Health equity has always been the turning tide for the healthcare industry, but now regulatory leaders have pushed this effort to the top of the list. A subset of measures calculated in CMS Star Ratings includes the social risk factors for low-income, dually eligible, or disabled beneficiaries, of which Medicaid, Medicare Advantage, and D-SNP members reside.
Originally introduced as the Health Equity Index, CMS has renamed the program to Excellent Health Outcomes for All (EHO4all). The goal remains the same: incentivize MA and Part D plans to improve health outcomes for member populations by better coordinating social risk factors (SRFs). The renamed program is also removing the reward factor when the EHO4all reward will be implemented with the 2027 Star Ratings.
Under a new name, the program continues to:
- Focus on social risk factors by targeting enrollees at greater risk for poor healthcare quality.
- Impact 2027 Star Ratings based on data from 2024 and 2025.
- Motivate plans to identify and address health equity gaps across member populations.
The new name does not alter the program priorities to ensure equitable care delivery, but it does consider future expansion into geographic disparities.
This blog series provides valuable advice for health plans to continue prioritizing health equity index EHO4all efforts in 2025, laying the foundation for Star success and CMS compliance ahead.
Unpacking the Now – EHO4all
Regardless of the name change, plan priorities are expected to remain the same. The 2026 final rate notice specifically targets enrollees who are at higher risk for poor health outcomes, including D-SNP, low-income subsidy recipients, and disabled beneficiaries.
While 2027 Star Ratings seem far away, these ratings will be measured from 2025 preparedness and performance in 2026. This ruling and its addition of the EHO4all reward still encourages health plans to drive clinical outcomes and interventions for members facing Social Determinants of Health (SDOH) risks, but also requires them to perform as well or better than other plans.
It is important to understand how the proper use of SDOH data is vital to your plan’s sustainability. Here are two immediate priorities to consider. Part Two of this blog series will define priorities three, four, and five.
Priority 1: Expand the collection, reporting, and analysis of standardized data
In 2021, CMS recognized the importance of SDOH data and introduced the Community Health Access and Rural Transformation (CHART) Model to close gaps in care for members facing expansive disparities, particularly in rural locations. Further prioritizing the collection of SDOH data collection, CMS encouraged voluntary SDOH reporting in 2023.
From recognizing the importance of SDOH capture to now reiterating its importance throughout two administrations, CMS has expanded this initiative.
CMS recognizes the vast disparities and unmet SDOH needs plaguing vulnerable SRF populations with best practice SDOH screenings to encompass:
- economic stability
- neighborhood and physical environment
- education
- food
- community and safety
- social context
- healthcare system accessibility and coverage
CMS understands the direct correlation between disparate populations facing adversities in DOH barriers to care. Therefore, they have prioritized the collection, reporting, and analysis of this data.
CMS wants plans to use collected data to pinpoint risk factors for each member and take action to conduct proper health interventions. Determining how to do so requires more regulation and adherence, leading to the next priority for plans.
Priority 2: Access causes of disparities within CMS programs, and address inequities in policies and operations to close gaps
As barriers to equitable care run rampant in Medicare Advantage, Medicaid, and D-SNP plan members, CMS wants to reward the removal of those barriers. The 2026 final rate notice reinforces new standards for health plans regarding how they remove barriers that hinder members’ healthcare and wellness.
Using the existing Star Rating measures, CMS will compare the outcomes of populations with social risk factors to those without. This replaces the previous reward factor model starting with the 2027 Ratings. Therefore, outcomes driven in 2024 through 2026 will impact the benchmark Star Rating measurements in the framework’s 2027 goal year.
This strategy encompasses the CMS plan over the next decade, which moves past identifying socially at-risk members to fully bridge the equity gaps in care.
CMS will initially evaluate contract performance against each health equity measure for low-income, dually eligible, and disabled plans and how they rank among each other.
- Highest performing plans in the top third rankings will receive 1 full point.
- Medium plans performing in the middle third ranking receive 0 points.
- Low performing plans in the bottom third ranking receive -1 point.
Each point will be multiplied by the weight of each measure, the sum of which will create the contract’s total weighted score. Then, dividing this score by the total measure weights, CMS presents the contract with the finalized score, which is held against measurable outcomes of regular plans. Those scoring above 0 points to meet the SRF membership enrollment threshold will be rewarded. However, those scoring below 0 points are ineligible for rewards and face further setbacks.
Most health plans and their leaders find the rebranded CMS Ruling, changes to Star Ratings measurements, the reward factor, and reporting SDOH data and proven outcomes daunting. However, with the right strategies, technologies, and partnerships, plans can sustain their standings and also improve their Star Ratings and rewards.
86Borders stands ready to serve health plans as they prepare to navigate CMS changes. Three additional priorities for plans will be covered in Part 2 of this blog. Look for Part 2 to further explain the foundational steps health plans must take now for 2027 success.
To learn more about our services, click here »