For those of us working in Medicare Advantage, springtime brings a sense of anticipation, as the annual events that shape our industry begin to ramp up. Just ten days after everyone returned from RISE National in Orlando, CMS dropped two of the most consequential releases of the year — the CY2027 Final Rule on April 2 and the Final Rate Announcement on April 6.
Taken together, the themes present at RISE 2026 and subsequent CMS releases align to tell the same story. The rules governing Medicare Advantage are being actively rewritten, and the window for health plans to absorb and respond to these changes is shorter than most planning cycles account for.
Read on for our summary of RISE 2026 and where the Medicare Advantage industry is headed—and how CMS plans to get us there.
What CMS Just Announced
The Final Rate Announcement landed at a 2.48% net average payment increase for CY2027 — over $13 billion in additional MA payments. This represented a significant revision from the 0.09% proposed in January, driven by industry pressure over rising medical cost trends. But the rate headline is not the most operationally significant piece of either release.
On risk adjustment: CMS confirmed it will continue using the 2024 MA risk adjustment model for CY2027 rather than implementing the updated formula. More immediately, CMS finalized the exclusion of unlinked chart review diagnoses from risk score calculations starting in CY2027. With a limited exception for members switching between MA organizations, diagnoses not tied to a documented patient encounter will not count. Plans that have been relying heavily on unlinked chart reviews to support their RAF scores will feel this directly.
On Star Ratings: the CY2027 Final Rule removes 11 measures focused on administrative process, adds a new Depression Screening and Follow-Up measure starting with the 2027 measurement year, and eliminates the Health Equity Index reward in favor of the historical reward factor. Fewer measures mean higher stakes per measure, so coding accuracy, thorough care planning, and clearly linking HCCs and encounters, are more important than ever.
Along those lines, CMS also communicated that even with the higher payment rate, the agency will continue scrutinizing coding intensity and upcoding practices that appear designed to maximize RAF rather than accurately reflect clinical burden. In an industry where proof equals payment, thorough and accurate documentation are keys to success.
What RISE 2026 Made Clear
RISE National 2026 marked the conference’s 20th anniversary and, by most accounts, one of its most attended and engaged editions to date. With five parallel tracks and thirty-five sessions across three days, every health plan leader left with part of the picture. This covers the full one.
Across all five tracks, the same conclusion kept arriving from different directions: the way most Medicare Advantage plans currently manage risk adjustment, quality, compliance, and technology was designed for an environment that no longer exists.
- Risk and Quality Have to Be One Program Now
This ran through every track at RISE 2026, and the conclusion was consistent. Complete, specific clinical documentation serves risk adjustment and quality measurement from the same clinical record. A well-documented diagnosis with appropriate specificity captures the correct HCC and supports relevant HEDIS measures simultaneously. Plans with fragmented documentation programs consistently show higher rates of HEDIS gap closure failures and higher HCC unsupport rates in RADV audits — two separate scorecards tracking the same underlying problem.
Plans managing HCC coding, Stars performance, and HEDIS compliance through separate teams and separate strategies create gaps that are increasingly visible in audit results and quality scores. The NCQA plenary reinforced the direction from a regulatory standpoint. NCQA’s 2026 program priorities signal continued emphasis on documentation-linked quality measurement, making this convergence both an operational question and an accreditation one.
The CY2027 Final Rule adds weight to this: with 11 Star measures removed and a new behavioral health measure added, the remaining measures carry more per percentage point. Plans running quality and risk adjustment as separate programs cannot afford to lose ground on either side.
The governance implication that several sessions named directly: if your risk adjustment leadership, quality improvement team, and compliance function are not aligned under a shared operational framework, that structural gap impacts much more than your workflow efficiencies.
- AI Is in Production. The Question Is Whether It Is Audit-Defensible
Autonomous coding and AI-assisted CDI have moved from pilot programs to standard operational consideration across Medicare Advantage. The AI track at RISE demonstrated that these tools produce measurable improvements in coding throughput and documentation review at scale. This shifts the conversation from whether AI works in this context to whether it will hold up when a specific coding decision is challenged in a RADV audit.
The distinction that emerged most clearly is between general-purpose AI and purpose-built systems. A general-purpose model can identify patterns in clinical text. It cannot produce an auditable, explainable rationale tied to ICD-10-CM coding conventions, MEAT criteria, and RADV documentation standards in a form a medical reviewer will accept. Purpose-built systems, trained specifically on healthcare regulatory requirements, are designed to generate that rationale at the point of coding. The difference is not marginal in an audit context.
One session raised the question of coding bias directly: do AI systems introduce systematic anomalies into coding patterns that only become visible when an auditor looks for them? Plans deploying AI in production coding environments need a clear, documented answer to that question before CMS asks it during the audit process.
- Compliance as Strategic Function, not Back Office Process
The OIG keynote on the final day of RISE made the compliance posture of Medicare Advantage explicit and data-backed. $23.7 billion in improper risk adjustment payments in 2025. $7.5 billion tied specifically to HRA-driven diagnoses without clinical follow-up. A 97% error rate on certain diagnosis codes in completed RADV audits. The detail in that presentation is worth a dedicated read, and we have covered it fully in a separate piece.
What CMS’s April releases add: the unlinked chart review exclusion is not a future concern. It takes effect in CY2027. Plans that have not already restructured their chart review sourcing and documentation protocols now have one planning cycle to do it.
The issue of compliance came up in virtually all sessions: not just enforcement, but also artificial intelligence, risk adjustment, and quality. The clear takeaway is that compliance is no longer considered a downstream or ad-hoc operational check. It’s central to how programs are designed, how vendors are selected, and how coding decisions are made in the first place. Plans treating it as a separate function from risk adjustment and quality are structurally behind where the industry is moving.
- Member Engagement is Moving from Gap Closure to Longitudinal Strategy
The quality and engagement track covered a shift that is less visible than the compliance and AI conversations but equally consequential for plan performance. In-home programs, historically designed around episodic HCC capture and gap closure, are being restructured as platforms for sustained member management. Sessions on day-one engagement for new members and evolving in-home program strategy pointed in the same direction: the goal is an ongoing clinical relationship, not a point-in-time intervention.
A single in-home visit that closes a documentation gap serves risk adjustment once. A longitudinal program connecting a member to primary care generates ongoing clinical documentation that serves risk, quality, and care management across multiple periods. Several sessions examined the payer-provider collaboration structures that make this viable, particularly in markets where independent provider networks are carrying a larger share of the member relationship.
The behavioral health access data presented at RISE adds context. With most behavioral health providers listed in Medicare Advantage networks found to be inactive or unavailable, access gaps lead to both engagement and compliance failures. The new CY2027 Depression Screening and Follow-Up Star measure makes this a scored metric, so it’s more than just a question of access.
- V28 is Fully Realized
V28 sessions were consistent on one point: the phase-in framing is over. The model expanded HCC categories from 86 to 115, introduced more granular diagnosis specificity requirements, and reclassified the weighting of several conditions that carried significant RAF value under V24. Plans that built their CDI and coding programs around V24 logic have been coding to the wrong model.
The CMS Rate Announcement confirmed that the 2024 risk adjustment model will continue for CY2027. This isn’t a reprieve, but rather confirmation that V28 is now the stable operating environment, and the documentation specificity requirements it introduced are not going away. Plans still calibrating to V24 logic are carrying that gap forward another year.
V28 changes which patient populations are highest priority for risk capture, what level of documentation specificity is required to support a valid HCC submission, and how care delivery programs need to be structured to identify and document the right conditions at the right time. These are not changes that coding team training resolves. They require aligning clinical workflow, provider education, and documentation standards across the organization.
Sessions also surfaced a V28 opportunity that plans with integrated programs are better positioned to capture. The model’s structure creates new overlap between conditions that are high value for risk adjustment and conditions central to HEDIS performance — an advantage that flows naturally to plans that have already aligned these two programs. Annova works with plans to close that gap.
The Overall Picture
RISE 2026 and CMS’s April releases are saying the same thing from two different directions. The conference showed where MA programs are breaking down operationally. The regulatory releases showed what CMS is doing about it — tightening rules around unlinked chart reviews, maintaining scrutiny on coding intensity, and recalibrating Star Ratings to reduce noise and increase the signal on clinical performance.
The plans that are best positioned have one thing in common. They stopped managing these functions in parallel and started managing them as one.
How Annova Can Help
Annova Solutions works with health plans, providers, and ACOs across HCC coding, medical record retrieval, HEDIS abstraction, and CDI support. If you are evaluating where your program stands heading into CY2027, let’s talk.
