Understanding Medicare Advantage quality measures and medication therapy management requirements
Earlier this year, the Centers for Medicare & Medicaid Services (CMS) implemented significant changes to its 2025 Medicare Advantage Star Ratings program and medication therapy management (MTM) requirements, impacting health plans’ initiatives, operations, and member care. The 2025 regulatory updates combine targeted Star Ratings measure adjustments with substantial MTM program expansions, requiring strategic recalibration from health plans committed to quality performance and financial sustainability.
According to CMS’s official 2025 Star Ratings fact sheet, “Ensuring that Medicare works for seniors and people with disabilities, and that people with Medicare have access to robust, stable, high-quality, and affordable options for the coverage they need, are top priorities for the Centers for Medicare & Medicaid Services (CMS). As part of this, CMS is focused on continuing to improve the quality of the MA and Part D programs.” This mission drives the ongoing refinements to both Star Ratings methodology and MTM program requirements.
For payers navigating these regulatory shifts, success requires moving beyond compliance-focused approaches toward integrated strategies that deliver measurable improvements in clinical outcomes and member engagement. While introducing operational challenges, these adjustments to Star Ratings and changes to MTM programs also open new competitive opportunities for organizations ready to evolve their quality management strategies.
Understanding the 2025 CMS Star Ratings Landscape
CMS Star Ratings remain the cornerstone quality benchmark influencing plan reputation, member enrollment decisions, and financial incentives through quality bonus payments. As CMS states in its official documentation, “The Star Ratings system helps people with Medicare compare the quality of Medicare health and drug plans being offered so they are empowered to make the best health care decisions for themselves.”
The 2025 Star Ratings changes and targeted adjustments signal CMS’s continued emphasis on clinical outcomes and care coordination, with the agency noting that these updates are designed “to promote continual quality improvement to help ensure that Medicare enrollees receive high quality care and to incentivize plans to continue to strive for high performance.”
Key Changes to the Star Ratings Assessment System
- Measure Weighting Adjustments: The Plan All-Cause Readmissions measure increased to triple-weighting, reflecting CMS’s heightened focus on care transitions and hospital avoidance strategies.
- Cut Point Methodology Implementation: CMS implemented the Tukey outlier deletion method for determining cut points, creating more stringent performance thresholds by removing extreme performance outliers from calculations.
- Guardrails Application Changes: CMS’s guardrails system limits how much performance thresholds (cut points) can change year-over-year, typically capping movements at 5% to provide stability for health plans. For 2025, the Medicare Plan Finder measure now has guardrails applied, meaning its cut points cannot move more than 5% from 2024 levels, creating more predictable performance requirements. Conversely, the Controlling Blood Pressure (CBP) measure is considered new, with guardrails not applied, allowing CMS to set initial cut points at any level without year-over-year constraints. This creates different strategic planning considerations for health plans depending on whether measures have guardrail protection.
- Baseline Recalculation: 2025 cut points were baselined off newly reported 2024 performance, as prior year ratings were recalculated after successful lawsuits by SCAN Health Plan, Zing Health, and Elevance Health.
According to CMS data, industry analysis shows that average plan ratings decreased from 4.07 to 3.92, with the percentage of 4+ star plans dropping from 32% to 30%. As CMS explains, “Increases in measure-level cut points result both from contracts’ performance and from CMS policies that continue to drive quality improvement for the program.”¹ These tighter standards make every quality improvement initiative more critical for maintaining competitive positioning.
With Star Ratings increasingly tied to clinical outcomes and care coordination, the expanded MTM requirements play a pivotal role in helping health plans achieve higher ratings by addressing medication adherence and comprehensive member care.
MTM Eligibility Expands Dramatically: More Members, Higher Standards, Greater Star Ratings Impact
The changes to Medicare Part D MTM program requirements dramatically expand eligible populations while establishing more rigorous quality standards for comprehensive medication reviews (CMRs). These modifications represent one of the most significant updates to medication therapy management requirements in recent years.
CMS designed these MTM program changes with clear member benefits in mind. Under federal regulations established in the CY 2026 proposed rule, MTM programs must be designed to “ensure that targeted beneficiaries appropriately use covered Part D drugs to optimize therapeutic outcomes and reduce the risk of adverse events.” The expanded eligibility criteria ensures that more Medicare beneficiaries with complex medication needs receive comprehensive pharmaceutical care.
Key MTM Changes for 2025
- Expanded Targeting Criteria: CMS implemented changes to all three of the eligibility criteria, broadening the eligible member population requiring MTM services.
- Diseases. Plans must now include all ten core chronic diseases in targeting criteria, adding HIV/AIDS to the existing nine conditions.Â
- Cost Threshold: The 2025 MTM cost threshold dropped significantly to $1,623 for 2025, calculated based on the average annual cost of eight generic drugs.
- Drug Count. Plans must include all Part D maintenance drugs in their targeting criteria, eliminating previous flexibility to limit specific drug classes or medications.Â
- CMR Quality Standards: Interactive consultations remain mandatory, conducted in-person or via synchronous telehealth, with stricter documentation requirements for cognitive impairment determinations. These standards ensure personalized medication management tailored to individual member needs.
The MTM program expansion directly intersects with Star Ratings through the MTM Program Completion Rate for CMR measure, which evaluates how effectively plans deliver comprehensive medication reviews. The measure returns to the Star Ratings in measurement year 2027, associated with Star Year 2029, making current investments in MTM infrastructure critical for future competitive positioning.
As Dannielle Mack, Senior Vice President at Clarest, explains, “With MTM returning as a Star measure, health plans face mounting pressure to deliver outcomes amid uncertain funding and expanded eligibility. Clarest’s clinical call center offers CMS compliant, scalable, hybrid and fully delegated solutions, ensuring high CMR completion, improved adherence, and strong Star performance, all through our proven software platform and clinical infrastructure.”
These regulatory changes create multifaceted challenges requiring integrated responses across clinical, operational, and technology domains.
Scalable Clinical Resources and Data Integration Become More Critical Than Ever
Success demands advanced analytics capabilities for member risk stratification, real-time performance monitoring, and predictive intervention modeling. Plans need systems that can identify high-risk members eligible for expanded MTM services while tracking outcomes that influence Star Ratings performance.
Data integration becomes critical as plans must coordinate information across multiple sources: pharmacy claims, medical utilization, member satisfaction surveys, and clinical outcomes data. Effective platforms provide unified dashboards enabling care teams to identify intervention opportunities and measure impact.
The expanded MTM eligible population requires scaling clinical resources, particularly pharmacists trained in chronic disease management and motivational interviewing techniques. Successful plans will balance in-house capabilities with vendor partnerships to ensure adequate coverage while maintaining quality standards.
Scaling for Success: Advanced Analytics, Strategic Partnerships, and Continuous Measurement
Successful adaptation to these changes requires comprehensive planning and strategic execution that can scale. We list here our predictions of the most significant areas of investment for health plans:
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Assessment and Technology Investment
- Conduct comprehensive gap analysis comparing current MTM capabilities against expanded requirements. Evaluate technology infrastructure, clinical workforce capacity, and member outreach effectiveness to identify priority improvement areas.
- Implement predictive analytics platforms enabling proactive member identification and risk stratification. Focus on systems providing real-time performance monitoring and outcome tracking across multiple quality measures.
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Clinical Excellence and Vendor Partnerships
- Conduct comprehensive gap analysis comparing current MTM capabilities against expanded requirements. Evaluate technology infrastructure, clinical workforce capacity, and member outreach effectiveness to identify priority improvement areas.
- Implement predictive analytics platforms enabling proactive member identification and risk stratification. Focus on systems providing real-time performance monitoring and outcome tracking across multiple quality measures.
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Performance Measurement and Continuous Improvement
Effective implementation requires robust measurement frameworks tracking both immediate compliance metrics and longer-term outcome improvements.Â
- Monitor MTM program reach rates, CMR completion percentages, and member satisfaction scores alongside traditional Star Ratings measures
- Establish benchmarking processes comparing performance against industry standards and identifying best practices for continuous refinement
- Maintain awareness of ongoing CMS policy development, including potential future changes to MTM requirements and Star Ratings methodology
Partner with Clarest Health for Scale and Outcomes
Clarest Health’s clinical and compliance teams continuously monitor regulatory changes and responds with agile solutions tailored to evolving CMS requirements. Leveraging a robust medication management platform and comprehensive clinical call center services, Clarest supports critical measures such as CMR Rate, Adherence, COB, SUPD, SPC, Poly-ACH, and Diabetes Care while delivering consistent, high-quality outcomes.
Recent adherence initiatives have achieved reach rates of 46–69%, completion rates of 51–80%, and 26–46% conversion to 90-day fills, based on recent client performance data. These results reflect Clarest’s commitment to scalable, efficient quality improvement, enabling operational excellence across diverse Medicare Advantage environments without additional staffing burdens.