Medicare Star Ratings are a good indicator of the quality of care they provide to their members. An increase from 3 to 4 stars can result in a revenue boost of $12 million to $16.2 million (for a plan with about 9,600 members).[1] A 1-star increase is also associated with an 8% to 12% growth in enrollment the following year.[2]
Unfortunately, many Medicare Advantage Organizations (MAOs) went in the other direction in 2025. The top 15 MAOs saw an average 0.23-star decline, while some fared even worse.
Plans could see further declines in the future if they don’t prioritize providing members quality care. Recent changes in the Medicare Star Ratings formula have put increased emphasis on clinical measures and health equity. For 2026, Healthcare Effectiveness Data and Information Set (HEDIS) scores account for 25% of a health plan’s Star Rating — up from 19% the previous year — making HEDIS the largest single factor.
“For the next program year, the Centers for Medicare and Medicaid Services is shifting the focus slightly away from patient experience,” says Kirk Loveless, health plan executive director of healthcare analytics and solutions at Quest Diagnostics. “Going forward, maintaining or improving Star Ratings will require an increased focus on clinical and member outcomes, including in areas where Quest can make an impact.”
Closing gaps in care is a key way to boost HEDIS scores, but doing so requires engagement from both members and providers. That can be a challenge. In a survey Quest commissioned, more than 55% of health plans named member compliance and provider engagement as the top barriers they face in closing gaps in care and improving HEDIS scores. Providers too often fail to order needed tests. And, when they do, members too often fail to follow through.
“This is where programs like the Quest Lab Gap Closure Program (QLGCP) can help,” Loveless says. “Our program enables health plans to rely less on providers to initiate tests for their members, and, since we incorporate tests into the members’ natural course of care, tests are more likely to be completed without much member abrasion.”
QLGCP covers tests associated with nine quality measures:
Glycemic Status Assessment for Patients With Diabetes (GSD).
Kidney Health Evaluation for Patients With Diabetes (KED).
Colorectal Cancer Screening (COL).
Lead Screening in Children (LSC).
Chlamydia Screening in Women (CHL).
Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM).
Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia (SMC).
Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD).
Diabetes Monitoring for People With Diabetes and Schizophrenia (SMD).
The program is a year-round proactive approach to close testing gaps. It includes member outreach and convenient methods for members to complete their test, either at one of Quest’s 2,200+ patient service centers or in the comfort of their home through a test kit.
Since QLGCP is a value-based program, health plans only pay for gaps closed uniquely by the program, not in the patient’s normal course of care. For example, if a member completes a test initiated by both Quest and their provider in the same year, Quest doesn’t charge for closing that gap.
Oscar Health used the program in the 2022 and 2023 measure years, focusing on members who needed a completed HbA1c test, uACR + eGFR, and colorectal cancer (CRC) screening. The first year, Quest helped to successfully close 9% of open gaps; the following year, it helped successfully close 14% of open gaps.
In a recent case study, Kristine Green, HEDIS manager at Oscar Health, praised Quest’s support. “The Quest team has demonstrated remarkable agility in addressing gaps and aligning the program with our organization’s goals,” she said. “They have provided translated materials to help address disparities and implemented effective outreach for CRC screening, which helped mitigate potential performance penalties.”
Even more importantly, the program ensured that Oscar Health members received essential screenings that could point them toward better health outcomes. And that benefited the members and the health plan alike.
Learn more about how the Quest Lab Gap Closure Program can help your health plan improve its HEDIS scores.
