When the complaints measure is removed from the Star Ratings, the measure will be moved to the display page and continue to be publicly reported.

Comment: Some commenters requested that more information be shared by CMS about the complaints process itself, so that beneficiaries and providers are able to navigate the system effectively.

Response: Information on how to file a complaint with 1-800- MEDICARE is available in multiple Medicare publications and online references. An online complaints form is available, and CMS recently released a provider

complaint form to improve consistent intake of those issues. We will continue to work with stakeholders to improve the visibility of these important avenues for beneficiaries and providers to contact CMS.

After considering the comments we received and for the reasons outlined in the Contract Year 2027 proposed rule and our responses to the comments, we are finalizing the removal of the complaints measure beginning with the 2029 Star Ratings. e. Medicare Plan Finder (MPF) Price Accuracy (Part D)

We proposed removing the MPF Price Accuracy (Part D) measure. Average scores on this measure were very high at 98 for MA-PD contracts and 97 for PDP contracts in the 2025 Star Ratings. Additionally, there is not a lot of variability across most contracts on this measure. If this measure were removed, CMS would continue to monitor plan performance related to drug prices posted on MPF.

We solicited comment on removing the MPF Price Accuracy measure from the 2029 Star Ratings. A discussion of the MPF Price Accuracy measure removal comments, along with our responses, follows.

Comment: Many commenters supported the removal of this measure. Most supporters mentioned their agreement with the reasons for removal stated in the Contract Year 2027 proposed rule, such as high average scores and limited variability across contracts, which limits ability to distinguish between plan performance. A few commenters mentioned that removal of this measure would reduce administrative burden, with a couple mentioning resources could be redirected to patient outcomes. Another commenter stated that the measure does not meaningfully reflect quality.

Several commenters supportive of removal also noted that they agreed with CMS's plan to continue to monitor these data outside of Star Ratings. One commenter specifically stated that CMS's announcement of MPF monitoring in the October 31, 2024 HPMS memorandum with the subject “Medicare Plan Finder Part D Drug Pricing Data Submission Monitoring” was an important step for drug price monitoring, and recommended CMS continue to improve the methodology of this measure when it is removed from the Star Ratings.

A couple of commenters stated that this measure has methodology issues, with one offering ideas to improve the measure if it is not removed. A commenter also stated there was potential “gaming” of this measure through artificial adjustments of pricing files. Another stated that several large national insurance providers “control” the measure due to their dominance in the Pharmacy Benefit Manager (PBM) market, so removal of the measure would create a more level playing field.

Response: We thank these commenters for their support.

Comment: Many commenters opposed the removal of this measure. Most of these commenters noted the importance of accurate data on the MPF so that beneficiaries can make informed choices about their drug coverage. Several noted that the measure is important for holding plans accountable for transparent and accurate pricing data. A commenter noted that lower-income beneficiaries would be especially impacted by removal of the measure since they are more sensitive to price changes. A commenter stated that removing the financial incentive that this measure provides for plans to provide accurate pricing data could reverse progress toward beneficiary protection.

Response: We agree that transparent and accurate data on the MPF are critical for all beneficiaries to make informed decisions about coverage. We would like to assure commenters that CMS will continue to monitor the accuracy of plans' MPF pricing data when this measure is removed from the Star Ratings. This measure will be moved to the display page, and CMS will explore potential future improvements to the measure methodology. CMS will follow up with plan sponsors with poor performance on the MPF price accuracy display measure as necessary.

CMS also performs validations when the pricing data are submitted to CMS for the MPF. The May 27, 2025 HPMS memorandum titled “Contract Year (CY) 2026 Part D Pricing Data Submission Guidance” states that HPMS uses a multi-tiered approach when validating the in-bound drug pricing file submissions from plan sponsors. These validations are tools used by CMS to identify potential inaccuracies prior to display on MPF and may prompt CMS to contact a sponsor for clarification of the accuracy of its submission.

CMS will suppress the display of a sponsor's information when the sponsor fails to correct its data, confirm the accuracy of its data, or respond to a CMS inquiry. Sponsors may be subject to Part D program compliance actions because of MPF suppressions or inaccurate data submissions.

Validations may be added or updated based on CMS's monitoring of the MPF drug pricing data.

Comment: A few commenters that opposed removal of the measure noted that beneficiary experience with MPF in the 2025 Annual Enrollment Period (AEP) was difficult due to the prices constantly changing from week to week, and that this pricing information needs to remain reliable.

Response: CMS notes that the MPF Price Accuracy measure does not use data from AEP (October-December). CMS has a separate monitoring initiative for price changes between AEP and the contract year (CY), as announced in the HPMS memorandum dated October 31, 2024 with subject “Medicare Plan Finder Part D Drug Pricing Data Submission Monitoring”.

Comment: A commenter stated that this measure is important for small plans to distinguish their plan performance for prospective enrollees.

Response: This measure has high average scores and limited variability across contracts, limiting its ability to distinguish between plan performance.

After consideration of the comments we received and for the reasons outlined in the Contract Year 2027 proposed rule and our responses to comments, we are finalizing the removal of the MPF Price Accuracy measure for the 2029 Star Ratings. f. Diabetes Care--Eye Exam (Part C)

We proposed removing the Diabetes Care--Eye Exam (Part C) measure as part of our effort to streamline the Star Ratings measure set and increase the focus on patient experience and outcome measures. There are several other measures currently in the Star Ratings that focus on diabetes care, thus, covering a similar topic area as this measure. Given the importance of diabetes care, we proposed to move this measure to the display page.

We solicited comment on removing the Diabetes Care--Eye Exam measure from the 2029 Star Ratings. A discussion of the Diabetes Care-- Eye Exam measure removal comments, along with our responses follows.

Comment: Most commenters opposed the removal of the Diabetes Care-- Eye Exam measure from the Star Ratings. Some commenters noted that diabetic retinopathy is a leading cause of preventable blindness and that routine eye exams are essential for early detection of asymptomatic disease and timely intervention preventing severe vision loss. They also emphasized that the eye exam measure captures a clinically distinct and non-duplicative aspect of diabetes care that is not

addressed by other Star Ratings measures related to glycemic control, medication adherence, or kidney health. Other commenters noted that these exams serve as one of the most efficient and non-invasive tools for identifying broader health concerns. A number of commenters argued that preventing vision loss helps avoid expensive late-stage ophthalmic treatment, caregiver and long-term services and supports costs, functional decline and institutionalization.

Response: CMS appreciates the extensive feedback received on the Diabetes Care--Eye Exam measure and agrees with commenters that routine retinal screening is a critical component of comprehensive diabetes care. We agree that retinal examinations can identify broader health concerns and that preventing vision loss may help avoid costly late- stage treatment, functional decline, caregiver burden, and long-term services and supports. CMS also agrees that these considerations are consistent with the goals of the Star Ratings program to promote preventive care, preserve functional independence, and support whole- person care.

After careful consideration of public comments, CMS is retaining the Diabetes Care--Eye Exam measure in the Star Ratings program. Continued inclusion of this measure will help maintain plan accountability, support access to preventive screening, and encourage care coordination and innovation in screening approaches, particularly for high-risk and underserved populations.

Comment: Many commenters stated that removing this measure would create a vision-care gap in the Star Ratings program, as this measure is the only ophthalmic/vision-focused measure. They argued that downgrading the measure to display-only would lead to fewer screenings and more avoidable blindness, as well as other economic and public- health repercussions.

Response: CMS acknowledges commenters' concerns regarding the importance of monitoring vision-related preventive care for beneficiaries with diabetes and agrees that diabetic eye exams are a critical component of comprehensive diabetes management. Regardless of whether the measure is included in the Star Ratings calculation, MA plans and their contracted providers remain responsible for ensuring beneficiaries have access to clinically appropriate preventive services and supporting beneficiaries in obtaining recommended care, including diabetes-related eye exams. After consideration of the comments received, we are retaining this measure in Star Ratings.

Comment: Several commenters argued that Star Ratings measures drive outreach, provider engagement, care-gap closing, benefit design, and investment, whereas display-only measures receive far less operational prioritization. Many commenters stressed that if the measure is no longer included in Star Ratings, plans may redirect resources away from screening programs even if coverage technically remains.

Response: CMS recognizes that inclusion as a Star Ratings measure can influence plan prioritization, operational focus, and investment. At the same time, the Star Ratings program cannot encompass every facet of clinical care, and the absence of a specific measure from the ratings calculation does not diminish the clinical importance of the service. Eye exams are a critical component of high-quality diabetes care regardless of whether the measure is included in Star Ratings. CMS expects plans to support appropriate screening, outreach, and provider engagement to ensure beneficiaries receive recommended diabetes-related eye exams consistent with established standards of care.

Comment: Numerous commenters disputed that the measure is topped out or no longer differentiates plans. They pointed to continued gaps in screening rates and variation across plans, arguing plan performance still has room to improve and the measure still functions as an accountability lever.

Response: CMS agrees with commenters that performance on this measure has not topped out and continues to show variation across plans. As discussed in the Contract Year 2027 proposed rule, CMS proposed to remove this measure as part of a broader effort to streamline the Star Ratings measure set in areas where multiple measures address diabetes care. However, after consideration of public comments, CMS is retaining the Diabetes Care--Eye Exam measure in the Star Ratings program because it captures a clinically distinct and preventive aspect of diabetes care that is not fully addressed by other measures.

Comment: Some commenters expressed concern that removing the measure from the Star Ratings program could reduce MA plans' outreach, care coordination, and investment in screening programs, potentially leading to declines in screening rates. Commenters emphasized that the measure is particularly important for SNP (D-SNP, C-SNP, and I-SNP) populations with complex chronic conditions, as well as beneficiaries in rural communities facing provider shortages, transportation challenges, and other access barriers. Commenters also noted that homebound, low-mobility, and underserved beneficiaries often rely on in-home, mobile, and community-based screening programs, which are frequently structured around closing Star Ratings measure gaps and may be scaled back if the measure is no longer scored.

Response: CMS agrees that ensuring access to recommended diabetes- related preventive services is especially important for beneficiaries with complex needs and those facing access barriers, including SNP enrollees and beneficiaries in rural or institutional settings. Regardless of whether a measure is included in Star Ratings, plans remain responsible for ensuring all beneficiaries have access to appropriate preventive services and supporting timely diabetes-related screenings. CMS will be keeping this measure in Star Ratings since routine retinal screening is a critical component of comprehensive diabetes care and can identify broader health concerns. As we have considered the comments received, we agree this measure focuses on a clinically distinct and preventive aspect of diabetes care that is not fully addressed by other measures.

Comment: Many commenters stated that inclusion of this measure in the Star Ratings program has been a significant driver of innovation in care delivery. Commenters noted that the measure has incentivized MA plans and providers to adopt new screening models such as teleophthalmology, mobile and in-home screening services, point-of-care retinal imaging in primary care settings, and FDA-cleared autonomous artificial intelligence technologies to help expand access to diabetic eye exams. Commenters emphasized that these innovations have helped overcome workforce shortages, transportation barriers, and specialist access challenges, particularly in rural and underserved communities, while improving efficiency and reducing administrative burden. Several commenters expressed concern that removing the measure from the Star Ratings calculation could slow or reverse investment in these innovative approaches.

Response: CMS appreciates commenters' perspectives on the role of this measure in encouraging innovation and expanding screening access. As previously explained, CMS is retaining this measure in the Star Ratings program.

Comment: Several commenters offered alternatives to removal,

including refining or strengthening the measure rather than deleting it (i.e., adjusting weighting, improving reporting alignment), adding follow-up care or care coordination after abnormal results, adopting hybrid or chart review approaches, and revisiting exclusions and/or measurement scope for certain populations (e.g., ESRD patients and members who receive optical care through other benefits or coverage). These commenters suggest delaying removal until a suitable replacement exists. A commenter supported moving the measure to the display page but urged ongoing monitoring and possible reassessment if screening rates decline.

Response: CMS appreciates the recommendations for potential future refinements, including approaches related to follow-up care, exclusions, and measurement methodology. We will take these suggestions into consideration for potential future updates to this measure.

Comment: Some commenters supported removing this measure, stating that diabetes care is already represented in Star Ratings through other measures and that removing this process measure supports streamlining and refocusing on outcome and patient experience measures.

Response: CMS appreciates support for streamlining the Star Ratings measure set and focusing on measures that best reflect outcomes and beneficiary experience related to diabetes care. We agree that several existing diabetes measures capture important aspects of diabetes clinical management and treatment outcomes. Collectively, these measures provide meaningful insight into plan performance in managing diabetes. At the same time, after consideration of public comments, CMS is retaining the Diabetes Care--Eye Exam measure in the Star Ratings program because it captures a clinically distinct and preventive aspect of diabetes care that is not fully addressed by other measures.

Comment: A few commenters raised concerns about persistent data gaps, challenges capturing eye exams completed outside MA plan networks or channels, coding and interoperability limitations between primary care and vision providers, and confusion regarding what services qualify for measure compliance. Commenters stated that these issues may limit the measure's ability to fully reflect true care delivery or plan performance and may contribute to administrative burden.

Response: CMS appreciates the feedback regarding data collection, measurement reliability, operational burden, and clarity of measure specifications. CMS recognizes the challenges associated with capturing services furnished across multiple care settings and providers, including those outside plan-contracted networks, as well as coding and interoperability limitations. CMS will continue to evaluate data sources and measurement approaches and consider opportunities for improvement.

After considering the comments we received and for the reasons outlined in the Contract Year 2027 proposed rule and our responses to the comments, we are not finalizing this proposal to remove the Diabetes Care--Eye Exam measure from the Star Ratings. g. Statin Therapy for Patients With Cardiovascular Disease (Part C)

We proposed removing the Statin Therapy for Patients with Cardiovascular Disease (Part C) measure as part of our effort to streamline the Star Ratings measure set and increase the focus on patient experience and outcome measures. There is not a lot of variation in performance across contracts on this measure, and there are other measures, such as Medication Adherence for Cholesterol (Statins), currently in the Star Ratings that cover a similar topic area as this measure. As noted in the Announcement of Calendar Year (CY) 2026 Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies, the National Committee for Quality Assurance (NCQA) reevaluated the Statin Therapy for Patients with Cardiovascular Disease (Part C) measure for the 2026 measurement year. The changes finalized by NCQA expand the eligible population and are considered a substantive change to the measure. In light of this substantive change, the Statin Therapy for Patients with Cardiovascular Disease measure was already set for removal to the 2028 display page following the process described at Sec. 422.164(d)(2), and any adoption of the updated measure would need to be proposed and finalized through future rulemaking. While Sec. 422.164(d)(2) gives CMS the discretion to continue to use a legacy measure in Star Ratings while a substantively updated version is on the display page, use of the legacy measure was not feasible here due to the nature of the substantive changes. CMS will monitor changes in performance for this measure, as updated and included on the display page, since statin therapy is important in lowering cholesterol and reducing the risk of cardiovascular disease.

We solicited comment on removing the Statin Therapy for Patients with Cardiovascular Disease measure from the 2028 Star Ratings. A discussion of the Statin Therapy for Patients with Cardiovascular Disease measure removal comments, along with our responses follows.

Comment: Many commenters supported removing this measure due to minimal performance variation and the availability of similar measures already in Star Ratings, such as Medication Adherence for Cholesterol (Statins). Commenters highlighted significant clinical limitations with the measure, such as that it captures prescriptions but not adherence, inadequately accounts for statin intolerance, creates administrative burden, and encourages coding behaviors that conflict with clinical judgment. A commenter also emphasized that a single prescription is insufficient for cardioprotective benefits, with some commenters adding that the measure excludes alternative cholesterol-lowering treatments, such as diet, exercise, or alternative medications. Commenters also noted the measure would remain on the 2028 display page as another reason for their support.

Response: We thank these commenters for their support of our proposal.

Comment: Some commenters opposed removing the measure, emphasizing its importance for the health and quality of life of patients with cardiovascular disease. Commenters noted that statin therapy is evidence-based for this population and linked to reduced mortality. Others urged CMS to delay removal until another validated outcome-based measure is introduced.

Response: This measure will be on the display page so it will still be publicly reported and used for monitoring. Given the substantive change for the 2026 measurement year for this measure, the measure has to be moved to the display page for at least two years following the process described at Sec. 422.164(d)(2). The updated measure would need to be proposed through rulemaking. We do not have data for the legacy measure to continue to include in the Star Ratings.

Comment: Some commenters recommended replacing the Statin Therapy for Patients with Cardiovascular Disease process measure with a low- density lipoprotein cholesterol (LDL-C) control or LDL-C response outcome measure. These alternative measures would account for statin intolerance while expanding the denominator to include all patients who could benefit from cholesterol-lowering therapy. Additionally, rather than

removing the measure, a commenter recommended considering a complimentary measure focused on medication access, affordability, and utilization since statins remain underused in peripheral arterial disease. Another commenter recommended that CMS eliminate the exclusion of individuals aged 66 and above to align with the Statin Use in Persons with Diabetes.

Response: We appreciate the suggestions and will take them into consideration as we consider future measure changes. If we were to introduce an alternative measure in the future, it would need to be proposed and finalized through the rulemaking process. It is important that providers and plans provide appropriate care for Medicare beneficiaries with cardiovascular disease whether the Star Ratings includes the Statin Therapy for Patients with Cardiovascular Disease measure or not.

Comment: Some commenters noted that despite an apparent performance ceiling for this measure at the contract level, substantial disparities in statin initiation and adherence persist among older adults, women, and racial/ethnic minorities, populations disproportionately represented in MA organizations.

Response: This measure will be on the display page so performance on this measure will still be publicly available. While Part C and D Star Ratings cannot measure every aspect of care delivery, providers and plans should still deliver clinically appropriate care to all populations.

Comment: Some commenters argued that removal of this measure is premature given NCQA's recent substantive specification changes expanding the eligible population. They urged CMS to evaluate the updated measure's performance before removal. Some commenters urged CMS to reintroduce the measure after the two-year display period, with one commenter arguing that the measure is more robust at identifying high risk patients than the Statin Use in Persons with Diabetes (Part D) measure and more methodologically sound as it includes clinically justified exclusions.

Response: The measure will be on the display page starting with the 2028 Star Ratings due to the substantive change made by NCQA discussed above. CMS is committed to continuing to monitor performance on the updated measure. If CMS were to bring back this measure into Part C Star Ratings, it would have to be proposed through future rulemaking.

After considering the comments we received and for the reasons outlined in the Contract Year 2027 proposed rule and our responses to the comments, we are finalizing the removal of the Statin Therapy for Patients with Cardiovascular Disease beginning with the 2028 Star Ratings. h. Members Choosing To Leave the Plan (Part C and Part D)

We proposed removing the Members Choosing to Leave the Plan (Part C and D) measure as part of our effort to streamline the Star Ratings measure set and increase the focus on patient experience and outcome measures. We proposed removing the measure based on previous feedback from Part C and D sponsors that they would prefer this measure be at the parent organization level versus the contract level or that they would like additional exclusions for the measure such as exclusions for terminations of provider networks. Additionally, without knowing the reasons for disenrollment, it is hard for enrollees to interpret what this measure score means and make meaningful comparisons between contracts. The current measure at the contract level would move to the display page.

We solicited comment on removing the Members Choosing to Leave the Plan measure from the 2029 Star Ratings. A discussion of the Members Choosing to Leave the Plan measure removal comments, along with our responses, follows.

Comment: Some commenters supported removing the measure, emphasizing that disenrollment can be driven by non-quality factors and can be hard for beneficiaries to interpret without context on why members left. Common reasons for supporting removal included cost or price shopping, broker or marketing dynamics, competitors, geographic moves, policy changes, and other external forces.

Response: CMS appreciates these comments and agrees there can be challenges in interpreting why beneficiaries may leave a plan and the extent to which disenrollments may be influenced by factors not solely related to plan quality.

Comment: Some commenters argued that voluntary disenrollment is one of the most straightforward indicators of whether a plan is meeting member needs so should remain in Star Ratings. They stated that disenrollment rates serve as the best proxy for beneficiary dissatisfaction by reflecting members' decisions to leave a plan. Many of these commenters contrasted this measure with the CAHPS survey, noting that CAHPS relies on survey sampling and captures reported perceptions rather than observed enrollment behavior.

Response: CMS appreciates these comments regarding the value of voluntary disenrollment as an objective, behavior-based indicator that may reflect enrollee experience with the plan. Although the Members Choosing to Leave the Plan measure may reflect beneficiary dissatisfaction to an extent, it is difficult to interpret from an overall disenrollment rate why beneficiaries are leaving a contract, so it is less useful as a quality measure. Disenrollments do not necessarily reflect issues with the quality of care provided. We know that beneficiaries disenroll for many reasons, including financial reasons, issues receiving needed care, coverage related to doctors, hospitals, and prescriptions, and issues getting information and help from the plan. The most common reasons for disenrollment are financial reasons and doctors, clinics, and hospitals not belonging to the enrollee's plan network. CMS plans to continue publicly reporting this measure on the display page so overall information about voluntary disenrollment remains transparent and available to beneficiaries and other interested parties.

Comment: Some commenters noted that the Members Choosing to Leave the Plan measure functions as an accountability and oversight mechanism, and that reporting it on the display page does not create the same incentive for plans to fix root causes.

Comment: Several commenters emphasized that the disenrollment measure is especially important for high-need populations (particularly individuals diagnosed with end-stage renal disease (ESRD) and SNP enrollees) because disenrollment can indicate serious mismatches between plan design and member needs. Some of these commenters urged CMS to retain the measure and refine it with these vulnerable groups in mind.

Response: CMS appreciates these comments. CMS will continue public reporting of this measure on the display page and will take into consideration recommendations for future measure updates.

Comment: Some commenters suggested that we retain the measure in Star Ratings but modify the technical specifications to better measure voluntary disenrollments. Several commenters argued that evaluating disenrollment at the contract level can misclassify switching within the same parent organization as negative performance. They encouraged CMS to evaluate disenrollment at the parent

organization level. Other commenters urged CMS to refine exclusions by excluding disenrollments tied to state Medicaid eligibility or policy changes affecting dual status and using reason codes to better capture true voluntary disenrollment.

Response: CMS appreciates these comments. CMS will publicly report this measure on the display page and take into consideration recommendations for future measure updates.

Comment: Some commenters raised concerns that if the Members Choosing to Leave the Plan measure is removed from Star Ratings, plans might face less pressure to avoid practices that frustrate members. A commenter specifically warned that removing this measure could enable plans to adopt policies that drive away members and could distort CAHPS survey participation (since members who leave may not be captured as intended).

Response: CMS disagrees that retiring this measure will meaningfully reduce plan incentives to address disenrollment-related issues, as plans have existing financial and operational incentives separate from Star Ratings to retain enrollees and maintain high- quality performance. Additionally, we will continue to monitor performance on this measure over time.

After considering the comments we received and for the reasons outlined in the Contract Year 2027 proposed rule and our responses to the comments, we are finalizing the removal of the Members Choosing to Leave the Plan measure beginning with the 2029 Star Ratings. i. Customer Service and Rating of Health Care Quality (Part C)

We proposed removing the Customer Service and Rating of Health Care Quality (Part C) measures as part of our effort to streamline the Star Ratings measure set. Compared to other patient experience of care measures, there is less variation in performance across contracts on these measures. We would continue to collect these data for quality improvement purposes and report the measures on the display page.

We solicited comment on removing the Customer Service and Rating of Health Care Quality measures from the 2029 Star Ratings. A discussion of the Customer Service and Rating of Health Care Quality measure removal comments, along with our responses, follows.

Comment: Some commenters supported the removal of the Customer Service and Rating of Health Care Quality measures, noting there is minimal variation in performance across contracts and that cut points have been stable for many years. A couple of commenters noted that these measures often reflect factors outside a health plan's direct control.

Response: We appreciate the support for removing the Part C Customer Service and Rating of Health Care Quality measures. As stated in the Contract Year 2027 proposed rule, we are proposing removal as part of an effort to streamline the Star Ratings. We disagree, however, that these measures are outside of health plans' control. Consumer experiences with customer service and perceptions of health care quality are important aspects of a patient's experience. The MA and PDP CAHPS surveys have been rigorously developed and tested to assess enrollee experiences on domains that enrollees have reported to be important to them in defining high quality care from Medicare health and drug plans.

Comment: Many commenters opposed the removal of the Customer Service and Rating of Health Care Quality measures, noting the importance of measures that reflect member experience. Commenters stated that excluding these measures from Star Ratings calculations diminishes their value and ability to incentivize health plans to invest in high-quality beneficiary experiences. Some commenters stated these measures are important for individuals selecting a health plan to consider, as well as for CMS to measure the overall quality of care provided by plans.

Response: CMS agrees these measures capture important areas of plan performance. The measures will still be collected through the MA and PDP CAHPS Survey and results will be included in the CAHPS health plan reports provided each year to plans to support their quality improvement efforts and reported as display measures on CMS.gov. Also, the Rating of Health Plan measure that will remain in the Star Ratings will capture these areas of performance.

Comment: Many commenters expressed concern that removing the Customer Service measure assessing beneficiary experience with MA plan operations will reduce MA plan oversight to ensure enrollees are receiving timely and quality access to their respective benefits and coverage. Commenters recommend that CMS consider opportunities to better measure customer service, rather than removing the measure entirely from the Star Ratings program.

Response: CMS appreciates commenters' emphasis on the importance of customer service and beneficiary experience with MA plan operations. CMS agrees that timely, accurate, and high-quality customer service is essential to ensuring enrollees' access to benefits, regardless of whether such measures are included in the Star Ratings program. Removing the Customer Service measure from Star Ratings does not reduce CMS's expectations that MA plans will provide high-quality customer service to their enrollees. CMS will continue to report this measure on the display page and continue to monitor performance. CMS also remains committed to evaluating opportunities to better measure beneficiary experience and customer service.

After considering the comments we received and for the reasons outlined in the Contract Year 2027 proposed rule and our responses to the comments, we are finalizing the removal of the Customer Service and Rating of Health Care Quality measures beginning with the 2029 Star Ratings. 2. Adding Measure a. Depression Screening and Follow-Up (Part C)

We are committed to continuing to improve the Part C and D Star Ratings system by focusing on improving clinical and other health outcomes. Consistent with Sec. Sec. 422.164(c)(1) and 423.184(c)(1), we continue to review measures that are nationally endorsed and in alignment with the private sector as described at 83 FR 16533. For example, we regularly review measures developed by NCQA and the Pharmacy Quality Alliance (PQA). As we continue to align with the Universal Foundation, we also proposed to add the Part C Depression Screening and Follow-Up (DSF) measure to the 2029 Star Ratings (measurement year 2027). CMS began reporting the DSF measure on the display page for the 2026 Star Ratings. As provided at Sec. Sec. 422.164(c)(3) and (4) and 423.184(c)(3) and (4), as new performance measures are developed and adopted they are initially posted on the display page for at least two years.

We solicited feedback regarding whether to add the DSF measure to the 2026 Star Ratings display page (using data from the 2024 measurement year) in the Advance Notice of Methodological Changes for Calendar Year (CY) 2024 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies and noted that it would need to go through rulemaking to be added to the Star Ratings.\92\ DSF

measures the percentage of eligible MA plan members who were screened for clinical depression using a standardized instrument and, if screened positive, received follow-up care within 30 days. This aligns with the U.S. Preventive Services Task Force recommendations regarding screening and follow-up for depression,\93\ supports CMS's efforts to implement the Universal Foundation set of measures across quality programs, and focuses on improving the well-being of beneficiaries as well as MAHA priorities by encouraging MA health plans to screen for depression and follow-up with appropriate care. Although this is a process measure, health outcomes can be improved by identifying individuals with depression and providing treatment. There are currently no measures specific to behavioral health care in the Part C and D Star Ratings, so adding this measure would fill an important gap.

\92\ See page 162 at https://www.cms.gov/files/document/2024-announcement-pdf.pdf for a summary of comments.

\93\ https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-depression-suicide-risk-adults.

Depression is a common mental disorder that occurs in people of all ages, and estimates of major depression were 13.1 percent in people age 12 and older and 8.7 percent in people age 60 and older during the period from August 2021 through August 2023.\94\ Depression can exacerbate other chronic medical conditions, and it increases the risk of morbidity and mortality. There is evidence that screening tools used in primary care settings can accurately identify depressed individuals and treatment can improve depression outcomes.\95\

\94\ https://www.cdc.gov/nchs/data/databriefs/db527.pdf.

\95\ https://pmc.ncbi.nlm.nih.gov/articles/PMC7661597/ and https://www.amjmed.com/article/S0002-9343(22)00524-1/fulltext.

We submitted the DSF measure through the 2024 Pre-rulemaking Review Process for review by the Measures Application Partnership, which is a multi-stakeholder partnership that provides recommendations to HHS on the selection of quality and efficiency measures for CMS programs, and the Measures Application Partnership provided support for this measure.\96\ Consensus was not reached on this measure. The committee recommended that the Merit-based Incentive Payment System (MIPS) program consider replacing their similar measure with this one to improve alignment across quality programs \97\ and to report the screening and follow-up rates separately. The HEDIS measure differs slightly from the MIPS measure since the specification is at the health plan level and also focuses on examining follow-up actions when positive screenings occur. CMS will display separate rates for screening and follow-up on the display page and take an average of the rates for the Star Ratings measure.

\96\ https://p4qm.org/sites/default/files/2025-02/PRMR-2024-2025-MUC-Recommendations-Report-Final.pdf.

\97\ The MIPS measure differs from the NCQA one in that the MIPS version requires a qualifying encounter, whereas the NCQA-stewarded version looks for a screen at any time in the measurement period; the follow-up component of the MIPS version entails documentation of a follow-up plan, whereas the NCQA-stewarded version is more intensive requiring follow-up care; the follow-up timeframe in the MIPS version is on or up to 2 days after the date of the qualifying encounter, whereas the NCQA-stewarded measure uses a timeframe of on or up to 30 days after the date of the positive screen; and the MIPS version only excludes individuals with a diagnosis of bipolar disorder, whereas the NCQA version excludes individuals with bipolar disorder or a current diagnosis of depression.

We solicited comment on adding the Depression Screening and Follow- Up measure to the 2029 Star Ratings. A discussion of the Depression Screening and Follow-Up measure addition comments, along with our responses, follows.

Comment: Many commenters supported adding the DSF measure to the Star Ratings program. Commenters noted that this measure would encourage MA plans to screen for depression and follow up with appropriate care and to expand access to behavioral health services. Some commenters noted that the DSF measure would fill a gap in the Star Ratings program related to behavioral health and is aligned with the Universal Foundation set of measures across quality programs.

Response: We thank the commenters for their support.

Comment: Some commenters were concerned with the administrative burden related to the DSF measure, such as the investment needed to set up the data structures and workflows to track and report depression screening and follow-up data. Other commenters noted challenges implementing the measure due to inconsistent availability of data and issues with the interoperability of electronic data. Specifically, a few commenters had concerns with the measure requiring the use of Logical Observation Identifiers Names and Codes (LOINC) codes, which they claimed are inconsistently used and not always transmitted to plans. Some commenters recommended expanding the measure to include hybrid reporting or use of any digital data source including both claims and clinical data including CPT and HCPCS codes such as 96127, 96160, 96161, and G0444 (Annual Depression Screening). A commenter further suggested that CMS should work with smaller practices and community-based organizations to address technical barriers they face with Electronic Clinical Data Systems (ECDS) reporting and LOINC codes. Another commenter recommended that CMS: (1) publish detailed ECDS specifications, including accepted standardized instruments, LOINC tables, and mapping examples for common EMRs, (2) issue an electronic medical records (EMR)/Health Information Exchange (HIE) readiness checklist and provider toolkit that include clinical workflow, documentation, and data flow, and (3) offer technical assistance with measure testing, data ingestion pilots, and feedback on cases.

Response: We appreciate the feedback on the challenges of implementing this measure. ECDS is a HEDIS reporting method for health plans to collect and submit quality measures. The DSF measure uses the ECDS reporting method, which was developed to allow for better tracking of patient outcomes across systems and to reduce the burden on providers to conduct manual chart reviews by pulling in data across EHRs, HIEs, clinical registries, and claims data. While we understand that this ECDS measure will require upfront investment in setting up the IT and workflow infrastructure, over time the ECDS, rather than traditional or hybrid reporting, will decrease the burden on providers. The ECDS reporting method used in DSF requires the use of electronic data standards and that all data be stored in structured fields in a standard layout. The data sources for ECDS reporting include electronic health records/personal health records, health information exchange/ clinical registry, case managements systems, and data from administrative claims. Given the need for structured data, DSF requires the use of LOINC codes. To allow some flexibility, HEDIS does allow mapping to the measure's specified LOINC codes as appropriate. For example, if the questions of a specified instrument are used, but are labeled with the name of a different instrument (e.g., PHQ-2 questions within the PHQ-A), mapping to one of the specified LOINC codes is acceptable.

CMS appreciates the commenters' recommendations regarding additional technical resources to support implementation of this measure. The measure specifications are developed and maintained by NCQA, the measure steward, and include the technical requirements necessary for reporting. Detailed specifications, including

coding and data element guidance, are available through NCQA's established measure maintenance processes. CMS encourages stakeholders to refer to NCQA resources for the most current technical guidance. CMS is not prescribing EMR- or HIE-specific implementation tools, workflow guidance, or mapping examples through regulation, given the significant variation in health IT systems, data sources, and clinical workflows across MA organizations and provider settings. MA organizations remain responsible for working with their providers and vendors to operationalize measure reporting within their existing infrastructure.

Comment: Some commenters were concerned about their ability to track whether follow-up care occurred, noting limitations such as state-specific legal barriers to accessing behavioral health data and limited visibility into care delivered outside their network. A couple of commenters further suggested that CMS conduct an impact analysis of how federal and state privacy laws may affect data availability given stricter limits on sharing mental health records in some places.

Response: CMS acknowledges that data availability and access to behavioral health information may vary based on state law, privacy requirements, and whether care is furnished outside of a given organization's network. However, CMS does not agree that these considerations warrant modification of the finalized policy. This measure does not require access to detailed psychotherapy or mental health treatment records. The measure is designed to allow reporting based on information reasonably available to health plans, including documentation of referral, care coordination, or other appropriate follow-up actions consistent with existing legal and operational constraints. CMS notes that similar considerations apply broadly across quality measurement and care coordination activities and are not unique to depression screening or follow-up care.

Comment: A few commenters stated their belief that this measure will disproportionately burden physicians and indicated that the responsibility for strong performance is primarily the responsibility of providers rather than MA plans. These commenters requested that CMS hold MA plans accountable for providing support and increasing access to behavioral health resources. Another commenter suggested that CMS help ensure community mental health and substance use provider organizations are seamlessly able to contract with MA plans.

Response: CMS does not agree that the measure inappropriately places the burden of performance solely on physicians or other individual providers. The DSF measure is reported at the MA contract level and reflects the collective performance of the MA organization's provider network. MA contracts are responsible for establishing provider networks, designing benefits, furnishing care management and care coordination services, and implementing quality improvement strategies to support measure performance. Accordingly, MA organizations retain primary accountability for ensuring that their networks are equipped to conduct depression screening and facilitate appropriate follow-up care.

MA organizations already have multiple mechanisms to support providers and improve access to behavioral health services, including network adequacy requirements, utilization management policies, care coordination programs, supplemental benefits, and quality improvement initiatives. The measure is intended to encourage MA organizations to leverage these existing tools to strengthen screening and follow-up processes, including addressing gaps in access to behavioral health resources, and to collaborate with providers.

Comment: Some commenters request that CMS delay implementation of this measure to give plans and providers more time to get systems and processes in place to meet requirements. A commenter specifically asked for phasing in follow-up requirements over time.

Response: This measure was reported on the 2026 display page. This measure will be on display for three years prior to it being added to the 2029 Star Ratings. This provides sufficient time for MA organizations to prepare for inclusion of this measure in Star Ratings.

Comment: Some commenters were concerned about inadequate behavioral health resources in communities that already face significant behavioral health workforce and capacity shortages, potentially limiting their ability to provide follow-up care for those who screen positive for depression. These commenters requested that CMS monitor behavioral health network adequacy before implementing this measure.

Response: We recognize the health care workforce shortages facing many communities, particularly in the field of behavioral health. Measuring depression screening and follow-up care will increase focus on behavioral health and likely lead to MA plans expanding access to behavioral health care. In addition, the measure specifications allow for telehealth or virtual appointments so that enrollees with limited access to follow-up care in their local vicinity may be able to access services in a virtual setting.

Comment: Some commenters recommended that CMS report the depression screening and follow-up rates separately because averaging the rates may discourage depression screening since plans that screen fewer people may more easily achieve high follow-up rates. A commenter also suggested a higher weight for the follow-up rate.

Response: There is incentive to do well on both rates. For the screening rate, performance will be worse if fewer individuals are screened since the measure focuses on screening among the general population. We will display the rates for screening and follow-up separately on the display page so this information is publicly available. For the Star Ratings program, CMS plans to take an average of the rates to minimize the number of measures displayed on Medicare Plan Finder. We will monitor the rates for both the screening and follow-up measures and may propose changes over time if we see issues with combining the rates.

Comment: Some commenters recommended including telehealth and home- based depression screening and follow-up care in the measure.

Response: We clarify that telehealth visits and home-based visits can count toward this measure if other requirements are met.\98\

\98\ NCQA HEDIS Measurement Year 2026 Volume 2.

Comment: A commenter recommended restricting the measure denominator to the subset of patients with at least one valid encounter during the measurement year to increase the likelihood of screening being performed by a provider with an established relationship with the patient and minimize the need for population-wide outreach by health plans or other providers with no previously established relationship.

Response: We appreciate the commenter's recommendation to restrict the measure denominator to patients with at least one valid encounter during the measurement year. The inclusive denominator is intentionally designed to encourage comprehensive preventive care for all enrolled members, regardless of their recent utilization patterns. This

ensures that screening opportunities are not inadvertently limited to only those individuals who have already accessed care during the measurement year.

While we recognize the commenter's concern regarding the administrative burden of outreach to members without established provider relationships, proactive engagement with all enrollees is a fundamental component of effective preventive care delivery. Members who have not had recent encounters may represent a population at higher risk for unmet health needs and would benefit most from targeted outreach and screening initiatives.

Comment: A few commenters requested CMS provide clear guidance about what counts as “appropriate follow-up care.”

Response: Follow-up care includes outpatient, telephone, e-visits, or virtual check-in follow-up visits; depression case management encounters; behavioral health encounters including assessment, therapy, collaborative care, or medication management; an encounter for exercise counseling; or a dispensed antidepressant medication.\99\

\99\ NCQA HEDIS Measurement Year 2026 Volume 2.

Comment: Out of concern for the impact of this measure on medically complex individuals, a commenter recommended applying a case-mix adjustment that includes geography, LIS/DE status, and other demographic data. Another commenter recommended tracking rates across demographic groups.

Response: Since this is a process measure, there is no case-mix adjustment so as not to set different performance standards for different groups or to mask differences in the quality of care across parts of the country. We encourage contracts to analyze their data and track and address differences in performance across subpopulations in their contract.

Comment: A commenter requested flexibility as to who may administer the screening, especially for rural and underserved areas.

Response: The HEDIS specifications for the depression screening rate are focused on screening using a standardized instrument rather than who administers the screening. The specifications also indicate that depression screening captured in health risk assessments or other types of health assessments are allowed if the questions align with a specific instrument that is validated for depression screening.

Comment: A commenter recommended avoiding duplicative requirements such as rescreening patients already diagnosed with depression.

Response: The HEDIS specifications for the DSF measure already exclude individuals with a history of bipolar disorder or a current diagnosis of depression.\100\

\100\ NCQA HEDIS Measurement Year 2026 Volume 2.

Comment: As an alternative to the proposed measure, a commenter recommended implementing the Follow Up After Hospitalization for Mental Illness (FUH) measure. Another commenter recommended using a measure of Medicare Annual Wellness Visit (AWV) since depression screening often occurs at wellness appointments. Another commenter suggested moving to an outcome performance measure such as improvement in depression as measured by the Patient Health Questionnaire (PHQ-9).

Response: We appreciate the recommendations, but we disagree that these measures are feasible alternatives. The DSF measure was chosen over the FUH measure because of the focus on earlier identification and intervention for depression in an outpatient setting. The DSF measure is also part of the Universal Foundation set of measures across quality programs, which focuses on improving the well-being of beneficiaries. It is also aligned with MAHA priorities by encouraging MA health plans to screen for depression and follow up with appropriate care. Wellness visits are often an encounter where depression screening occurs, yet this alone is an insufficient way to measure depression screening. It also does not address a key component of DSF which is follow-up care for those who screen positive for depression within 30 days. Although DSF is a process measure, health outcomes can be improved by identifying those with depression early and giving them access to treatments for depression.

Comment: A few commenters recommend that CMS exclude patients with Major Neurocognitive Disorder (dementia) from this measure because the PHQ-9 is an invalid tool for this population. Another commenter recommended that CMS incorporate clinically appropriate exclusions for grief and loneliness, which may be prevalent in the Medicare population.

Response: We appreciate the feedback from commenters. Depression is prevalent among older adults, including individuals with Major Neurocognitive Disorder (dementia), and appropriate screening and treatment may improve quality of life, reduce morbidity, and help manage symptoms. While the PHQ-9 is a commonly used and validated screening instrument, it is not the only tool that may be used to meet the depression screening requirement under the DSF measure. Clinicians may use other standardized, validated depression screening instruments that are appropriate for the patient's cognitive status and clinical circumstances, consistent with accepted clinical practice.

We also acknowledge commenters' recommendations regarding grief and loneliness. Grief and loneliness are recognized risk factors for clinical depression and are prevalent in the Medicare population. Their presence does not preclude depression screening; rather, it underscores the importance of screening to identify individuals who may benefit from further assessment, monitoring, or treatment. Accordingly, we do not find that categorical exclusions for dementia, grief, or loneliness are warranted, as the DSF measure is intended to support clinically appropriate, whole-person care and relies on provider judgment to determine the most suitable screening approach for each patient.

Comment: A commenter indicated the measure is misaligned with MAHA principles and suggested using the MAHA Elevate model that emphasizes lifestyle and prevention over medicalized screening.

Response: We thank the commenter for their feedback; however, we disagree that the DSF measure is misaligned with MAHA principles. There is a transparent process for adding measures to the Part C Star Ratings described at Sec. 422.164(c). Any new measure first needs to go through the Pre-Rulemaking Review process and initial input is solicited through the Advance Notice process before being proposed through formal rulemaking. New measures must be on the display page for at least two years prior to inclusion in the Star Ratings. The DSF measure supports MAHA priorities by promoting whole-person care through early identification of depression and timely, appropriate follow-up, which are foundational to prevention and long-term health. Depression screening is a well-established, evidence-based preventive service that enables clinicians to identify individuals who may benefit from a range of interventions, including lifestyle-based, psychosocial, and clinical approaches.

Follow-up care under the DSF measure is not prescriptive or one- size-fits-all. Appropriate follow-up for individuals with a positive depression screen may include outpatient, telephone, e-visits, or virtual check-in

follow-up visits; depression case management encounters; behavioral health encounters including assessment, therapy, collaborative care, or medication management; an encounter for exercise counseling; or a dispensed antidepressant medication. By supporting early detection and flexible, patient-centered follow-up, the DSF measure advances prevention, wellness, and individualized care consistent with MAHA principles.

Comment: A commenter stated that the measure encourages MA plans to interfere with the patient-physician relationship by incentivizing MA plans to screen for depression and provide appropriate follow-up care.

Response: We thank the commenter for this feedback, yet we disagree. This measure should encourage collaboration between the plan and the provider to ensure the enrollee gets the care they need.

Comment: Several commenters request CMS align the DSF measure with other CMS quality programs, such as the DSF measure used in the Merit- based Incentive Payment System (MIPS), before implementation to avoid conflicting specifications, duplicative reporting, and additional administrative burden on providers.

Response: We agree with the efforts to align measures across CMS quality programs. In the 2024 Pre-rulemaking Measure Review Process (PRMR), the committee recommended that the MIPS program consider replacing their measure with the one used for Medicare health plans to improve alignment across quality programs.\101\ There are key factors that make the NCQA-stewarded version of the DSF measure more appropriate for the Star Ratings program, including that the specification is at the health plan level. The follow-up component of the MIPS version entails documentation of a follow-up plan, whereas the NCQA-stewarded version is more intensive, requiring follow-up care. Regarding clinical exclusions, the MIPS version only excludes individuals with a diagnosis of bipolar disorder, whereas the NCQA- stewarded version excludes individuals with bipolar disorder or a current diagnosis of depression.

\101\ https://p4qm.org/sites/default/files/2025-02/PRMR-2024-2025-MUC-Recommendations-Report-Final.pdf.

Comment: A commenter stated that depending on the denominator definition and exclusions, the DSF measure may disproportionately limit applicability for I-SNP and Institutional Equivalent (IE)-SNPs, which may exacerbate measurement gaps for these plan types.

Response: We thank the commenter for the feedback. As long as an I- SNP only contract meets the denominator requirements for the measure, it will have a score for this measure. If an I-SNP is part of a larger contract that has non I-SNP enrollees, the measure score will include I-SNP and non I-SNP enrollees.

Comment: A few commenters stated that the large number of measures proposed for removal, as discussed in section V.B of this final rule, may negatively impact plans and that CMS should not implement a new measure at the same time.

Response: Removing multiple measures should help reduce burden for plans and help them focus on new areas where there is significant room for improvement in clinical care. Depression screening is a serious and common mental disorder that occurs in people of all ages. The lifelong prevalence of depressive disorders is estimated to range from 10 to 15 percent.\102\ Depression can exacerbate other chronic medical conditions and it increases the risk of morbidity and mortality. There is evidence that screening tools used in primary care settings can accurately identify depressed individuals and treatment can improve depression outcomes.\103\ The addition of the DSF measure to the Star Ratings program will encourage screening and follow-up care for depression.

\102\ L[eacute]pine, J.P., M. Briley. 2011. “The Increasing Burden of Depression.” Neuropsychiatric Disease and Treatment 7(suppl 1): 3-7.

\103\ O'Connor, E.A., E.P. Whitlock, T.L. Beil, B.N. Gaynes. 2009. “Screening for Depression in Adult Patients in Primary Care Settings: A Systematic Evidence Review.” Annals of Internal Medicine 151(11):793-803.

Comment: A commenter recommended implementing the DSF measure through coordinated, interdisciplinary workflows that integrate physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) due to their high frequency touchpoints with patients and to leverage existing data sources to minimize administrative burden. Another commenter recommended alternative screening options such as voice-based and modality-agnostic tools, which may be appropriate for older adults and those with limited English proficiency.

Response: We thank the commenters for their recommendations. The DSF measure is provider and team agnostic, so implementation through coordinated interdisciplinary workflows is accepted and encouraged. For alternative screening options, if there is evidence that alternative screening mechanisms are clinically validated, these options will be considered for inclusion in the future.

After considering the comments we received and for the reasons outlined in the Contract Year 2027 proposed rule and our responses to the comments, we are finalizing the addition of the Depression Screening and Follow-Up measure to the Star Ratings beginning with the 2029 Star Ratings. 3. Summary of Measure Changes for the Part C and Part D Star Ratings

Table 4 summarizes the additional measure addressed in this final rule, beginning with the 2029 Star Ratings. The measure description listed in this table is a high-level description. The annual Star Ratings measure specifications supporting document, the Medicare Part C & D Star Ratings Technical Notes, provides detailed specifications for each measure. Detailed specifications include, where appropriate, more specific identification of a measure's: (1) numerator, (2) denominator, (3) calculation, (4) timeframe, (5) case-mix adjustment, and (6) exclusions. The Technical Notes document is updated annually. The annual Star Ratings are produced in the fall of the prior year. For example, Star Ratings for the year 2029 are produced in the fall of 2028. If a measurement period is listed as “the calendar year 2 years prior to the Star Ratings year” and the Star Ratings year is 2029, the measurement period is referencing the January 1, 2027 to December 31, 2027 period. As noted earlier in section V.B. of this final rule, CMS does not codify the specific measures for the Part C and D Quality Rating System in regulation; doing so would be unnecessarily lengthy and cumbersome due to the relative regularity with which measure specifications are updated.

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