# Why CAHPS still swings Star Ratings at half its old weight

By MarketScale Newsroom · Published 2026-11-02 · Healthcare on MarketScale
Canonical: https://www.marketscale.com/industries/healthcare/why-cahps-still-swings-star-ratings-at-half-its-old-weight-1290463

> mPulse analysts show the CAHPS chapter moved with overall Star Rating changes from the 2026 to the 2027 cycle, after CMS cut its weight from 4 to 2.

## Key points

- CMS cut CAHPS from a weight of 4 to 2 in the CY2025 final rule, effective with the 2026 Star Ratings, yet mPulse's chapter data shows CAHPS still moved in the same direction as overall stars for the 2027 cycle.
- The April 2026 final rule removes 11 administrative measures, but none leave before the 2028 Star Ratings; the 2027 measure set is unchanged and the Health Equity Index reward is cancelled.
- CAHPS stars are set by percentile cutoffs and reliability tests, and in the 2025 Star Ratings 13 percent of CAHPS results landed on a different star than the cutoff implied, 93 percent of them lower, according to RISE Health.

Sam Oliver sorted every Medicare Advantage contract into three buckets: contracts whose overall Star Rating rose between the 2026 and 2027 ratings, contracts that held flat, and contracts that fell. Then he checked what the CAHPS chapter did inside each bucket. The split was wide enough that he called it telling.

Oliver, who says on the recording he has helped lead mPulse's client analytics and research analytics functions, walked the chart through with Reva Sheehan, the company's VP of Customer and Market Strategy, on Hot Takes on 2027 Stars, a MarketScale Studio segment. CAHPS is the Consumer Assessment of Healthcare Providers and Systems, the member survey behind the Stars measures on getting needed care, getting appointments quickly, care coordination and customer service. A chapter, in Stars shorthand, is a group of related measures averaged into a single score.

The timing is the October release. CMS published the 2027 Star Ratings on Medicare Plan Finder on Oct. 8, 2026, according to its fact sheet that day, and those ratings sit in front of shoppers through the open enrollment window of Oct. 15 to Dec. 7, 2026 before setting 2028 quality bonus payments. For the quality director deciding where next year's outreach budget goes, the question Oliver and Sheehan raise is whether the survey still deserves the attention it got when it carried twice its current weight.

## The CAHPS chapter moved with the overall rating in both directions

Contracts that gained overall stars also gained CAHPS chapter stars, and contracts that fell lost them, by Oliver's count. He described the comparison as measurement year 2024 against measurement year 2025, the data that produced the 2026 and 2027 Star Ratings. The CAHPS chapter was, in his words, the next order of importance after the overall rating itself.

Oliver then ran the two movements against each other. A correlation runs from zero, meaning two things move independently, to one, meaning they move in lockstep, and he put the CAHPS chapter's result high enough to matter.

The figures are mPulse's own analysis of CMS results. The scale is what makes them worth attention: CMS says in its Oct. 8, 2026 fact sheet that an MA-PD contract is rated on up to 43 unique measures, and the CAHPS chapter is one slice of that set. For a quality team, a single chapter tracking the whole rating that closely is an argument about where the first dollar goes.

## CMS halved the weight in 2025, and the measure set is shrinking around it

The weight history explains the word still in Oliver's reading. AdhereHealth wrote on its own site in January 2021 that CMS would quadruple-weight CAHPS measures beginning with contract year 2021, which the vendor calculated at 32 percent of the overall Star Rating. mPulse's own October 2020 post placed the first 4x survey as the 2021 CAHPS fielding, feeding the 2023 Star Ratings, with questions covering the prior six months and responses starting Feb. 1.

The rollback came three rating cycles later. RISE Health reported, in its coverage of the contract year 2027 final rule issued April 2, 2026, that the reduction of patient experience, complaints and access measures from a weight of 4 to a weight of 2 was finalized in the CY2025 final rule and took effect with the 2026 Star Ratings. The current scale, per RISE Health, puts improvement measures at 5, outcome measures at 3, experience and access measures at 2 and process measures at 1.

A weight is the multiplier a measure's star carries in the weighted average that becomes the overall rating. A CAHPS measure at 2 counts twice a clinical process measure at 1, so a one-star swing on it moves the average twice as far. CMS's stated reason for the 2025 cut does not appear in its 2027 announcements; its Nov. 25, 2025 press release frames the newer changes as a refocus on clinical care, outcomes and patient experience.

The newer changes push CAHPS back up in relative terms. Becker's Payer reported on Nov. 26, 2025 that removing administrative measures would raise the relative weight of HEDIS measures and CAHPS scores. HEDIS is the Healthcare Effectiveness Data and Information Set, the clinical quality measures drawn from claims and charts.

One published distribution of the 2029 weighted set cited by RISE Health puts CAHPS at 21 percent of the score, behind HEDIS at 28 percent. The same distribution puts pharmacy at 20 percent, improvement at 16 percent, HOS at 15 percent and administrative measures at zero. So the survey chapter keeps roughly a fifth of the rating with no reweighting at all.

The cycle Oliver charted also lifted a different chapter. CMS says in its 2027 fact sheet that the Improving or Maintaining Physical Health and Improving or Maintaining Mental Health measures rose from a weight of 1 for the 2026 Star Ratings to 3 for 2027, and three clinical process measures entered at a weight of 1. Those two measures come from the Health Outcomes Survey, or HOS, which asks members whether their own health has held or declined, and mPulse's own October 2024 post has HOS rising from 3 percent of the summary score in 2025 to 11 percent in 2027.

That complicates the chart. Part of what moved overall ratings from 2026 to 2027 was a tripling of HOS weight that had nothing to do with CAHPS, so a CAHPS chapter that moved with the total was moving alongside a reweighting it did not cause. Oliver's answer is that the correlation held with CAHPS already down to its original weight, which was the point he made on the chart.

## How a survey mean becomes a star, and why 13 percent land off the cutoff

CAHPS stars are not set the way clinical stars are. RISE Health, in an analysis published after CMS released the 2025 Star Ratings in October 2024, laid out the steps. A contract's adjusted mean score on each measure is placed against percentile cutoffs at the 15th, 30th, 60th and 80th percentile of all contracts, which sets a base star group.

CMS then tests whether the contract's mean is statistically different from the national average, so a score sitting above a cutoff by chance alone may not be treated as above it. A reliability score from zero to one, driven by respondent count and response variation, decides whether the result is trustworthy; RISE Health reports that above 0.70 counts as high and a measure below 0.60 receives no star. The standard error, supplied through the CAHPS vendor, can push a low-reliability contract to one star if its mean sits more than one error below the 15th percentile, or to five if it sits more than one error above the 80th.

In the 2025 Star Ratings, 13 percent of CAHPS results landed on a different star than the cutoff implied, 93 percent of them lower, according to RISE Health. Cutoffs also climbed. RISE Health reports the Getting Appointments and Care Quickly cutoff rose six points at every level between 2024 and 2025, with five stars moving from 80 to 86, and the Care Coordination cutoffs rose across the board.

This bounds the thesis. A chapter can fall because members answered worse, because the national cutoff moved, or because a small respondent pool failed a reliability test, and the chart Oliver showed does not separate those causes. The interview also does not break the chapter into individual measures, so the specific surveys driving the swings a given plan sees are not named; the cutoff shifts RISE Health reports point at appointment access and care coordination as the measures where the bar rose fastest.

The operator reading is that a raw CAHPS improvement is an input, and the cutoff is set by everyone else. The mock survey work RISE Health recommends between July and January is aimed at the mean score, while the star depends on how every other contract moved in the same season.

## D-SNP concentration still shows, and the equity reward built for it is gone

Sheehan pulled the conversation toward population mix. A D-SNP is a dual eligible special needs plan, a Medicare Advantage contract built for members who also qualify for Medicaid, and the chart, in her reading, sorted along those lines.

D-SNPs scored 5.8 percent worse on CAHPS than non-D-SNP plans in contract year 2018, AdhereHealth wrote on its own site in January 2021. That was when CAHPS carried a weight of 1.5, and the vendor added that CMS applies no CAHPS curve for D-SNPs the way it adjusts some other measures. Sheehan described plans with a higher concentration of dual eligible and other special needs members as facing different challenges, and said the split remains an important piece of plan performance even without the focus the market had years ago.

The reward designed to offset that gap is now cancelled. Deft Research explains, in an explainer written after CMS's 2024 final rule, that the Health Equity Index reward was to start with the 2027 Star Ratings, calculated on data collected in 2024 and 2025, and replace the reward factor in use since the 2009 Star Ratings. Becker's Payer reported on Nov. 26, 2025 that the reward, renamed Excellent Health Outcomes for All, was designed to pay for high performance among enrollees with social risk factors including dual eligibles, low income beneficiaries and people with disabilities.

RISE Health reports the final rule issued April 2, 2026 cancelled the reward and kept the historical reward factor, so the reward factor plans have modeled for years stays in place.

For a contract with heavy D-SNP enrollment, the arithmetic is plain: the CAHPS gap AdhereHealth measured carries into the rating with no equity offset, at a weight of 2, in a chapter mPulse's chart says moves with the total. Becker's Payer also reported that CMS is exploring whether to require state Medicaid contracts for chronic condition and institutional special needs plans with high dual eligible concentration, a sign the agency is watching the same population mix.

## Eleven measures leave, but the first three wait for the 2028 ratings

Sheehan put a scenario on the table: take current year performance, strip out the 11 administrative measures CMS is removing, and see what the rating looks like. She called it lots of scenario planning and said mPulse would keep an eye on it.

The rule behind that scenario is final. RISE Health reports CMS issued the contract year 2027 final rule on April 2, 2026, published in the Federal Register on April 6 at 91 FR 17384, removing 11 measures focused on administrative processes. The proposed rule from November 2025 had listed 12; CMS kept the Diabetes Care Eye Exam measure after stakeholder feedback, per RISE Health.

None of the 11 removals touch the 2027 Star Ratings; the earliest leave with the 2028 ratings, RISE Health reports. Measurement year 2026, feeding the 2028 Star Ratings, drops Call Center Foreign Language Interpreter and TTY Availability for both Part C and Part D, and Statin Therapy for Patients with Cardiovascular Disease. Measurement year 2027, feeding the 2029 ratings, drops appeals timeliness and appeals review, Special Needs Plan Care Management, Complaints about the Health or Drug Plan, Members Choosing to Leave the Plan and Medicare Plan Finder Price Accuracy.

Two CAHPS measures go with them. Published analyses of the final rule place Customer Service and Rating of Health Care Quality, both Part C CAHPS measures, in the 2029 removal group, according to RISE Health. So the chapter Oliver charted will be thinner by 2029 even as its share of the weighted score rises, and the one addition, a Part C Depression Screening and Follow-Up measure, starts counting in the 2029 ratings.

The improvement measures grow in the process. RISE Health explains that Health Plan Quality Improvement and Drug Plan Quality Improvement survive at a weight of 5, so removing measure identifiers from the denominator hands those two a larger share of the total. The three Part D adherence measures drop to a weight of 1 for the 2028 ratings while sociodemographic risk adjustment is added, then return to 3 for 2029, per consultant analyses RISE Health cites.

CMS estimated the rule's net impact at $18.56 billion to the Medicare Trust Fund from 2027 through 2036, driven largely by higher bonus payments, RISE Health reports, and published analyses it cites put roughly 63 percent of contracts at no change to their overall rating. Cut points did not move: Tukey outer fence outlier deletion, mean resampling with hierarchical clustering and the five percentage point guardrail all stand. A guardrail caps how far a cut point can move year over year, and RISE Health notes it does not apply to new measures in their first year or to the weight-5 improvement measures, so Depression Screening arrives with no ceiling.

## What a quality team does with the chapter chart in October

Oliver's own use of this kind of chart, from his years at Centene helping lead CAHPS and HOS insights and strategy and at Humana in corporate quality, was comparison rather than forecasting.

The money behind that comparison is large. AdhereHealth wrote on its own site in January 2021 that a four-star rating was worth roughly $450 per member per year from an annual quality bonus pool of about $11.6 billion. Those are a vendor's figures from five years ago, but they are the order of magnitude a quality director is defending when a chapter slips.

Three modeling jobs fall out of the interview and the rule, each with a named owner:

- Rerun the 2027 result with the 11 removed measures out of the denominator, the scenario Sheehan described, and watch what the weight-5 improvement measures do to the average.
- Model the 2028 adherence dip to a weight of 1 and the 2029 return to 3 that RISE Health describes, so the pharmacy chapter's swing is planned rather than discovered.
- Pull peer contract CAHPS trends over several years, as Oliver did at a plan, and look for the contracts that climbed while yours held flat.

The next dated milestone is already running. Measurement year 2026 feeds the 2028 Star Ratings with the first three removals, per RISE Health, and the next CAHPS fielding opens Feb. 1 covering the prior six months, by mPulse's own account on its site. The signal Oliver points to is the peer trend: when the contracts around yours are gaining CAHPS chapter stars and yours is not, the fix may sit in a toolkit you have not opened.

## Sources

- [CMS Proposes New Policies to Strengthen Quality, Access and Competition in Medicare Advantage and Part D](https://www.cms.gov/newsroom/press-releases/cms-proposes-new-policies-strengthen-quality-access-competition-medicare-advantage-part-d) (CMS)
- [CY2027 final rule removes 11 Star Ratings measures](https://www.risehealth.org/insights-articles/star-ratings-measure-set-shrinks-cut-point-strategy/) (RISE Health)
- [2027 Medicare Advantage and Part D Star Ratings](https://www.cms.gov/newsroom/fact-sheets/2027-medicare-advantage-part-d-star-ratings) (CMS)
- [CMS pitches star ratings reform in 2027 Medicare Advantage rule](https://www.beckerspayer.com/payer/medicare-advantage/cms-pitches-star-ratings-reform-in-2027-medicare-advantage-proposed-rule-7-notes/) (Becker's Payer)
- [Monitoring the impact of CAHPS surveys on Star ratings](https://www.risehealth.org/insights-articles/monitoring-the-impact-of-cahps-surveys-on-star-ratings/) (RISE Health)

Tags: mPulse, CAHPS, Medicare Advantage Star Ratings, Member experience, D-SNP, Quality improvement

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