Clover Health Lawsuit Against CMS May Have Implications for Coverage Universe

Research evidence excerpt

Clover Health Lawsuit Against CMS May Have Implications for Coverage Universe

Healthcare Facilities & Managed Care

Clover Health Lawsuit Against CMS May Have June 5, 2026

Implications for Coverage Universe

●Clover Wins Lawsuit Against CMS in MA Stars Lawsuit – In November 2025,

Clover Health filed a lawsuit against HHS and CMS against the calculation of

its 2026 Medicare Advantage Star ratings. Clover alleged that CMS improperly

included 20 measures in the 2026 Star rating calculation, which resulted in a

Star rating decline from 4 Stars to 3.5 Stars in Clover’s PPO plan, covering a Justin Lake, CFA

majority of its MA membership. According to the lawsuit, the downgrade to 3.5 jlake@wolferesearch.com

(646) 582-9280

Stars will cost the company ~$120M in missed Quality Bonus Payments. Clover View Justin’s Research

argues that CMS “departed from the measures of clinical quality and health View Comp Table

outcomes that Congress authorized, instead relying on a host of other measures Dillon Nissan

that have little or nothing to do with quality” (link to lawsuit). This pertains dnissan@wolferesearch.com

(646) 582-9281

to measures that were included in Star ratings that did not go through the

proper rulemaking process required under Medicare statutes. Last week, a US Ben Tenner

btenner@wolferesearch.com

District Court in Georgia granted partial summary judgment for Clover, striking (646) 582-9289

20 of the 42 measures included in the Star rating calculation and ordering

CMS to recalculate Clover’s H5141 PPO contract. CMS has already filed for

reconsideration. See attached slides for more detail and we will host a webcast

this morning at 10:00 am ET to discuss this and more – signup link here.

●Potential Implications to our Coverage Universe – If the Clover Insurance Co.

v.