Stars didn’t cause the crisis. V28 didn’t cause the crisis.
They exposed it. Medicare Advantage has been running on a constant catch-up game — where risk isn’t visible soon enough and members don’t engage until it’s too late.
When Elevance Health said it would exit standalone Part D and scale back Medicare Advantage in counties that “aren’t meeting expectations,” it wasn’t surprising. It was confirmation of what many in the industry already knew: the model is straining at its core.
The Pressures Payers Can’t Ignore
🔶 Risk adjustment is changing (V28).
➤ CMS is phasing in the updated HCC model: for 2025, payments are based on a 67% V28 / 33% V24 blend, moving to full V28 in 2026.
➤ This transition, along with risk-score normalization, is putting downward pressure on RAF scores for many plans — even when patient acuity hasn’t changed.
🔶 Stars are tighter.
➤ For 2025, about 40% of MA-PD contracts earned 4 or more stars.
➤ Roughly 62% of enrollees are in 4-star or higher plans. That’s lower than prior peaks and raises the bar for quality-linked revenue.
🔶 Part D redesign.
➤ Starting in 2025, beneficiaries’ annual out-of-pocket prescription costs will be capped at $2,000.
➤ They’ll also have the option to spread costs monthly through the Medicare Prescription Payment Plan.
➤ It’s a big win for members, but it adds new margin pressures for plans.
🔶 Claims lag.
➤ Closed claims data typically trails by 6 months or more.
➤ In some cases, it can take up to 8 months, meaning payers often don’t see risk until it’s already a cost.
Playing Catch-Up
The regulations didn’t create these challenges. They simply ripped the cover off what’s been true for years:
🔶 Acuity blindness: plans can’t see risk in real time.
🔶 Member disengagement: outreach often fails to trigger action until members are already in crisis.
That’s not managed care. That’s catch-up care.
The New Reality for MA
Stars revenue is under pressure. RAF is harder to sustain under V28. Medical loss ratios are rising. And large payers are exiting unprofitable geographies and products to protect performance.
This isn’t a temporary disruption. It’s the new reality of Medicare Advantage.
The Path Forward
To succeed in this environment, payers need to:
🔶 See risk before it becomes cost
🔶 Engage members before they reach the ER
🔶 Drive timely action with smarter, more effective outreach
How Kbrax Helps
This isn’t a concept for tomorrow. It’s a solution we’ve already built.
Kbrax delivers what today’s market demands:
🔶 Clarity: real-time visibility that makes risk clear before it becomes cost
🔶 Accuracy: timely data and notifications to intervene when it matters most
🔶 Confidence: tools that stabilize RAF under V28, protect Stars revenue, and manage MLR sustainably
We accomplish this in partnership with health plans, combining our proven solutions with available data sources to trigger timely notifications and escalations before it’s too late.
No more playing catch-up. Instead, clarity, accurate and timely data, and trusted engagement when it matters most.
Conclusion
Regulations didn’t cause the cracks in Medicare Advantage. They exposed them.
The future belongs to organizations that stop playing catch-up and start acting in real time.
That’s the future Kbrax delivers today — as a trusted partner to payers and health plans.