If your Stars strategy still assumes administrative measures will carry the rating, the math has changed under you. The cushion that let plans absorb a rough call-center season is being removed, and member experience is moving to the center of the score.
This is easy to misread, because one of the 2026 changes looks, on its surface, like experience matters less. Read the full picture and the opposite is true. The plans that understand the distinction will protect their rating and the revenue attached to it.
Here is what actually changed, why it makes the call center a revenue lever rather than a cost center, and how the same logic now applies to ACA plans through the Quality Rating System.
What Actually Changed
Beginning with the 2026 Star Ratings, the per-measure weight for patient experience and complaint measures decreased from 4 to 2, and the same applied to access measures (Calculation of Star Ratings, 2026). Taken alone, a lower weight reads as lower priority.
That reading misses the larger redesign happening around those weights. CMS is also moving to remove roughly a dozen measures from the methodology over the coming rating cycles, including several high-performing administrative measures that many plans quietly relied on to prop up their overall ratings. In the same redesign, CMS reversed the anticipated Excellent Health Outcomes for All reward (formerly the Health Equity Index) and retained the Reward Factor.
The measures coming out are largely the process and administrative ones plans found easiest to score well on, the dependable points that padded a rating even when member experience lagged. Remove them, and the rating leans more heavily on what is left.
Why a Lower Weight Means Experience Matters More
When high-scoring administrative measures are removed, the remaining measures carry more of the total. Press Ganey estimates the removals equate to roughly $1.3 billion in lost Quality Bonus Payment dollars when applied to the 2026 results, and projects that CAHPS and HOS together will approach 40 percent of total Star weight by 2029 (Press Ganey, 2026). Milliman’s independent simulation of the same removals points the same direction, with a national average decline near 0.15 stars and roughly 158 contracts projected to drop by half a star (Milliman, 2026).
So the per-measure weight came down, but the share of the rating driven by member experience is climbing. The safety net is gone, and there is nowhere left to hide a weak member services operation..
A simple way to see it: picture the rating as a fixed pie. For years, administrative and process measures were large, reliable slices that many plans counted on to hold up the total, even when member experience lagged. Now CMS is removing several of those slices. The pie does not shrink; the remaining slices grow to fill it. A measure weighted at 2 in a methodology with fewer administrative measures can carry more practical influence than the same measure weighted at 4 when it was surrounded by easy points.
Timing sharpens the point. CAHPS surveys return to members’ hands in March 2026, which means the first-quarter experience is what members carry into the survey that sets the following year’s rating (Press Ganey, 2026).
The Same Logic Now Applies to ACA Plans
Marketplace plans face a parallel system. The ACA Quality Rating System (QRS) is a 5-star program that rates qualified health plans across three domains, Medical Care, Member Experience, and Plan Administration, with the Member Experience domain drawing on the CAHPS-based QHP Enrollee Survey (Centers for Medicare & Medicaid Services, 2026).
Those ratings are displayed to shoppers during open enrollment, so an ACA plan’s member-experience performance is visible at the exact moment a consumer is choosing a plan (Centers for Medicare & Medicaid Services, 2026). For a marketplace plan, experience is both a quality signal and a competitive one.
Where the Call Center Shows Up in the Score
Member experience is not an abstraction. It is the sum of concrete call-center outcomes that plans already measure.
- CAHPS and enrollee survey results. Shaped by wait times, first-call resolution, and how a member is treated on the hardest calls.
- Complaints. Driven up by unresolved issues and inconsistent service and counted directly against the rating.
- Disenrollment. The downstream result of a member who could not get a clear answer when it mattered.
Each of these traces back to who was on the phone, how well-trained they were, and whether the team stayed consistent throughout the season.
The Revenue Chain, Priced
The chain from a single resolved call to next year’s revenue is concrete, and it is worth pricing. Plans that reach 4 stars or higher earn a 5 percent bonus to their CMS benchmark payment, along with more favorable rebate percentages. Those dollars fund richer benefits, which attract and retain members, which in turn feed the next rating.
The magnitude is not small. Industry analysts have shown a single half-star improvement, from 3.5 to 4.0, worth roughly $20 million in additional revenue for a plan of about 40,000 members, achieved without adding a single new enrollee. That is the lever a member services operation sits on. When CAHPS, complaints, and disenrollment all trace back to the call center, the call center is a direct input to Quality Bonus Payment and rebate dollars on roughly a one-year lag.
What This Changes in the Budget Conversation
For an operations leader, the practical fallout lands in the annual budget discussion. The case for investing in member services used to compete against the comfort of strong administrative scores, and that comfort is leaving. With administrative measures stemming from the methodology, the member services line is no longer the easiest place to trim. It is one of the few remaining levers that directly move the rating, reframing it from a discretionary cost to a rating-protection investment.
The dangerous move in 2026 is to see the weight drop from 4 to 2 and quietly pull back on member-experience spending. Several plans will do exactly that, and their next rating will surprise them. The plans that read the full methodology will do the opposite, protecting and investing in the member services operation precisely because the administrative cushion that used to forgive a weak call center is gone.
The leaders who win this argument internally will be the ones who can show, in plain terms, how the call center connects to CAHPS, to complaints, to disenrollment, and from there to Quality Bonus Payment and rebate dollars. Practically, that means modeling how the rating shifts once administrative measures come out, protecting the January-to-March window as survey season by avoiding disruptive operational changes during it, and building member-experience targets into how the member services function, in-house or outsourced, is measured and managed.
It also reframes how plans think about outsourcing. If member experience is becoming the score, then the partner running the member services operation is no longer a back-office cost decision. It is a quality decision with direct revenue consequences, and it deserves to be evaluated on that basis. None of this requires a plan to overhaul its operation this quarter. It requires leadership to stop treating the call center as the safe place to cut, because in the new methodology it is anything but.
Stop budgeting the call center as a cost center.
Join the Live Session
Our webinar, Staffing Medicare and ACA Member Services: The Six-Month Dedicated Team Model, walks through the six roles, the activation timeline, and what continuity changes for member experience.
Join us live Thursday, July 23, 2026, at 10:00 a.m. PT / 1:00 p.m. ET, or watch on demand afterward.
A Note on the Operating Model
ConfieBPO structures member services around the experience metrics that move ratings, an approach refined for insurance and regulated industries since 1998. The argument here is not about a vendor, though. It is that the call center is now a rating input and budgeting it like a cost center is a strategic mistake.
Frequently Asked Questions
Did CMS make member experience worth less in 2026?
The per-measure weight for patient experience and complaint measures dropped from 4 to 2 (Calculation of Star Ratings, 2026), but the removal of administrative measures means experience is a growing share of the overall rating, projected near 40 percent for CAHPS and HOS by 2029 (Press Ganey, 2026).
How much revenue is tied to these changes?
Press Ganey estimates roughly $1.3 billion in lost Quality Bonus Payment dollars when the measure removals are applied to the 2026 results (Press Ganey, 2026). Quality Bonus Payments and rebates are determined by the rating.
When do CAHPS surveys reach members?
CAHPS surveys return to members’ hands in March 2026, so first-quarter call quality shapes the rating that drives the following year’s revenue (Press Ganey, 2026).
Do ACA plans have a comparable rating?
Yes. The ACA Quality Rating System is a 5-star program based partly on a CAHPS-derived enrollee survey, displayed to shoppers during open enrollment (Centers for Medicare & Medicaid Services, 2026).
What call-center metrics feed these ratings?
First-call resolution, wait and abandonment rates, complaint volume, and disenrollment, all of which trace back to staffing quality and consistency.
What is the single most important takeaway?
The administrative safety net is going away. Member experience, driven by the call center, is becoming the lever that decides the rating and the revenue tied to it.
Should we cut member services spending given the lower weight?
No. The lower per-measure weight is offset by the removal of administrative measures, which makes member experience a larger share of the overall rating (Press Ganey, 2026). Cutting the call center now works against the score.
How quickly do these changes reach revenue?
The rating set by this year’s performance drives the following year’s Quality Bonus Payments and rebates, so first-quarter member experience reaches revenue on roughly a one-year lag (Press Ganey, 2026).
References
- Calculation of Star Ratings, 42 C.F.R. § 422.166 (2026). https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-D/section-422.166
- Centers for Medicare & Medicaid Services. (2026). Health insurance marketplace quality initiatives. https://www.cms.gov/marketplace/about/health-insurance-marketplace-quality-initiatives
- Milliman. (2026). Falling Star Rating trajectory: 2027 Proposed Rule implications. https://www.milliman.com/en/insight/falling-star-rating-trajectory-2027-proposed-rule
- Press Ganey. (2026). Are you ready? CMS just ignited the biggest Stars shake-up in a decade. https://www.pressganey.com/resources/blog/cms-stars-shake-up/
