Executive Summary
EHO4All, D-SNP Quality, and the LTSS Integration Imperative
The Landscape for Medicare Advantage (MA) quality, as we know is ever evolving, particularly in light of the just released Contract Year (CY) 2027 Proposed Rule. The proposal, as currently written, proposes major changes to Star Ratings and the ongoing integration initiatives for dual- eligible members. While these policies are not yet finalized, they offer signals from The Centers for Medicare and Medicaid Services (CMS) about where this administration is hoping to take the MA industry. Health plans and state agencies should take note of these signals now, as they reinforce the importance of outcome-focused care and more effective alignment between Medicare and Medicaid.
Notably, CMS has proposed not to implement the Excellent Health Outcomes for All (EHO4All), reward in the 2027 Medicare Star Ratings, opting to retain the existing reward factor instead. This pivots from prior plans to replace the historical reward factor with the Health Equity Index (HEI). By forgoing these initiatives (at least for now), CMS is doubling down on underscoring that high performance must be achieved across all members without receiving bonus points for serving high-risk populations.
At the same time, the proposed rule would streamline the Star Ratings program by removing a dozen measures (mostly administrative or low variance metrics) and concentrating more on clinical outcomes and patient experience. Again the signal is strong that this administration continues to focus on core quality metrics and member experience over Health Equity.
1. The 2026 Landscape: Stable Stars, Higher Pressure
Across the industry, 2026 Star Ratings signal a landscape of modest improvement mixed with persistent pressure. Cut-point guardrails constrain upward movement for many measures, while experience-driven metrics continue to dominate overall scores. Incremental improvement is no longer sufficient to meaningfully change performance; plans should demonstrate consistent improvement for members with complex needs, especially dual-eligible individuals even in light of the new proposed rule. The CY 2027 proposed rule does not fundamentally alter this trajectory, it maintains the current methodology and guardrails, meaning these challenges will persist into the next cycle as well. In other words, plans should anticipate that the heightened emphasis on patient experience and clinical quality will continue.
2. What EHO4All Changes—and What It Doesn’t
EHO4All was originally slated to replace the Reward Factor beginning with Star Year 2027 and would evaluate plans based on: (1) the proportion of members with social risk factors, and (2) performance on designated clinical and experience measures for those members. Importantly, EHO4All would not introduce new measures. Instead, it increases the weight of existing clinical quality metrics: diabetes control, blood pressure control, medication adherence, and transitions of care, for the members most affected by functional limitations.
However, as noted above, CMS’s CY 2027 proposed rule now signals a pause on this initiative. The absence of the equity specific reward does not diminish the importance of the underlying focus, in fact, with CMS simultaneously removing many process measures from Stars, the remaining clinical and patient experience measures become even more critical to overall scores.
3. Why Long-Term Services and Supports (LTSS) Determines Clinical Performance for Duals
Dual-eligible beneficiaries experience higher multimorbidity, cognitive impairment, and functional limitations, all of which directly influence outcomes for key Star measures. Their reliance on Home and Community Based Service (HCBS) providers means that quality for this population cannot be separated from LTSS performance. LTSS providers often serve as the primary touchpoint for addressing medication management, self-management, nutrition, transportation, and environmental safety—all critical contributors to clinical outcomes. This fundamental relationship between LTSS and clinical quality is reinforced by the latest policy direction. The proposed rule does not add new LTSS-specific measures, but its emphasis on integrated care for duals acknowledges that outcomes on existing measures depend on addressing social and functional needs. Members lacking adequate supports often struggle to achieve measure targets on key clinical metrics, underscoring that improving LTSS coordination amongst duals is pivotal for Stars success.
4. The D-SNP Integration Era: LTSS Is No Longer Optional
CMS continues to expand expectations around Dual Special Needs Plans (D-SNP) integration via HIDE/FIDE requirements, unified enrollment strategies, and strengthened alignment between Medicare Advantage and Medicaid LTSS and Behavioral Health programs. This momentum is continued with the proposed rule, which flagged concerns that some MA organizations may be avoiding D-SNP integration rules by steering enrollments into less integrated products like Chronic Condition Special Needs Plans (C-SNP). Along with the proposed rule CMS included an RFI asking for comment on whether to limit dual enrollment in C-SNPs and I-SNPs unless they meet Medicaid coordination standards. States continue to push in parallel, for example California and others are incorporating LTSS outcomes into quality frameworks, signaling a broader national trend toward aligning LTSS and medical care quality.
5. Clinical Measures Most Affected by LTSS Integration
- Chronic Condition Control: Diabetes and hypertension control remain among the most challenging measures for plans serving duals. LTSS assessments reveal functional and environmental barriers; mobility issues, meal preparation challenges, and medication access, that directly affect these metrics.
- Medication Adherence: Adherence outcomes for statins, RAS antagonists, and diabetes medications correlate strongly with the level and reliability of LTSS supports.
- Transitions and Readmissions: Care Management, LTSS involvement, SNFs, HCBS agencies, and caregivers, determine whether warm handoffs, medication reconciliation, and in-home follow-up occur in a timely way, directly affecting readmission rates.
- Member Experience & Access: Fragmented Medicaid–Medicare communication disproportionately impacts duals’ experience scores.
6. How LTSS Integration Improves Outcomes
Integrated delivery models improve clinical outcomes through:
* LTSS-informed assessments that identify functional, environmental, and cognitive risks
* Joint care plans across MA and LTSS providers
* Real-time transitions protocols linking hospitals, plans, and HCBS providers
* Home-based interventions that reinforce adherence and address HRSN factors
The proposed rule continues this policy direction and reinforces that these integrated practices should become standard operating procedure. By promoting integrated care for dual eligible populations, CMS is effectively encouraging plans to embed these strategies into their care models to drive outcomes for high-need members.
7. Operational Blueprint for EHO4All-Aligned D-SNP Strategy
The operational blueprint for succeeding with an equity-focused D-SNP strategy remains largely unchanged, and perhaps even more crucial, in light of the proposed rule. Plans aiming to excel in serving high risk populations should adopt integrated governance models aligning Stars, LTSS, behavioral health, and Medicaid operations. Data integration across Medicare claims, Medicaid LTSS encounters, HCBS documentation, and functional assessments will enable dual-specific risk stratification and targeted intervention design. Likewise providers and LTSS agencies should be incentivized through value-based arrangements that directly target care transitions, reduced readmissions, and care plan execution for dual-eligible enrollees. These approaches not only prepare plans for any future equity focused incentives, but also drive immediate improvements under the existing Stars framework.
8. Conclusion
Even without an immediate EHO4All implementation, the essence of quality improvement in the MA space remains unchanged. The CY 2027 proposed rule’s changes reinforce that success will come from excelling on fundamental clinical and experience measures, especially for populations with complex, LTSS-driven needs. In other words, focusing on dual-eligible members and coordinating LTSS is not just an operational exercise, it’s a strategy for high performance. Plans that treat LTSS as a core infrastructure, not just a side Medicaid obligation, will be best positioned to thrive under whatever Stars rating system is eventually implemented.
© Copyright 2025. The views expressed herein are those of the author(s) and not necessarily the views of Ankura Consulting Group, LLC., its management, its subsidiaries, its affiliates, or its other professionals. Ankura is not a law firm and cannot provide legal advice.
