Navigating the 2025 CMS Star Ratings: How Behavioral Science, Predictive Analytics, & Personalized Engagement Can Help Health Plans Reclaim High Score

The 2025 CMS Star Ratings present a challenging landscape for Medicare Advantage (MA) and Part D plans. With the average star rating dropping to 3.92 from 4.07 in 2024, many health plans are struggling to maintain their high-performance standards. Only seven plans achieved a 5-star rating, compared to 38 in the previous year, highlighting the increasing difficulty of meeting CMS’s stringent requirements. Additionally, 57% of contracts that held a 5-star rating in 2024 dropped to lower ratings in 2025, underscoring the volatile landscape.

This decline impacts more than just ratings—health plans risk losing critical bonus payments, seeing reductions in member enrollment, and facing reputational damage. The path forward requires rethinking strategies in key areas like medication adherence, preventive care, and member engagement. By leveraging behavioral science, predictive analytics, and personalized strategies, health plans can improve these critical metrics and reclaim their star ratings.

1. Medication Adherence: A Key Focus Area

Medication adherence remains one of the biggest challenges for health plans, particularly for members managing chronic conditions such as diabetes and hypertension. Non-adherence not only negatively impacts member health but also significantly affects plan star ratings.

How Behavioral Science and Predictive Analytics Can Help:

The behavioral design process starts with understanding the underlying reasons why members struggle with adherence, whether it’s due to low health literacy, difficulty accessing medications, or confusion about regimens. Behavioral design pinpoints these barriers and offers actionable solutions, giving members the tools and support to overcome them.

Predictive analytics can further enhance adherence efforts by identifying members who are at risk of non-adherence before it becomes an issue. By proactively targeting these members with tailored interventions, health plans can prevent issues before they negatively affect scores. Integrating real-time data into these efforts allows plans to adjust outreach dynamically, ensuring members receive timely, relevant support.

Conversational AI and Natural Language Understanding (NLU) also play a key role by offering personalized, real-time support. For example, AI-driven conversations can adapt to individual needs, providing immediate assistance when members feel overwhelmed by their medication schedules. These tailored interactions break down complex regimens into simple, actionable steps, helping members stay on track.

Encouraging Results:

From mPulse’s client projects, one Medicare Advantage plan using behavioral science approaches saw a 3.48 percentage point improvement in medication refill rates over the course of a year. Specific improvements included a 9.63 percentage point increase in cholesterol medication adherence and a 14.1 percentage point increase for diabetes medications. By understanding members' challenges and providing personalized support, health plans can make adherence more manageable for their members and significantly improve star ratings.

2. Preventive Care: Engaging Members with Flu Vaccination Campaigns

Preventive care, including flu vaccinations, is another area where many health plans are falling behind. The average star rating for flu vaccinations remains low at 3.2, leaving much room for improvement.

How Behavioral Science and Real-Time Data Can Help:

A powerful behavioral technique is the endowment effect, which can position preventive actions like flu shots as something members already “own.” By shifting how the message is presented, plans can significantly increase the likelihood of members acting on it.

Adding real-time data integration allows health plans to track member engagement dynamically, enabling quick adjustments to outreach strategies. This responsiveness is particularly crucial during flu season when the timing of communication can make a significant difference in vaccination rates.

Positive Outcomes:

In one mPulse SMS campaign targeting 2.2 million members, those who were contacted saw a 74% higher completion rate for flu vaccinations. In some states, such as Maryland, the completion rate was as much as 126% higher for members who received these personalized messages.

Incorporating behavior change techniques such as social proof (e.g., “80% of people in your community have already received their flu shot”) can further increase engagement. By making preventive care feel more familiar, relevant, and socially normative, health plans can see higher participation in these essential services. But make sure to avoid negative social proof.

3. Health Equity: Addressing Social Determinants of Health

With the growth of special needs plans (SNPs) by 9% in 2025, addressing social determinants of health (SDOH) and promoting health equity is becoming an even more critical focus for CMS. For health plans, improving outcomes for underserved populations is not just a regulatory requirement—it’s a moral imperative.

How Personalized Outreach and Predictive Analytics Can Help:

Culturally competent communications are key to ensuring that all members, regardless of their background, feel supported and empowered to engage in their care. This involves personalizing communications to reflect members’ unique cultural contexts and addressing social determinants like access to care, transportation, and health literacy.

By leveraging predictive analytics, health plans can identify and target members who are most affected by SDOH. This allows for tailored interventions that address specific barriers, such as transportation issues or limited healthcare access, ensuring that all members receive the support they need.

Closing Equity Gaps:

By tailoring outreach to meet the specific needs of underserved populations, health plans can reduce equity gaps, particularly in areas like preventive care and medication adherence. Data analytics can help identify where these gaps exist, allowing plans to craft messages that resonate more deeply with each member segment.

4. Future-Proofing for 2026 and Beyond

As CMS shifts the weighting of member experience metrics in future Star Ratings, plans will need to take a multidimensional approach to performance improvement, focusing not only on CAHPS but also on HEDIS, pharmacy, and operational measures.

Health plans can further benefit by optimizing vendor partnerships to ensure that all stakeholders are aligned with Star Rating goals. Regular reviews and shared performance metrics can help ensure consistent quality improvement across the board, driving success in all areas of CMS’s evolving metrics.

Conclusion: Moving Forward Together

The 2025 CMS Star Ratings reflect the growing challenges health plans face in maintaining high performance. But the path forward, while complex, offers clear opportunities. By leveraging behavioral science, real-time data, and predictive analytics, health plans can improve member outcomes, increase preventive care participation, and enhance medication adherence.

At mPulse, we're here to help health plans navigate these changes. Whether you're looking to boost medication adherence, drive engagement in preventive care, or prepare for upcoming rating updates, we provide the tools and insights to support your goals.

Ready to safeguard your star rating? Contact us today to learn how mPulse's personalized engagement solutions, informed by our client success stories, can make an immediate impact on your plan’s performance. By taking small, strategic steps now, health plans can make a big impact on their future ratings and member outcomes.