If your Stars strategy still assumes administrative measures will carry the rating, the math has shifted beneath 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.<\/p>\n\n\n\n
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. Plans that understand the distinction will protect their rating and the revenue attached to it.<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
Beginning with the 2026 Star Ratings, the per-measure weight for patient experience and complaint measures decreased from four to two, and the same change applied to access measures (Calculation of Star Ratings, 2026). Taken alone, a lower weight suggests lower priority.<\/p>\n\n\n\n
That reading overlooks the broader redesign underway for those weights. CMS is also removing 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. As part of the same redesign, CMS reversed the anticipated Excellent Health Outcomes for All reward (formerly the Health Equity Index) and retained the Reward Factor.<\/p>\n\n\n\n
The measures coming out are largely the process and administrative ones that 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 remains.<\/p>\n\n\n\n
It is worth being concrete about what survives. As administrative and process measures phase out, the remaining measures lean toward clinical outcomes, gap closure, and the member-experience and access measures fed by CAHPS. CMS also added a Part C Depression Screening and Follow-Up measure, signaling that behavioral health and follow-through are part of the new emphasis. The common thread is that the surviving measures are harder to manufacture without process discipline. They reward plans that close gaps and earn member trust, and member trust is built or lost on the calls the member services operation handles.<\/p>\n\n\n\n
When high-scoring administrative measures are removed, the remaining measures account for a larger share of the total. Press Ganey estimates that 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 in 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).<\/p>\n\n\n\n
The per-measure weight has come 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.<\/p>\n\n\n\n
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 two in a methodology with fewer administrative measures can carry more practical influence than the same measure weighted at four when it was surrounded by easy points.<\/p>\n\n\n\n
The timing makes this urgent rather than theoretical. CAHPS surveys reach members in March 2026, so the experience a member had in January and February is what they rate, and that rating sets the following year’s revenue (Press Ganey, 2026). The first quarter is also, not coincidentally, the hardest stretch for the call center. Medicare OEP runs January through March; new plan-year formulary and network changes drive confused and frustrated calls, and ACA effectuation generates its own wave. The quarter in which members form the judgment that becomes the rating is the same quarter when a thinly staffed or freshly rebuilt operation is least able to handle them well. Plans are advised to stabilize operations and avoid disruptive changes during the survey window for exactly this reason. The operation you field in January is the rating you post next year.<\/p>\n\n\n\n
Marketplace plans are subject to 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).<\/p>\n\n\n\n
Those ratings are shown 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 serves as both a quality and a competitive signal.<\/p>\n\n\n\n
Member experience is not an abstraction. It is the sum of concrete call-center outcomes that plans already measure.<\/p>\n\n\n\n
Each of these traces back to who was on the phone, how well trained they were, and whether the team remained consistent throughout the season.<\/p>\n\n\n\n
For the leader who runs daily operations, the trap in the new math is that the survey measures are lagging indicators. CAHPS and the QHP Enrollee Survey tell you how members felt months after the calls that shaped those feelings, and by then the rating is largely set. The job, then, is to manage the leading indicators that feed those measures while there is still time to move them.<\/p>\n\n\n\n
Three are within the operation’s direct control. First-call resolution is the closest proxy for the Customer Service and overall plan-rating measures because a member whose issue is resolved on the first try rarely rates the plan poorly. Wait time and abandonment map to the access and getting-care-quickly measures because a member who could not get through did not receive needed care quickly by any definition. Complaint volume is both a leading indicator and a Star measure in its own right, since unresolved issues become logged as CMS complaints. Watch those three weekly, and the March survey result stops being a surprise. Ignore them until the rating posts, and the lever is already out of reach..<\/p>\n\n\n\n
The chain from a single resolved call to next year’s revenue is concrete and worth pricing. Plans that reach four stars or higher receive a 5%bonus on their CMS benchmark payment, along with more favorable rebate percentages. Those dollars fund richer benefits t hat attract and retain members, which in turn feed the next rating.<\/p>\n\n\n\n
The magnitude is not small. Industry analysts have shown that a single half-star improvement, from 3.5 to 4, is 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, with roughly a one-year lag.<\/p>\n\n\n\n
The figures above are industry illustrations, but the exercise that matters is the one a plan runs on its own book. Take your current overall rating and identify which surviving measures you are closest to their thresholds. For most plans, several of those will be the CAHPS experience and complaint measures fed by the call center. Then model the rating two ways: once assuming the administrative measures you have leaned on are gone, and once assuming a realistic move in the experience measures the operation can influence. The gap between those two scenarios, expressed in Quality Bonus Payment and rebate dollars, is the size of the bet you are placing on your member services operation. For most plans running the math honestly for the first time, the number is larger than the line item they were tempted to cut.<\/p>\n\n\n\n
This is also where the choice of operating partner stops being a cost decision. A generic, high-volume contact center is engineered to optimize metrics that lower its own costs: shorter handle times, more calls per hour, lower cost per interaction. None of those is the metric that moves your rating, and several of them work against it, because the fastest way to end a call is not the same as the way that resolves it. A vendor rewarded for throughput will, rationally, push for throughput.<\/p>\n\n\n\n
Offshore distance compounds the problem by making the exact measures that now carry the rating harder to meet. A queue many time zones from the member cannot align with U.S. business hours without thin overnight coverage, and a Spanish line staffed without cultural fluency answers the words but not the worry, which shows up directly in the survey average for plans with significant Hispanic membership. Rigid seat minimums and per-minute pricing, the hallmarks of a general-purpose outsourcer, optimize the contract, not the member experience. When experience is the score, a partner whose economics reward speed and volume is structurally misaligned with the rating you are trying to protect.<\/p>\n\n\n\n
For an operations leader, the practical fallout lands in the annual budget discussion. The case for investing in member services used to compete with the comfort of strong administrative scores, and that comfort is fading. With administrative measures coming out of 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.<\/p>\n\n\n\n
The dangerous move in 2026 is to see the weight drop from 4 to 2 and quietly cut member-experience spending. Several plans will do exactly that, and their next rating will surprise them. Plans that read the full methodology will do the opposite, protecting and investing in the member services operation precisely because the administrative cushion that once forgave a weak call center is gone.<\/p>\n\n\n\n
The leaders who win this internal argument will be the ones who can, in plain terms, show how the call center connects to CAHPS, complaints, and disenrollment, and, from there, to Quality Bonus Payment and rebate dollars. In practice, that means modeling how the rating shifts once administrative measures are released, protecting the January-to-March window as survey season by avoiding disruptive operational changes during that period, and building member-experience targets into how the member services function, whether in-house or outsourced, is measured and managed.<\/p>\n\n\n\n
For a chief operating officer or quality leader putting the operation out to a partner, the new methodology changes the specification. The questions that matter are no longer only about price per seat and service-level adherence. They are about whether the partner can move the measures that now drive the rating and whether you can see it happening in time to act.<\/p>\n\n\n\n
A sound arrangement shares specific, experience-linked KPIs, including first-call resolution, complaint rates, and disenrollment, rather than service levels alone. It uses transparent measurement with agreed definitions and reporting so both sides read the same numbers. It runs on a governance cadence frequent enough to catch drift in service before it reaches a member or a survey. And it staffs the licensed, in-language work with certified professionals who can carry a rating-impacting conversation, not temporary agents flexed in to hit a seat count. A partner built for regulated health plans, aligned with U.S. hours and culture, and measured on the outcomes that move the rating is the one whose incentives match yours. None of this requires a plan to overhaul its operations this quarter. It requires leadership to stop treating the call center as a safe place to cut, because, under the new methodology, it is anything but.<\/p>\n\n\n\n
There is a competitive edge hidden in this shift that the budget conversation often overlooks. Star Ratings and the ACA Quality Rating are, in effect, graded on a publicly visible curve. When the administrative safety net disappears and experience carries more weight, the plans that protect their member services operations not only hold their own rating; they gain ground relative to the plans that cut. A competitor that reads the shift in weight as permission to trim its call center will slip, and in a market where a half-star can move benchmark-bonus eligibility and the rebate dollars that fund richer benefits, that slip compounds. On the ACA side, the effect is even more direct because the Quality Rating is displayed to shoppers at the moment of choice, so a stronger experience score is a visible advantage on the marketplace shelf.<\/p>\n\n\n\n
That turns member experience from a defensive cost into an offensive lever. A plan that invests while peers retrench can move up half a star, qualify for or protect a bonus, fund a more attractive benefit design, and attract and retain members who then rate the plan well, feeding the next year’s rating. The flywheel runs in both directions. The same logic that punishes a neglected call center rewards a well-run one, and the gap between the two widens as experience measures carry more weight each year. The plans that understand the new math are not merely protecting a number. They are pulling ahead while others misread the change.<\/p>\n\n\n\n
Stop budgeting the call center as a cost center.<\/strong><\/p>\n\n\n\n Our webinar, Member Services Experience Across Medicare and ACA: How Member Services Performance Decides Future Revenue<\/strong>, walks through the new Stars math, the ACA Quality Rating parallel, and what to hold a member services operation accountable for.<\/p>\n\n\n\n Join us Thursday, August 27, 2026, at 10:00 a.m. PT \/ 1:00 p.m. ET.<\/p>\n\n\n\nJoin the Live Session<\/h2>\n\n\n\n