Star Ratings are one of the most powerful determinants of a health plan's long-term success. Published annually by the Centers for Medicare & Medicaid Services (CMS), these ratings evaluate plans on both the quality of services offered and the value of care delivered, directly impacting key business outcomes including revenue, enrollment, and market competitiveness.
At the center of this dynamic sits member behavior: how individuals perceive, experience, and act on their healthcare coverage. When members feel engaged and supported in their care journey, satisfaction rises, churn decreases, utilization shifts upstream, and clinical outcomes improve––making timely, meaningful healthcare communication an essential tool in every plan's arsenal.
Today's health plans are aware that member engagement offers a critical lever. But when it comes to evaluating and improving their strategy, many tend to focus on the wrong indicators––overlooking the key operational signals that offer real-time insight into member behavior.
Success is Written in the Stars
Roughly 40 measures determine plans' Stars Ratings. Drawing on numerous data sources including HEDIS clinical quality metrics, Consumer Assessment of Healthcare Providers and Systems (CAHPS) scores, health outcomes surveys, and operational customer service metrics, the program ranks plans on a five-point scale, assigning sizable rewards (or consequences) depending on where plans fall.
Plans that achieve four stars or higher qualify for quality bonus payments (QBP) of 3.5% to 5%, while plans that fall below three stars risk removal from the Medicare Advantage program entirely. Within this framework, even minor changes in rating can have a major financial impact. Improving a rating from three to four stars, for instance, can increase enrollment by 12% and strengthen revenue by nearly 18%. Meanwhile, the drop from four to three stars can equate to millions lost in withheld bonus payments and member churn. As such, plans have a clear incentive to strengthen the customer experience, increase retention, and leverage engagement to guide their members toward low-cost, high-impact behavior.
Medication adherence, preventive screenings, access to care, and reported satisfaction all tie back to how––and when––members engage with their health plan. For instance, members who feel supported and confident in their coverage are significantly more likely to utilize preventive services, attend medical appointments, report a positive experience, and recommend their health plan to others. As demand for seamless, consumer-centric journeys expands, so does the weight (and impact) of members' perceived experiences, making it essential that plans show up with meaningful, accessible, and context-aware communication. To do so, organizations need a clear-eyed understanding of the relationship between upper-funnel engagement and downstream member behavior.
Why Utilization Data Is the Wrong Signal for Managing Engagement
Many plans still evaluate and manage engagement using utilization data. The issue? Healthcare claims are inherently retrospective, making them a poor window into where, when, and why members disengage. Member behavior––how individuals understand and act on their coverage––encompasses far more than downstream utilization and is heavily influenced by social determinants of health (SDoH) like age, income, health literacy, and cultural background. Emotional drivers such as anger, confusion, and anxiety can also play a major role in the member journey.
Utilization data, though useful, does not provide the insight needed to tailor upstream engagement around these emotional and contextual factors. Instead, it can only ever reflect what has already happened: missed appointments, unfilled prescriptions, non-urgent emergency department visits, and other avoidable outcomes. Consider this example: in 2025, 90% of Americans reported postponing or skipping care due to emotional drivers such as fear, confusion, frustration, or anxiety. Unlike claims data, important operational signals like call volume, missed appointments, and low program enrollment can indicate member friction in real time, giving plans the opportunity to intervene before problems occur and influence patient experience, complaints, and access measures captured through the CAHPS survey.
Using AI to Optimize Engagement Early and Often
Improving Star performance requires a proactive, data-driven engagement strategy that identifies barriers earlier in the member journey and deploys context-aware outreach rooted in an individual's channel preferences, SDoH, and behavioral patterns. Advances in AI-powered engagement platforms are helping health plans make this transition by providing greater visibility into how members interact with communications and how those interactions influence healthcare decisions.
Two capabilities are particularly important. First is closed-loop attribution, which connects engagement activities directly to downstream outcomes. Instead of measuring outreach effectiveness retroactively through claims data, plans can connect upstream outreach to behavioral outcomes in real time. This visibility allows organizations to identify which outreach strategies are most effective in driving the behaviors that determine Star performance. Next is intelligent orchestration, which leverages AI to continuously refine engagement strategies by optimizing message timing, communication channels, and personalization for individual members. Outreach can be custom-tailored around SDoH, member preferences, and historical data from the onset––and continuously refined based on real-world feedback.
Together, closed-loop attribution and intelligence orchestration enable health plans to optimize outreach for the greatest impact. In particular, transitions of care represent a critical window of opportunity, as members typically experience the greatest friction immediately following a care event. During this time, the likelihood of behavior change increases; plans that show up with timely, empathetic engagement can improve coordination across the continuum of care and directly influence outcomes across multiple quality measures.
Engaged Members + Better Outcomes = A Stronger Bottom Line
Star Ratings are often viewed as a reporting outcome, but in reality, they are the result of thousands of individual member decisions––decisions shaped long before they show up in claims data or CAHPS results.
As the Star Ratings program continues to evolve, the health plans that succeed will be those that shift their focus upstream. By using AI to better understand and influence member behavior, plans can improve engagement and strengthen quality performance, creating a positive ripple effect across the entire healthcare system.
