By Deepan Vashi, EVP & Head of Solutions for Health Plans and Healthcare Services, Firstsource
LinkedIn: Deepan Vashi
LinkedIn: Firstsource
CMS is rebranding its Health Equity Index reward program, now calling it the Excellent Health Outcomes for All (EHO4all) reward. The EHO4all program will affect 2027 Medicare Advantage star ratings, based on data from the 2024 and 2025 plan years.
The name change reflects the agency’s “goal of ensuring exceptional care for all enrollees,” according to the CMS April 2025 capitation rate announcement. Just as it planned to do under the Health Equity Index reward program that EHO4all supersedes, CMS will remove the current reward factor when the new reward program is implemented. CMS says this should incent improved plan performance across all enrollees, not just the those who typically are at higher risk, such as dual-eligibles, low-income subsidy recipients and disabled plan members. In addition, CMS may add geographic factors, such as urban and rural categories, to the EHO4all program via future rulemaking.
Pressure on Star ratings and bonuses
Many high-performing Medicare Advantage contracts have received rating boosts from the reward factor that CMS will eliminate with the EHO4all program. Without that factor, it stands to reason more payer organizations will find it difficult to achieve the higher Star ratings that result in significant bonus payments. Under EHO4all, plans that provide excellent service and have significant numbers of members with social risk factors will be the likely reward recipients.
Payers looking to build success under the EHO4all rewards program need to identify all members with social risk factors and ensure they are receiving quality care. The continued maturing of AI tools can help payers manage outreach, SDOH navigation, medication adherence, care management and more to provide the quality service that will be rewarded under EHO4all. Here’s a look at what to do.
Identify members with social risk factors. AI/GenAI tools offer payers multiple ways to find members with risk factors. In contact centers, the tools can scan and summarize frequently discussed topics during or after member interactions. Generative AI can identify patterns that indicate language barriers, cultural misunderstandings or difficulties in navigating care pathways. Analytics tools use this data to delineate the characteristics of different member segments and their likely reactions to different communication channels and content. Understanding members’ characteristics enables plans to anticipate member sensitivities about their SDOH challenges. Plans can then use these valuable insights to initiate targeted interventions, such as providing multilingual support, addressing specific health concerns through educational materials or coordinating community services to mitigate SDOH challenges.
Launch targeted digital outreach campaigns. AI enables health plans to create targeted digital outreach campaigns built on insights from Health Risk Assessment (HRA) surveys, risk adjustment HCC data, and already-identified underserved members. Combining this data with AI, plans can reach out to members with personalized, easily completed follow-up surveys that fit member contexts. Generative AI tools can even schedule primary care appointments during which AI agents can help physicians capture additional risk factor information.
Personalize member experiences and engagement. Plans can personalize onboarding experiences, remember member preferences and continuously assist members with generative AI tools. AI agents can interact with members whether they call or text, understand the context of member queries and accurately answer questions. These techniques will also help plans perform better on CMS measures such as ‘Getting Appointments and Care Quickly’, ‘Customer Service’, ‘Call Center’, ‘Foreign Language Interpreter and TTY Availability’, which are all weighted at 4x and can highly influence Star ratings.
In addition, generative AI agents can provide appointment coordination, follow-up reminders, and connections to community resources, all in a member’s preferred language. These all enhance a member’s healthcare experience.
Improve adherence. Multichannel outreach tailored to members’ specific needs and preferences will gently nudge patients towards preventive screenings or medication adherence. Generative AI-enhanced interactions support personalized interactions 24/7 on channels including emails, text messages, web, microsites and outbound IVR calls. Generative AI can even schedule appointments, including those with an impact on quality measures, such as mammograms.
Agentic AI, Visual IVR and conversational AI channels have proven most effective for individuals aged 65 and above. Millennials prefer portals and self-service AI-based apps. One payer using proactive, personalized appointment confirmations and reminders saw a more than 60% increase in engagement rate and an 85% increase in conversion rate. Another payer that implemented a hyper-personalized omnichannel visit adherence solution improved member experience ratings by more than 30% and significantly reduced no-shows and late cancellations.
AI tools can also identify when an at-risk member requires a high-touch experience. For example, generative AI tools can recognize when a member is having difficulty understanding the language being spoken and can route the member to a human agent or even switch into the member’s language.
Calculating the impact
The impact of the EHO4all on Star Ratings presents both a challenge and an opportunity for health plans. Payers need to start forming their response strategy immediately because 2027 Star ratings will reflect the EHO4all program reward based on data from 2024 and 2025 plan years.
Here are some immediate steps to take to succeed under the EHO4all program and maintain Star ratings:
- Calculate the potential impact of the EHO4 reward factor on current ratings and examine how well your organization addresses socially at-risk populations, including underserved members and dual eligibles.
- Assess current technological capabilities, inventorying dependencies on legacy tools and processes and whether the flexibility exists to implement generative AI or AI-like functions.
- Evaluate service providers’ abilities and experience in launching and managing multifaceted AI-first strategies to improve health equity.
By addressing these areas, plans can comply with new regulatory requirements and improve their service delivery and member satisfaction, positioning themselves to enhance their Star Ratings as healthcare equity standards evolve.