From policy awareness to operational readiness: How CMS rule changes shape annual quality performance strategies

Each year, the Centers for Medicare & Medicaid Services (CMS) issues rule changes that ripple across the healthcare landscape, forcing health plans and risk-bearing organizations to recalibrate their quality performance, operations and member engagement strategies. This can make leaders feel like each plan year is a reset. 

Recent CMS rulemaking for2027 push quality programs further away from administrative checklists and more toward demonstrable clinical outcomes and authentic member experiences. Here’s how.

Breaking down the 2027 CMS rule changes  

1. Contract year 2027  rules both tighten operational transparency in certain area while reducing overall administrative burden and cost 

CMS finalized multiple provisions that affect how plans manage and implement eligibility, benefits, and operational processes with the objective to increase transparency in necessary areas while reducing overall administrative burden and cost. Highlights include: 

• Posting eligibility criteria to determine which chronically ill members qualify for Special Supplemental Benefits for the Chronically Ill (SSBCI)
• Codifying and clarifying supplemental benefit debit cards must now be electronically linked to plan-covered items through a point-of-sale verification system that confirms eligibility at the time of purchase
• Rolling back health equity requirements, mid-year supplemental benefit notices, utilization management committee mandate, agent and broker restrictions, call center requirements, and creditable coverage disclosures

These provisions increase the importance of clean first-time decisions, timely data, and coordinated member communications across the year. The contract year 2027 Medicare Advantage (MA) and Part D final rule exemplifies this dynamic, implementing changes related to prescription drug coverage, Star ratings, D-SNPs and other programmatic areas.

2. Inflation Reduction Act (IRA) of 2022-related codifications carry operational deadlines

The final 2027 rule largely codifies existing IRA provisions like:

• Vaccine and insulin cost-sharing protections
• Implementing Medicare Part D redesign— including an out-of-pocket cap—elimination of the coverage gap, and restructuring of benefit phases
• Incorporating the Manufacturer Discount Program that replaced the Coverage Gap Discount Program
• Medical loss ration adjustments reflecting IRA-related payment changes

Stars, pharmacy and contact center teams must be aligned early in the plan year to implement these requirements to help avoid member abrasion.

3. Contract year 2027 CMS Star rules shift weight to clinical outcomes and member experience

For the 2027 measurement year, CMS plans to:

• Add new clinical measures such as depression screening and follow-up
• Not implement the previously planned Excellent Health Outcomes for All reward, reverting to the previous Reward Factor
• Continue to streamline and refocus measure sets, removing11 measures focused on administrative processes 

Simply put, plans must compete on closing clinical gaps, behavioral health follow-through and representing the voice of the member—not on paperwork proficiency. This could lead to greater volatility for quality teams, fewer base points, lower ratings as administration measures are typically high performing and a premium on continuous improvement to achieve 2029 quality performance. 

The operational imperative behind CMS regulatory changes 

Awareness of these changes only represents the starting point. The real challenge (and competitive requirement) for CMS Stars, HEDIS® and population health leaders lies in translating regulatory shifts into operational excellence—and doing so repeatedly while protecting ratings, protecting revenue and improving member outcomes and trust. 

The most consequential organizations recognize regulatory changes demand more than policy interpretation; they require operational adaptation, resource reallocation and strategic reconsideration. When CMS modifies Star ratings methodology or introduces new quality measures, health plans face immediate downstream implications for gap closure programs, outreach strategies, care management workflows and quality performance improvement initiatives. 

This operational imperative intensifies as health plans confront persistent resource constraints. Quality teams simply can’t expand staffing with each regulatory modification. 

These operational realities also mean that continuous quality improvement can’t rely on seasonal campaigns or last-minute interventions. Instead, organizations need to use year-round strategies powered by actionable intelligence that identifies opportunities earlier and prioritizes resources toward highest-impact interventions.

However, care management teams also struggle to prioritize interventions when working from fragmented, retrospective data sources, potentially resulting in excessive or inaccurate outreach that may decrease member satisfaction.

Why diagnostic intelligence belongs at the center of your operating model

The fundamental limitation of claims-based quality management lies in its retrospective nature. Claims data reveals what happened—services rendered, diagnoses coded, procedures completed—but often arrives weeks or months after the clinical encounter. 

For quality leaders working to close gaps and improve member health, this lag creates a perpetual disadvantage. By the time claims data signals an emerging risk or unaddressed gap, valuable intervention time has elapsed.

Diagnostic data offers a fundamentally different value proposition. Unlike claims data, which is payer-specific and often delayed, lab results follow the individual regardless of insurance status, provider network or plan enrollment.

Even when claims history is sparse or nonexistent, lab values mapped to HEDIS, CMS Stars and quality measures can rapidly flag members with:

• Uncontrolled diabetes
• Advancing chronic kidney disease (CKD)
• Cardiovascular risk factors requiring intervention

This clinical signal arrives at the point of care, enabling better prioritization of resources, proactive outreach and earlier interventions rather than reactive follow-up.

For new members—an increasingly critical population as market dynamics drive accelerated churn—longitudinal lab data provides what claims can’t: immediate visibility into clinical status and care history. A comprehensive lab record can show that a new member completed diabetic kidney disease screening, colorectal cancer (CRC) screening or appropriate monitoring for chronic conditions with a prior carrier before coverage transition. 

Comprehensive lab data helps:

• Minimize duplicative outreach
• Reduce member abrasion from redundant testing requests
• Allow care management resources to focus on members with genuine open gaps
• Close care caps earlier and throughout the year

Operational advantages include:

• Faster risk signal for new and churned members. Longitudinal lab trends for A1c, eGFR and LDLC values surface risk and open gaps in real time, without waiting months for claims. It also addresses temporary lack of data for new members that might have left a prior plan or network. This gives quality and care management a fast, informed start for targeted interventions with enrollment cohorts with thin histories, improving Consumer Assessment of Healthcare Providers and Systems (CAHPS) relevant experience, and reducing low-yield outreach.
• Cleaner documentation for Stars/HEDIS numerators. Timely, standardized lab feeds mapped to measure diabetes, CKD and CRC screening strengthen documentation, reduce manual resource involvement, and accelerate confirmation of gap closure.
• Behavioral health integration. With the proposed depression screening and follow-up measure for measurement year 2027, lab anchored workflows can be coordinated with behavioral health processes and follow-up protocols to improve clinical control and member experience. 

Strategy shift: From seasonal pushes to continuous gap closure

The era of Q3-Q4 salvage campaigns is over. With more weight on outcomes and member experience—and tougher cut points on many measures—continuous gap closure strategies outperform seasonal campaigns.

Leaders need year-round playbooks that combine:

• Early-year opt-in engagement to efficiently reach motivated members
• Mid-year data driven targeting for non-responders
• Late-year auto-deployment integrated with provider capacity and behavioral health workflows to maximize remaining outreach
• A multi-modality approach featuring patient service centers and at-home testing kits

How Labcorp helps organizations move from policy awareness to operational readiness

The strategic value of diagnostic intelligence and year-round strategies depends entirely on operational integration. Raw lab data holds limited utility unless it’s standardized, scalable and feeds test codes, result units and reference ranges from national lab partners that are mapped directly to quality measure specifications and integrated into existing workflows. 

Organizations that implement the appropriate technical infrastructure using lab data can automatically flag new members requiring outreach, testing or intervention based on lab evidence of gaps or rising risk.

Labcorp's comprehensive gap closure solutions provide the infrastructure, data and flexibility needed to execute these strategies effectively. We have access to a national dataset of over 45 billion lab results covering approximately half of the U.S. population, providing health plans with more than two years of historical lab data. 

This longitudinal clinical history follows members as they move between plans. For new members, this data reveals whether gaps have already been addressed and whether conditions are stable, deteriorating or undiagnosed—insights that would otherwise require months of claims accumulation to detect.

We also provide your members national access to Labcorp’s testing services with over 2,200 patient service centers. Our turnkey at-home test collection kit programs also remove transportation and scheduling hurdles to help close gaps in care. 

Labcorp’s phased, multimodal approach (in person and at-home programs) raises completion rates while smoothing operational load—supported by standardized HL7 feeds, dashboards and calculated member outreach. 

Multichannel outreach, via letters, email, text and/or calls, streamlines participation and reduces follow-up burden on care teams. Regardless of collection method, plans receive standardized feeds for HEDIS submissions, delivering timely, consistent data across the member population.

Our comprehensive data analytics, nationwide scale, convenient access and phased approach gives your plan a single partner for logistics, testing and reporting. This reduces handoffs, improves timeliness and closes more gaps with the same (or fewer) resources.

Labcorp can help health plans interpret regulatory changes and operationalize them through diagnostic intelligence, scalable execution and measurable outcomes, including:

1. Policy-to-operations translation. We help quality, Stars and population health leaders map enacted and proposed requirements into playbooks in the form of D‑SNP integration and PDE timeliness, and Stars measure refocus. This allows your teams to align resources early and avoid a Q4 scramble.
2. National scale, proven payer partnerships. Labcorp operates at national scale with established relationships across MA, Medicaid and commercial lines and experience integrating data into your existing HEDIS engines and population health platforms.
3. Continuous gap closure infrastructure. We have experience with year-round gap closure strategies and provide you with real time tracking and standardized reporting to confirm closure, while your members have access to bilingual materials and customer support. This model outperforms single channel, seasonal campaigns on both completion and member experience metrics.
4. Measurable impact and equity alignment. Lab-anchored analytics support coding accuracy, rising risk detection and targeted community interventions, which are capabilities plans need as Stars shift toward outcomes and experience and CMS continues to emphasize equity and access across programs. 

What to remember (and act on) this plan year 

The annual CMS regulatory cycle creates persistent demands for operational adaptation. Organizations that treat each rule change as an isolated compliance exercise will perpetually struggle with resource constraints, fragmented data and reactive interventions. 

Remember:

• Operational readiness > awareness. CMS rules affect daily workflows like appeals, D‑SNP integration, PDE timeliness and Stars weighting—plan accordingly, sooner than later
• Continuous beats seasonal. Year-round, multi-modal gap closure outperforms late-year, single-channel pushes, especially as Stars shift toward outcomes and quality of member experience
• Diagnostic intelligence fuels earlier interventions. Lab data surfaces risk, identifies actionable care gaps earlier, improves outreach prioritization and documentation, while confirming gap closure faster than with claims data alone
• Labcorp is your partner for readiness. We can help translate CMS policy into operational quality performance—bringing our national scale, proven payer partnerships and measurable results seamlessly into your organization

Ready to move from policy awareness to operational readiness? 

The difference between policy awareness and operational readiness ultimately determines which organizations protect their Stars ratings, improve HEDIS scores and deliver better member outcomes while managing resource constraints effectively. As you plan for the next regulatory cycle, consider how incorporating diagnostic intelligence into your Stars strategy, population health analytics and equity road maps can help you proactively address regulatory changes, reduce volatility and improve member outcomes and quality performance. 

If you’re ready to make continuous improvement your competitive advantage, Labcorp can help you prepare, adapt and perform. Request a consultation to review 2027 implications for your contracts and identify the quickest wins to stabilize quality performance. 

You can also contact us today to assist with your operational planning to help you codesign a year-round, multimodal gap closure program with standardized HL7 feeds and provider follow up that uniquely fits your needs.