AI Voice Agents can help Medicare Advantage plans maintain and improve their CMS Star Ratings for the Call Center metric

Why the Stars Matter

CMS uses the Medicare Advantage & Part D (MA-PD) Star Rating system to steer more than 31 million beneficiaries toward high-quality plans and to decide who receives quality-bonus payments worth billions each year. Contracts at 4-start (★★★★) or 5-star (★★★★★) get marketing benefits, extra rebate dollars, and enrollee growth, while plans that slip below ★★★ can be sanctioned or terminated.

A Quick Primer on How CMS Calculates the Rating

*Weights apply to 2025 Stars; CMS finalized a drop of Patient-Experience & Access measures from 4× to 2× starting with the 2026 ratings.
Level	What’s Rated	Example Measures	Weight*	Notes
Measure	1–5★ for each metric	Breast-cancer screening, CAHPS “Getting Needed Care,” Medication Adherence	1, 3, 4 or 5	Process = 1×, Intermediate/Outcome = 3×, Patient-Experience & Complaints = 4× (dropping to 2× in 2026), Improvement = 5×
Domain	14 Part C & 6 Part D groupings	Staying Healthy, Member Experience, Drug Safety	Weighted average	At least two measures needed per domain
Summary	Part C and Part D summaries	Up to 40 metrics for MA-PDs	Weighted average	Guardrails cap drastic cut-point moves
Overall	Combines C & D	Overall MA-PD Stars	Weighted by enrollment	Shown on Medicare Plan Finder each October

Where Plans Lose Stars

Member experience & complaints (currently 4× weight): CAHPS scores are sensitive to long hold times, language access gaps, and unresolved grievances.
Access & call-center metrics: CMS audits interpreter availability, TTY performance, and after-hours answer rates.
Preventive-care process gaps: Screenings, vaccines and follow-up calls drag ratings if members can’t be reached.
Medication adherence & MTM: Three adherence measures remain 3× weighted; missed refill reminders hurt scores.

Enter the Always-Available AI Voice Agent

Star-Rating Pressure Point	How a 24/7 AI Voice Agent Helps	Impact on Stars
CAHPS “Getting Needed Care” & “Customer Service”	Answers every call in < 1 ring, supports 200 + languages, and seamlessly escalates complex issues.	Higher patient-experience scores & fewer CTM complaints.
Call-center Access Measures	Guarantees interpreter & TTY routing and logs a 100 % answer rate after hours.	Protects 2×–4× weighted access metrics.
Preventive-care & Chronic-care Process Measures	Outbound campaigns remind members of screenings, vaccines, or post-ED follow-ups and update gap-closure status in real time.	Boosts 1× process and 3× intermediate-outcome scores (e.g., Controlling Blood Pressure).
Medication Adherence (3×)	Sends daily refill reminders, offers pharmacy warm-transfers, and supports smart IVR refills.	Improves adherence cut-points year-over-year.
Improvement Measures (5×)	Analytics dashboard flags at-risk metrics weekly; voice agent auto-tests scripts and measures lift.	Maximizes the single-heaviest weight in the program.

Voicegain Casey, an AI Voice Agent that can maintain and boost CMS Star Rating

Voicegain Casey—launched April 2025— is an AI Voice Agent that handles every incoming provider or member call. It understands the intent of the call, performs HIPAA validation and automates routine inquiries like claims status, eligibility and benefits inquiries. For calls that need live human agent assistance, it transfers calls to live agents with a real-time screen-pop and continues to assist the Agents. It shaves 2–3 minutes of after-call work and boosting CSAT/NPS for health plans and TPAs.

In addition it records and analyzes each and every interaction and flags an interaction that has not met the standard. This can be of immense value to the MA Health Plan.

Implementation Tips for Health-Plan Leaders

Start with high-volume intents (eligibility, claim status, pharmacy refills) to free agents for complex CAHPS-sensitive calls.
Integrate with your CCaaS & CRM so AI can pre-populate member data and log screenings automatically.
Set Stars-oriented KPIs—e.g., hold time < 30 s, outbound reach rate > 70 %, refill reminder completion—to quantify lift.
Monitor sentiment & compliance; modern voice AI can redact PHI, track interpreter usage, and surface grievances before they hit CTM.
Plan for 2026 weight changes: Even with Patient-Experience weight dropping to 2×, CMS still ties >30 % of Stars to access and experience—so keep delighting callers.

The Bottom Line

CMS Star Ratings increasingly reward real-time, patient-centric service. A 24/7 AI Voice Agent acts as a tireless first-responder—answering every call, closing care gaps, and feeding analytics back to your Stars team. For plans chasing ★★★★ or trying to stay above ★★★, deploying voice AI isn’t just a CX upgrade; it’s a direct lever on revenue-critical metrics.

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If this topic is of interest and if you want to see how other health plans are using Voicegain Casey, get in touch with us

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