Matt dives into a specific healthcare topic to help those in the industry, and those outside of it, better understand the market drivers causing today’s healthcare challenges.

CMS built the five-star rating so a 72-year-old could sit at her kitchen table during open enrollment and compare Medicare Advantage plans without a finance degree. On July 2, Elevance sued CMS over the arithmetic behind those stars, chasing $115 million. The rating promised to tell the senior which plan actually delivers care. It now tells a federal judge in Georgia which insurer keeps its bonus. She reads the same number and sees quality. The industry reads it and sees revenue. Only one of them gets a lawyer.

Elevance filed in the U.S. District Court for the Southern District of Georgia, arguing that CMS recalculated its 2026 star ratings inconsistently with a recent court ruling and cost the company $115 million (STAT, July 2, 2026). Elevance did not invent this playbook. It joined a line that already runs through UnitedHealth, Humana, Centene, and Clover, each of which dragged CMS into court over how the agency scores their plans. UnitedHealth won its challenge in late 2024 and forced CMS to recalculate. Clover won in May 2026 when Judge Lisa Godbey Wood found CMS had improperly stuffed 20 measures into the calculation and ordered the agency to redo the math. Elevance now wants the same recalculation Clover received. The lawsuits keep landing in the same courthouse, and the plaintiffs keep winning.

Follow the money and the intensity makes sense. Star ratings drive Quality Bonus Payments, and those payments reached at least $12.7 billion in 2025, with projections near $13 billion for 2026 (KFF). Since 2015, Medicare has poured at least $87 billion into the bonus program. A plan needs four stars to unlock the 5 percent bonus that lifts its payment benchmark, and every half-star above that line pulls more rebate dollars into the plan. So a plan sitting at 3.5 stars sits one measure away from losing all of it. Clover felt the drop firsthand. Its PPO fell from four stars to 3.5, roughly $120 million in bonus payments evaporated, and after the court forced a recalculation, CMS rescored the same plan at 4.5 stars. Nothing about the care changed between 3.5 and 4.5. Only the paperwork did.

Understand how thin the air gets near that four-star line. Only about 40 percent of Medicare Advantage prescription drug plans hit four stars or higher for 2025, though roughly 62 percent of enrollees sit inside those higher-rated contracts because the biggest plans cluster at the top. So a rating change does not nudge a rounding error. It reprices a plan that covers hundreds of thousands of seniors, and it does so on a benchmark that already runs into the billions. A four-star plan captures the 5 percent bonus and keeps 65 percent of the rebate spread. Push to 4.5, and that rebate share climbs to 70 percent. Slip below four, and the whole structure collapses to zero. The system built a cliff, painted a bright line on it, and then acted surprised when everyone learned to stand exactly on the edge and sue anyone who nudged them off.

Watch how the industry narrates that swing. When a plan slips from four stars to 3.5, the story becomes lost bonus payments, quarterly earnings pressure, and a lawsuit. The story almost never becomes what a lower score was supposed to tell the senior choosing that plan in October. The measure wears a patient-quality costume and does insurer-revenue work. That gap is the whole point of ELAVAY. 

I have spent years measuring the distance between how healthcare companies grade themselves and how the patients they serve grade them, and the internal number almost never survives contact with the external one. We built ELAVAY because companies grade their own patient performance generously, while the advocacy and patient community that lives with those companies sees something completely different, and the two numbers rarely match. Star ratings are the same disease in a different host. 

The company being graded tunes the score to flatter itself, a patient-experience number engineered by the very party the patient is trying to judge, and the further that number drifts from her, the more useful it becomes to everyone except her.

Read the actual complaints and note what the insurers argue. UnitedHealth, Humana, Centene, Clover, and now Elevance litigate the formula. They contest secret-shopper phone calls, cut points, and which measures CMS had the authority to include. They rarely stand up in court and argue that the measure failed the senior it was built for. The fight lives entirely inside the methodology, because the methodology is where the money lives. A plan does not suffice to prove it delivered better care. It seems to prove CMS owed it a higher number, and a higher number means a bigger check.

Look at what the insurers actually litigated, and the drift becomes obvious. Several plans attacked the secret-shopper phone calls CMS uses to grade customer service, arguing the agency marked a test call failed when it should not have. CMS blinked and agreed to weigh those call-center measures less starting in 2026. A single mishandled phone call moved millions of dollars, which tells you the money now rides on measurement mechanics rather than on whether a member reached help when she needed it. The mechanics outrank the member, and that inversion is the whole rot.

That is a structural failure, and CMS owns a large share of it. The agency made the ratings a financial instrument, so plans now optimize to the cut points rather than to the care. Chase the four-star line, weigh the measures that move fastest, and manage the score the way a trader manages a position. Judge Wood found that CMS included 20 measures it should not have, which tells you the scorekeeper cannot reliably keep the score. At least six insurers have taken CMS to court over star ratings in the last two rating cycles, and the plaintiffs keep collecting recalculations and back pay. Every one of those suits reframes the stars as a bonus dispute in the public record. And every reframing quietly erodes the one job the rating was hired to do: to give a senior a trustworthy signal. You cannot market a number as consumer protection while it functions as a revenue lever, and eventually the senior stops believing the number at all.

It's not a criticism. It's just math.

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Top performers refuse to run one scoreboard for two masters. They separate the metric that serves the patient from the metric that serves the balance sheet, and then they audit which one actually drives their decisions. That audit is uncomfortable because most organizations discover the balance sheet won, and nobody said so out loud. Leaders who get this right treat the star rating, the internal dashboard, and the earnings model as business inputs, and they build a second, independent instrument that answers a different question entirely: what does the patient feel at the point of care, and can we prove it?

Picture the two responses side by side. A plan drops half a star. The laggard convenes lawyers, files in Georgia, and works to restore the number. The leader convenes the people who actually touched that plan, the advocates and members who called the line and fought the denial, and asks a harder question: did the score fall because the measurement broke, or because the experience did. Sometimes the honest answer indicts the methodology, and the leader still challenges it. More often the honest answer indicts the plan, and the leader fixes the thing the patient felt instead of litigating the thing the balance sheet felt. Both plans might end up at 4.5 stars. Only one of them earned it in a way a patient would recognize.

This is exactly the behavior the top tier of ELAVAY companies shows. They measure how the advocacy and patient community actually perceives them, compare that external read against their own internal scorecard, and act on the gap instead of defending the number that flatters them. They treat outside perception as data, not as a threat to manage or a PR fire to contain. Concretely, that means building an access and quality strategy around what a patient can feel when she calls, waits, appeals a denial, or fills a prescription, and it means being able to point to a specific decision that changed because the patient told them it needed to. 

A leader can produce that receipt. A laggard produces a star rating and a press release. The difference shows up years later, when the recalculation lawsuits fade and the only plans still trusted are the ones that spent this decade closing the gap between the number and the experience instead of arguing about the number in court.

Laggards do the opposite. They litigate the scoreboard, defend the internal number, and mistake a favorable recalculation for a win with the patient. A 4.5-star plan that a senior cannot navigate is a lawsuit that happened to go well, not a quality outcome.

If Medicare Advantage plan quality shapes the access environment your patients live inside, stop treating star ratings as a fixed backdrop and start tracking who is litigating them and why. The scoreboard moves in courtrooms now, and the people who read those filings understand the terrain your patients navigate better than the people who quote the star rating on a marketing slide. 

For commercial and advocacy leaders who want to know how the patient community actually scores your organization, the 2026 ELAVAY: ADVOCACY INTELLIGENCE Report is live. To see your standing, or to benchmark the gap between the number you report internally and the reality your patients experience, reach me at [email protected]. 

And for teams who want to measure whether patient voice truly drives their decisions rather than just decorating them, take the free Advocacy Influence Diagnostic at https://aid.elavay.com/survey. Measure the gap yourself, on your terms, before a plaintiff measures it for you.