2026 raises the bar. As Medicare Advantage (MA) plans absorb the impact of the 2026 Star Ratings release, one message is clearer than ever:
With cut points climbing and intervention windows tightening, incremental gains won’t protect bonus eligibility. As margins for error continue to shrink, the threshold is moving further out of reach. In fact, CMS data shows a growing concentration of Medicare Advantage contracts clustered just below the 4.0‑Star threshold, as rising cut points make it harder for plans to advance into bonus‑eligible territory.
These challenges are driven by tougher measure requirements, tighter adherence windows, and elevated expectations for member experience.
Cut points for several HEDIS measures—including follow‑up and osteoporosis management measures—have generally moved higher year over year, often by several percentage points across contracts, according to recent analyses of Star Ratings cut point trends.
Bottom line: incremental improvement is no longer enough. Quality leaders need force-multiplying operational levers that influence multiple measures at once.
Why Quality Teams Struggle: Three Operational Gaps
Most quality teams aren’t failing for lack of effort. They’re failing because their operations weren’t designed for the speed and precision that 2026 demands. As cut points climb and intervention windows tighten, incremental improvement is no longer enough.
To consistently achieve and sustain 4.0★ performance, quality leaders must address three critical operational gaps that undermine measure performance and bonus eligibility.
Gap #1: You’re finding out about admissions and discharges too late
The challenge: Claims-based workflows mean you’re finding out about care transitions too late to close the care gaps for the time-critical measures hurting your star ratings.
Operational impact: Care managers are forced to react instead of plan, missing the chance to coordinate follow-up and close care gaps. This delay erodes performance on measures that depend on speed and accuracy.
Gap #2: Your care managers are working lists, not priorities
The challenge: Every member with an open gap looks the same. Without visibility into who has three days left in their window versus twenty, effort gets spread evenly instead of concentrated where it matters most.
Operational impact: Care managers spend precious time investigating instead of coordinating, and urgent cases may not receive the attention they need. This lack of prioritization leads to missed opportunities and diluted impact.
Gap #3: Your providers don’t know what you know
The challenge: PCPs are in the dark about hospitalizations. You’re calling members to schedule follow-up, but their doctor doesn’t know they were admitted. This means fragmented handoffs and delayed follow-ups.
Operational impact: Disconnected communication between health plans, providers, and members undermines the coordinated action required for quality performance.
Urgency for Medicare Advantage Plans: Bonus Eligibility Depends on Transition Performance
Why this matters now. Reaching and sustaining 4.0★ unlocks bonus payments, higher rebates, product design flexibility, marketability, and contract growth. Yet many contracts sit just below the line as cut points rise. The gap is operational: late data, unprioritized outreach, and uninformed providers erode timely follow‑up.
Reaching—and sustaining—4.0★ or higher is the gateway to:
- Quality bonus payments
- Increased rebate dollars
- Greater product design flexibility
- Stronger marketability
- Contract growth and member acquisition
Yet many plans currently sit just below this threshold. With cut points climbing, performance gains must come from interventions that influence multiple Star measures at once—not isolated point solutions.
The Importance of the First 72 Hours
Act early to prevent avoidable complications. Transitions of care represent the single most time-sensitive and quality-sensitive moment in a member’s journey. Transitions of care are among the most time‑sensitive and quality‑sensitive moments in a member’s journey. Yet an estimated one‑quarter to one‑third of hospital readmissions are potentially preventable when plans and providers can intervene effectively around discharge. Unfortunately, most can’t act in time.
The operational reality for your care managers:
- They’re busy reacting instead of planning—They don’t know who entered denominators in time to coordinate follow-up and close care gaps, which are essential for meeting quality measures. By the time claims arrive, measurement windows have closed.
- They’re unable to prioritize by urgency—All care gaps are treated equally instead of being triaged by time remaining within the measurement window.
- Their outreach lacks clinical context—Care coordinators spend precious time investigating instead of coordinating.
- Their provider network isn’t activated—Primary Care Physicians (PCPs) don’t know their patients were hospitalized until it’s too late to close care gaps and take the action necessary to drive quality performance.
How Transitional Care Excellence Boosts Quality Measures
Focus on transitions to raise multiple measures at once. When plans improve the speed, accuracy, and coordination of transitional care, the impact is felt across multiple high‑value Star measures. Strong performance in these workflows directly supports measures like FMC (Follow‑Up After ED Visit for High‑Risk Chronic Conditions), OMW (Osteoporosis Management in Women Post‑Fracture), and TRC (Transitions of Care)—all of which depend on timely follow‑up, clear clinical context, and reliable communication between care teams.
But the lift doesn’t stop there. Enhanced transitions also influence several high‑impact measures indirectly. By reducing unnecessary complications, strengthening continuity, and improving navigation for members and providers, plans see improvements in PCR (Plan All-Cause Readmissions)—a triple‑weighted measure—as well as broader clinical outcome measures tied to lower readmission risk and fewer adverse events. And because members receive faster answers, clearer instructions, and more coordinated touch points, improvements naturally extend into CAHPS, especially in communication and care coordination.
In short, transitional care excellence becomes a multiplier: one operational capability that raises performance across a spectrum of tightly connected measures.
The transitions multiplier
Discipline in transitions lifts FMC, OMW, TRC directly—and PCR (triple‑weighted), clinical outcomes, and CAHPS indirectly—by reducing complications and enabling timely, coordinated communication.
Because so many measures rely on timely, coordinated, and clinically informed follow-up, improving transitional care becomes a multiplier strategy. Plans that excel in transition workflows typically outperform in at least 5–7 measures simultaneously.
How to Find Avoidable Readmissions
Use real-time signals to intervene before issues escalate. Real-time visibility from acute through post-acute care settings enables timely intervention in the moments that matter to dramatically reduce readmissions. Scale operational excellence in transitions of care across acute, and post-acute settings to unlock the multiplier effect—driving improvement across multiple HEDIS and Star measures, safeguarding bonus eligibility, and elevating the member experience.
Leading health plans understand a single operational capability in transitions of care drives performance across multiple quality measures simultaneously.Plans that invest in real-time data exchange and scalable workflows are building a repeatable engine for quality performance.
What Quality Leaders Can Do Next
Leverage real-time insight to drive measurable lift. To build a performance engine capable of rising cut points and slimmer timelines, leading MA plans are:
- Automating real-time event detection across acute and PAC settings
- Standardizing time-critical workflows aligned to Star measure requirements
- Equipping care managers with clinical context at first touch
- Prioritizing member outreach based on urgency and remaining measurement window
- Integrating medication insights at the moment of discharge
Plans that do this well don’t simply react faster—they consistently outperform peers across multiple Star measures with the same effort. Transitional care excellence drives measurable results and sets high-performing plans apart.
How PointClickCare Helps Health Plans Improve Transitional Care and Quality Performance
As health plans work to navigate rising cut points, tighter intervention windows, and increasingly interconnected Star measures, many leaders find themselves facing the same operational reality: it’s not a lack of effort holding their teams back — it’s a lack of timely, clinically meaningful information. PointClickCare helps close this gap by giving plans the real‑time visibility and workflow structure needed to act during the moments when outcomes can still be influenced.
1. Real‑Time Insight Into Member Transitions
Across acute and post‑acute settings, PointClickCare provides immediate visibility into new encounters — long before claims arrive. This allows care teams to identify when members enter critical time-sensitive denominators tied to measures like FMC, OMW, and TRC, and to intervene while meaningful action is still possible.
2. Clinically Informed, Prioritized Workflows
Rather than asking care managers to search through disparate systems or wait for delayed data, teams receive prioritized, context-rich views of who needs attention and why. Encounters are filtered through measure logic, care gaps are surfaced immediately, and the remaining intervention window is clearly visible — removing guesswork and helping teams focus on the highest‑impact opportunities first.
3. Connected Communication Across the Care Ecosystem
Transitions break down when information breaks down. PointClickCare strengthens collaboration between health plans, post‑acute providers, and PCPs by ensuring that each party is informed at the right moment. This reduces lag time, supports safer handoffs, and equips providers with the awareness they need to deliver timely follow‑up aligned to Star requirements.
4. Scalable Support for Post‑Acute and Medication Safety
High‑quality transitions extend beyond the point of hospital discharge. By implementing robust post-acute care management practices, health plans can proactively identify medication risks, reduce preventable complications, and strengthen continuity of care. These efforts contribute to improved quality outcomes and foster a more stable, positive experience for members.
5. A Foundation for Consistent, Repeatable Quality Gains
Because measure logic, prioritization rules, and workflows are standardized, plans can rely on consistent processes that scale across markets and teams. This enables health plans to build a repeatable operational engine that improves performance across clinical measures, readmission rates, transition measures, and experience metrics.
Turning Operational Clarity Into Star Performance
Convert timely information into consistent quality gains. The plans outperforming rising Star cut points are the ones turning operational clarity into measurable results. By giving teams real-time visibility, prioritized workflows, and the context needed to act within narrow windows, health plans can move from incremental gains to the sustained, meaningful lift required to achieve and maintain 4.0★ and beyond. Our comprehensive portfolio of health plan solutions is purpose-built to support these critical transitions—empowering your teams to reduce readmissions, elevate member experience, and drive measurable quality gains across the continuum of care. With the right tools and partnership, your plan can confidently navigate rising cut points and deliver the outcomes that matter most to your members and your business.
See Your Transitions Window in Real Time
Understand where timely action can drive immediate lift across FMC, OMW, TRC, PCR, and CAHPS—and how real time insights transform outcomes.
Ready to experience it for yourself? Share a few details below to unlock a personalized look at how real-time signals and prioritized workflows can elevate your quality performance—right where it matters most.
