Ben Aylesworth.
Prepared for Clover Health Innovation & Delivery · November 2026

Clover's HMO is the star rating the team can move this year.

The PPO holds 5.0 stars for 2027 after the ruling, and planning as if it were 4.5 keeps it safe whichever way the appeal goes. The HMO, at 4.5, was never part of the case. Clover's own filings put a half-star gap at $120M.

Both contracts gained at least half a star this year, for different reasons.

CMS Star Ratings for Clover's two contracts at each step of Clover Insurance Co. v. HHS. Points are in sequence, not to a time scale.1

Since the ruling, CMS has appealed and Elevance and other insurers have filed similar suits. H8010 was never part of the case.

Two moves keep the PPO's score safe whichever way the appeal goes. The third lifts the HMO.

  1. H5141 · PPO
    Appeals measure

    Find the root causes behind overturned denials

    Named in the suit. It scores how often outside reviewers overturn the plan's coverage denials.

    First move. Audit the most recent overturned appeals for shared causes, so the score holds up if the measure counts again.

  2. H5141 · PPO
    Medication adherence

    Pilot on the lowest-adherence cohort

    The other measure named in the suit. Clover has argued it rewards refills over clinical benefit, so the pilot should show both.

    First move. A 90-day pilot on the lowest-adherence chronic-condition cohort, tracking CMS's refill-based score alongside one clinical marker the team already collects.

  3. H8010 · HMO
    4.5 stars, no litigation

    Push the HMO toward 5 on measures nobody is contesting

    Nothing here depends on the appeal, so progress shows up in the next rating cycle.

    First move. Pull H8010's measure-level scores from CMS's public Star Ratings data file and rank them by distance to the 5-star cut point.