Medicare Advantage 2027: how payer changes affect your clinic
CMS finalized the 2027 Medicare Advantage rule. The changes that reach clinics run through star ratings, which plans pass down into provider contracts. Here is what matters for your contracts.
What CMS finalized on April 2, 2026
The CY2027 Medicare Advantage and Part D Final Rule includes significant changes to how MA plans are rated and how they handle enrollment. These changes affect every clinic that contracts with Medicare Advantage plans.
The rule removes 11 star rating measures the agency viewed as either administrative or low-variation, and adds one new Part C behavioral health measure (Depression Screening and Follow-Up) starting with the 2027 measurement year and 2029 Star Ratings. For your practice, this means MA plans will be adjusting their priorities, and those priorities will flow down to their provider contracts and performance expectations.
Star ratings overhaul
CMS finalized removal of 11 measures from the star ratings system and added one new Part C Depression Screening and Follow-Up measure, both starting with the 2027 measurement year and reflected in the 2029 Star Ratings. MA plans live and die by their star ratings because ratings determine their bonus payments from CMS.
When plans change their star rating focus areas, they change what they demand from providers. Expect your MA contracts to include new quality metrics aligned with the updated star measures. Plans that drop star ratings lose Quality Bonus Payments, so they will push hard on providers to hit the new targets.
Network adequacy: what did not change
The 2027 rule does not change network adequacy. Plans still have to meet maximum time and distance standards and contract with a minimum number of providers of each specialty type, and since plan year 2024 (CMS-4201-F) those types include clinical psychology and clinical social work.
That still leaves room to negotiate. A plan that is thin on your specialty in your county needs providers more than it will admit, so if you are out of network, ask what it would take to join, and bring the gap up when you talk rates.
Prior authorization requirements
The 2027 rule leaves prior authorization alone, but two earlier rules already set the terms. Since plan year 2024 (CMS-4201-F), MA plans must follow traditional Medicare's national and local coverage determinations and may use prior authorization only to confirm a diagnosis or other medical criteria or to check that a service is medically necessary. Since January 1, 2026 (CMS-0057-F), they must decide standard requests within 7 calendar days and urgent ones within 72 hours.
Track denials and late decisions plan by plan. A denial that ignores traditional Medicare's coverage criteria, or a decision that misses those deadlines, is grounds for an appeal, and a pattern of them is worth taking to the plan's provider relations team and to CMS.
Impact on your MA contracts
Review your MA contracts that come up for renewal in 2026-2027. Plans pass their star targets down to providers, and the new Depression Screening and Follow-Up measure rewards behavioral health screening done well.
If your practice screens and follows up reliably, bring the numbers to the renewal. A plan protecting its rating has a reason to pay for that, and a plan at risk of slipping has an even stronger one.
What to do with your payer mix data
Pull your MA payer mix data. What percentage of your revenue comes from Medicare Advantage versus fee-for-service Medicare? Which specific MA plans do you contract with, and what are their current star ratings?
Plans that are at risk of dropping star ratings will be the most aggressive about pushing new quality requirements onto providers. Plans that are comfortably at 4+ stars may be more flexible. Knowing where your plans stand helps you anticipate contract changes.
What to do now
Pull your revenue breakdown by MA plan to understand which plans represent the most revenue.
Review the star ratings of your top MA plans to anticipate which will push hardest on new quality measures.
Log MA prior authorization denials that ignore traditional Medicare coverage criteria, and decisions that miss the 7-day and 72-hour deadlines, and appeal them.
Find the plans that are thin on your specialty locally and raise it at renewal.
Update your quality tracking to align with the new star rating measures CMS has adopted.
Schedule contract reviews for any MA agreements coming up for renewal in 2026-2027.
Who this affects
Sources
- CMS fact sheet: Contract Year 2027 Medicare Advantage and Part D final rule (April 2, 2026)
- CY2027 MA & Part D Final Rule (CMS press release)
- CMS fact sheet: 2024 Medicare Advantage and Part D final rule (CMS-4201-F)
- CMS fact sheet: Interoperability and Prior Authorization final rule (CMS-0057-F)
- 42 CFR 422.116, Medicare Advantage network adequacy (eCFR)
Founder of Sorso and a CFA charterholder. Before Sorso, Stan spent 19 years in corporate finance at institutions including UniCredit and Société Générale — managing a $450M loan portfolio and making senior partner at a major mezzanine lender by 29 — then built a fractional CFO firm exclusively for outpatient healthcare clinics.
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