Turning NCQA 2025 Health Plan Ratings into a Roadmap for Improvement
September 19, 2025
The 2025 NCQA Health Plan Ratings are out. For health plans, these results are more than just numbers — they’re a public reflection of quality, experience, and performance.
This year’s ratings highlight progress, new measures that raise the bar, and sharper contrasts between top performers and those falling behind. The challenge is clear: ratings are not only a benchmark; they’re a competitive differentiator.
At
Advent Advisory Group, an
NCQA-licensed organization, we help plans make sense of their results, identify opportunities, and implement changes that drive measurable gains.
What's New in 2025:
- Language Diversity of Membership (LDM): Plans must now report on members’ preferred spoken and written languages.
- CAHPS still critical: Member experience remains a top driver of ratings.
- Chronic condition gains: Improvements in diabetes management and care transitions.
- Coordination matters: Smooth transitions remain a differentiator — gaps still exist.
Why Ratings Matter
High NCQA ratings build trust with members, competitive positioning, and credibility with regulators and purchasers. Accreditation also earns bonus points, directly boosting scores.
Common Struggles
- Reporting readiness: Many plans aren’t fully prepared for reporting of descriptive measures, like LDM and Race/Ethnicity Diversity of Membership (RDM)
- Gaps in data: Sunsetting of the hybrid methodology presents new data challenges
- CAHPS performance: Member experience continues to drag down ratings.
- Inconsistent results: Strong in one area, weak in others — uneven performance.
The Bottom Line
As Betsy Seals, CEO of Alerion Advisors, recently noted: “Transparency and accuracy are now key differentiators in the Medicare Advantage market.”
Humana borrows UnitedHealth’s Medicare Advantage playbook - Modern Healthcare
At Advent, we don’t just react to ratings — we help you get ahead. Let’s turn your NCQA into a blueprint for stronger quality, compliance, and growth.
How Advent Helps
With NCQA licensing and deep HEDIS audit expertise, Advent provides:
- Compliance audit support to validate measures and correct discrepancies.
- Gap analysis across metrics impacting ratings.
- Support for new measures, from data to process.
- Benchmarking and competitive insight for market positioning.
Advent Advisory Group Insights
NCQA has opened the 2026 HEDIS® Public Comment period, running from February 13 through March 13, 2026.
CMS has released its CY 2027 Advance Notice of Methodological Changes for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies.
The CMS 2026 Program Audit Annual Updates bring several important changes that healthcare sponsors must address to stay compliant. These updates affect various aspects of the audit process, from condition classifications to new requirements for validation audits.
Aside from the usual updates to the audit timeline and other wording changes, this year’s HEDIS audit manual includes several changes of significance.
The Advent team had the opportunity to attend the NCQA Health Innovation Summit, where healthcare leaders and innovators came together to explore the next phase of digital quality measurement and value-based care.
HEDIS is shifting. Stars are flattening. Advantage goes to plans that act now. After several consecutive years of declines, the average Medicare Advantage (MA) Star Ratings are essentially flat for 2026.
As California leaders assess the sweeping implications of these proposed changes, Advent Advisory Group is helping health plans evaluate exposure, model financial impacts, and prepare operational strategies across Medicare, Medi-Cal, and Commercial lines.
CMS recently published its annual Part C and Part D Program Audit and Enforcement Report. The report provided recommendations and guidance for Sponsors to consider when preparing for future CMS Program Audits.
Advent’s HEDIS 2026 webinar series kicked off last month with Optimizing Clinical Data Quality, a presentation focused on common challenges with supplemental clinical data. Key takeaways include the following: Transition in Data Collection: The shift from manual data collection to digital HEDIS reporting has increased the focus on clinical data over claims data. NCQA’s planned elimination of the hybrid reporting method has added urgency to this transition, driving plans to acquire more electronic clinical data and adapt to year-round ingestion. Challenges with Clinical Data: The presentation highlighted several challenges to the acquisition of supplemental clinical data, including data timing, completeness, and accuracy. Issues such as short turnaround times, missing biometric values, and incorrect coding have impacted the useability of these additional data sources for HEDIS reporting. Tips for Navigating the Transition: Plans can navigate this transition by starting early with clinical data validation, engaging with IT departments, exploring vendor’s reports and supportive capabilities, and building executive leadership buy-in.
Another year of Medicare Part C and Part D Data Validation (DV) audits is in the books. Here are a few key takeaways and best practices from this year’s experience: 1. Share CMS Technical Specifications Early Ensure all report owners receive CMS technical specs and reporting requirements well in advance. This promotes clear understanding of required data elements and ensures alignment for HPMS submissions and audit readiness. 2. Strengthen Internal Quality Control A robust internal QC process is essential. Assign a lead to manage this effort and establish standardized checks. Block time in March to confirm that what’s submitted in HPMS accurately reflects your intended data. 3. Validate Vendor Data Throughout the Year Accurate reporting hinges on reliable vendor data. Set expectations for vendors with delegated reporting responsibilities to provide both summary and detailed data. Request clear references or documentation to interpret results effectively. 4. Create a Centralized Measure Reporting Library Maintain a central repository that includes final submissions (HPMS summary and supporting detail), measure logic, and relevant policies and procedures. These documents not only support measure reporting but also fulfill many DV audit documentation requirements. Congratulations to our Medicare clients on another successful reporting year. As always, early preparation and strong processes are the foundation of accurate reporting and DV audit success.
