Clover Health says the five-star rating that CMS gave its Medicare Advantage PPO plans for 2027 was calculated without 20 measures covered by a federal court decision, and that with those measures included the same plans would have scored 4.5 stars. The insurer laid out the claim in an October 8 news release issued the same day the Centers for Medicare & Medicaid Services published its 2027 Star Ratings. The decision, which Clover says is on appeal, is the reason the company’s headline rating and its fallback number differ by half a star.
The case is Clover Insurance Company v. Department of Health & Human Services, Civil Action No. 25-142 in the Southern District of Georgia, and the release says the court issued it on May 27, 2026. Clover says CMS removed the 20 measures named in the ruling when it calculated the PPO rating, which produced five stars. The company’s HMO plan received 4.5 stars, and the release does not say whether the ruling touched that rating.
For a person on Medicare weighing a switch, the useful distinction is between what the government has published and what the insurer says about how it got there. CMS lists Clover’s contract on its five-star roster, and the reader’s question is narrower than the legal fight: does a rating that depends on a disputed calculation make Clover’s PPO a better pick for 2027 than the plan already in hand?
Whether Clover’s PPO is a five-star or a 4.5-star plan matters less to a member than what it charges for that member’s own prescriptions and whether the doctors are in network. The 2027 Medicare Open Enrollment Decision Kit includes a cost calculator spreadsheet that compares plans on cost, drugs and doctors, so the rating dispute stops being the deciding factor.
Test Clover’s PPO against the current plan with the Decision Kit’s cost calculator →
What the numbers on the CMS roster show
The CMS fact sheet counts 15 Medicare Advantage drug-plan contracts with the high-performing icon this year, out of 508 rated. Clover Insurance Company, contract H5141, is one of them, with 155,135 enrollees as of October 2026, and the table marks it as not having held five stars last year. Only MCS Advantage, with 360,519 members, is larger on the list.
Clover’s own count is a little higher. The release says its Medicare Advantage membership grew about 48 percent year over year through the first half of 2026 to more than 157,000 members, and that about 98 percent of members are in its wide-network PPO plans. The CMS table reflects October 2026 enrollment in one contract, and the release describes membership through the first half of the year, so the two numbers are not the same measure.
Clover’s account of the 20 measures
The company’s argument is that the court decision changed what the rating should include. It says that with the 20 measures left in, its PPO plans would have received 4.5 stars, so five stars rests on the exclusion. Neither the 4.5 figure nor the statement that CMS excluded those measures comes from a CMS document: both are the insurer’s account in its own release, and the release carries a disclaimer that its views are the authors’ and not necessarily CMS’s.
The company’s leaders presented the rating as a business win. Chief Executive Andrew Toy said in the release that “success in the Star ratings system means an enhanced ability to support our members,” and Jamie Reynoso, who runs Clover’s Medicare Advantage business, said “with a higher Star rating, we are able to further reinvest in even more competitive benefits.” The release also says Clover scored 4.82 out of 5 on core HEDIS clinical measures, ranking first among non-SNP PPO plans with more than 2,000 members for the third year in a row, and that the 4.82 is the same under CMS’s 2027 methodology.
A second insurer plans its own challenge
Clover is not the only insurer questioning the way CMS builds the ratings. Alignment Healthcare said the same day that it intends to litigate the measures and methodologies it believes warrant review after its California HMO contract received 3.5 stars. Clover’s case differs in one important way: it already has a May 2026 court decision to point to, while Alignment says it plans to bring one.
Taken together, the two releases show the ratings are now a legal battleground as well as a consumer guide. Star ratings feed Medicare Advantage quality bonus payments, which CMS says the 2027 ratings affect in 2028, so a half star has payment consequences for an insurer.
Year-round enrollment and the actual rule
Clover says that at five stars its PPO plans can enroll beneficiaries year-round. Medicare’s own wording is narrower. The special enrollment page on Medicare.gov says a five-star plan available in the area can be joined using a special enrollment period that can be used only once between December 8 and November 30 of the following year. A person who has already used it cannot hop in again.
Open enrollment is the broader window: October 15 through December 7. The PPO also has to be sold in the person’s county, and the rating says nothing about that.
Weighing a rating dispute against a plan’s real costs
The free sources for this decision are CMS’s published ratings and the Medicare Plan Finder, which lets beneficiaries compare health and drug plans. CMS’s announcement of the 2027 plan landscape says 1-800-MEDICARE helps with comparing plans and costs, 24 hours a day, seven days a week. Enter the full prescription list and pharmacy, then compare the premium, drug costs and out-of-pocket maximum of Clover’s PPO with the plan in hand.
Two checks matter more than the star count. One is the provider network, because a wide-network PPO is only wide for the doctors it actually includes. The other is the cost of each regular drug across the whole year, including the deductible phase.
Clover’s release notes that enrollment depends on contract renewal. The court appeal will keep running; the December 7 close of open enrollment will not wait for it.
Clover’s five stars, or 4.5, still leave drug costs open
Switching on a star count alone can mean learning in January that a doctor is out of network or a regular prescription sits on a costly tier, and the choice then stands for the year. The 2027 Medicare Open Enrollment Decision Kit puts a prescription-by-plan comparison and a provider call script in one 55-page guide, so the network and drug prices are confirmed with the plan before December 7.
Confirm Clover’s network and drug prices with the Decision Kit’s provider call script →
This article was produced with AI assistance and reviewed by The Financial Wire’s editorial team.
David M. Keller is a finance writer based in Columbus, Ohio, covering personal finance and consumer-focused economic topics. He earned his degree in journalism from Ohio University and began his career reporting on local business and economic trends for a regional media outlet. Since then, he has contributed to a variety of online publications, focusing on clear, practical coverage of topics such as cost of living, debt, and everyday financial decision-making.
