You cannot control CMS raising cut points. But you can control how you respond.
The 2026 requirements are clear. CMS is implementing risk-adjusted measures focused on Social Determinants of Health. The new Excellent Health Outcomes for All reward ties STAR ratings exclusively to performance among your hardest-to-engage members—Dual-Eligible, Low-Income Subsidy, and disabled populations.
These changes represent a fundamental shift in how Medicare Advantage plans will be evaluated. What worked last year won't work next year. The question is not whether these changes will impact your plan. The question is whether you'll be ready.
Why Waiting Until 2026 Will Be Too Late
Building an effective adherence strategy for high-risk populations requires preparation. You need to configure data infrastructure for real-time claims analysis. You need to establish care teams proficient in both pharmacy and medical channels. You need to create data-sharing protocols with providers, pharmacies, and strategic partners.
This infrastructure cannot be implemented overnight but it can be ready to start for the new year. However, plans that wait until January 2026 will spend the first quarter or more troubleshooting systems while competitors who prepared in advance are already engaging members.
The measurement year waits for no one. Every day of delay means fewer opportunities to impact adherence rates. With rising cut points, even a single percentage point gain in triple-weighted measures is worth millions to your plan.
What You Need in Place Before 2026
High-performing plans are already implementing six critical components:
- Deploy automated systems that identify at-risk members daily using real-time claims analysis.
- Define your target population with precision—focus on members with social and clinical risk factors including heart failure, diabetes, COPD, and chronic kidney disease.
- Configure your technology for interoperability with secure file transfer protocols connecting your PBM, health plan, and pharmacy operations partners.
- Build care teams proficient in both pharmacy and medical channels who understand local healthcare landscapes.
- Enable comprehensive member support that goes beyond telling members what to do. Help them complete the process by addressing transportation, appointments, and billing issues.
- Establish ecosystem partnerships with clear communication channels across all stakeholders.
The Cost of Inaction
Plans that delay action face compounding challenges. They fall further behind in the current measurement year while simultaneously failing to prepare for 2026's more stringent requirements.
The bleeding doesn't stop on its own. Without intervention, declining STAR ratings trigger a cascade of negative consequences. Why risk lower quality bonus payments, and loss of competitive advantage in your market?
Meanwhile, high-performing plans continue to pull ahead. They're achieving adherence rates 2-3% above Medicare averages. They're improving STAR ratings despite rising difficulty. They're doing this by implementing the strategies outlined above—and they started months ago.
Control What You Can Control
Partner with specialists who have extensive experience in medication adherence for high-risk populations. The right partner can analyze your data quickly and identify gaps in your current approach. They can deploy automated, data-driven processes to increase engagement probability while implementing scalable, personalized outreach for challenging members who require human interaction.
Look for partners who understand that 71% of LIS members, 62% of Dual-Eligible members, and 37% of disabled members require specialized approaches. These populations consistently achieve 4-star performance when supported by the right combination of technology and pharmacist-centered care.
Start building your foundation now. Configure your systems. Train your teams. Establish your partnerships. By the time 2026 arrives, you'll be ready to execute.
Ready to build a winning medication adherence strategy for 2026?
Learn more at actualmeds.com/solutions#adherence-stars or contact our team today.
