Medicare Advantage Quality Management Guide 2025

Q: What is required in the Medicare Advantage UM Committee under 42 CFR 422.137?

The UM Committee must include: a majority of practicing physicians; at least one independent physician free of conflict with documented COI review; at least one physician expert in elderly or disabled care; members across clinical specialties (primary care and behavioural health required). From the applicable 2025 contract year: a health equity expert. All UM policies must be formally reviewed and approved by the committee, with decisions documented in writing and available for CMS review.

Q: What does the Internal Coverage Criteria requirement mean for prior authorisation policies?

Under 42 CFR 422.101(c)(1), when CMS has issued an NCD or LCD for a service, the plan's PA criteria may not be more restrictive than that NCD or LCD. Any additional test, longer trial period, or more restrictive diagnosis threshold that Medicare's coverage determination does not require is a non-compliant PA criterion. Where CMS guidance is silent, plans may develop internal criteria that must be UM Committee-approved.

Q: Which HEDIS measures have the most impact on Star Ratings?

Clinical quality improvement and effectiveness of care measures carry the highest weights, typically triple-weighted. Following removal of 11 administrative measures from 2025 Star Ratings, clinical HEDIS and CAHPS measures carry relatively greater weight. Plans should identify their triple-weighted measures and prioritise QI activity accordingly.

Q: What is the Chronic Care Improvement Programme and what must it include?

The CCIP (42 CFR 422.152(c)) requires MA plans to identify members with multiple or severe chronic conditions and deliver targeted interventions. It must include: a documented member identification method, a description of interventions deployed, and an outcome measurement approach. CMS auditors verify operational activity, member identification, outreach, enrolment, and outcome tracking. A written policy without operational evidence fails audit review.

Q: How does the Health Equity Index affect the MA QM programme from 2027?

The HEI reward launches with 2027 Star Ratings (Measurement Years 2024 and 2025). It recognises plans performing well for dual-eligible, LIS, and disabled members. Plans must stratify QM data by these populations now to build HEI evidence. UM policies producing access disparities for these populations will generate HEI penalties compounding Star Ratings exposure.

Q: What is the financial impact of the Quality Bonus Payment for Star Ratings?

Plans with 4+ stars receive a 5% QBP on their benchmark. At 4.5+ stars, the rebate share increases from 65% to 70%. For a 50,000-member plan at $1,000 PMPM benchmark, the 5% QBP is approximately $30 million per year. The 3.5-to-4.0 star transition is the most financially significant, moving from zero QBP to full QBP.

Q: What happens if a plan's HEDIS or CAHPS data fails audit validation?

CMS assigns a zero score for affected measures under 42 CFR 422.152(b). A zero score on any HEDIS or CAHPS measure directly reduces the overall Star Rating. For plans near the 4-star threshold, a single zero from a data validation failure can cause the plan to fall below 4 stars and lose the Quality Bonus Payment for that contract year.

GUIDES: Medicare Advantage Quality and Utilization Management

Medicare Advantage Quality Management
and Utilization Management: A Complete Guide

Quality management (QM) and utilization management (UM) are the two core operational programmes that determine how a Medicare Advantage plan performs on Star Ratings, passes CMS programme audits, and delivers compliant care to enrolled members. QM governs how the plan measures, monitors, and improves clinical outcomes. UM governs how the plan manages access to covered services through prior authorisation and medical necessity review. Both programmes are mandatory under 42 CFR Part 422 Subpart D and carry direct financial consequences through the Quality Bonus Payment programme. This guide covers what each programme requires, how to build and audit both, and what changed in 2024 and 2025 that every compliance and quality leader needs to act on now.

Quality Bonus Payment at 4+ Stars

MA plans with 4 or more Star Ratings receive a 5% Quality Bonus Payment added to their benchmark under 42 CFR Part 422 Subparts D and F. For a 50,000-member plan at a $1,000 PMPM benchmark, that is $30 million per year. The jump from 3.5 to 4.0 stars is the single largest revenue upgrade in Medicare Advantage, moving from zero quality bonus to full bonus in one step.

Quality Health: Star Ratings Cut Points and QBP Financial Stakes (2026)

Jan 2024

UM Committee Mandatory, All Policies Must Be Approved

From January 1, 2024, MA plans may not use any utilization management policies or procedures for basic or supplemental benefits unless those policies have been reviewed and approved by a UM Committee meeting the composition requirements of 42 CFR 422.137. Any prior authorisation policy in use without UM Committee approval is non-compliant from that date forward.

42 CFR 422.137, UM Committee Requirements

2027

Health Equity Index Reward Launches

Beginning with 2027 Star Ratings (based on Measurement Years 2024 and 2025), CMS will introduce a Health Equity Index reward for plans that perform well for members with social risk factors, dual-eligible, LIS, and disabled populations. Plans that stratify QM and UM data by health equity populations now are building the evidence base for 2027 HEI performance.

Greenspace Health: Mastering CMS Medicare Star Ratings (2025)

Medicare Advantage Quality Management: Why It Matters

Medicare Advantage plans are required under 42 CFR 422.152 to maintain a quality improvement programme covering all enrolled members and all contracted providers. Separately, they are required under 42 CFR 422.137 to establish a Utilization Management Committee that reviews and approves all UM policies. These are not optional programmes, they are mandatory compliance obligations with direct financial and regulatory consequences.

The financial stakes are highest at the Star Ratings boundary. Plans at 4 or more stars receive a 5% Quality Bonus Payment; plans below 4 stars receive nothing. For large plans, that is tens of millions of dollars per year that depend on the performance of the QM programme and the integrity of the UM programme. Plans that fail CMS programme audits in QM or UM areas face corrective action, sanctions, and potential audit findings that suppress Star Ratings scores.

What quality management governs

QM covers how the plan measures clinical performance (HEDIS measures), collects member experience data (CAHPS survey), monitors health outcomes (HOS), identifies and manages chronic conditions (Chronic Care Improvement Programme), and drives clinical quality improvement projects. QM performance determines the majority of a plan’s Star Ratings score and determines eligibility for the Quality Bonus Payment.

What utilization management governs

UM covers how the plan determines whether a service is medically necessary, who makes that determination, and which criteria govern it. UM includes prior authorisation requirements, medical necessity review, continuity of care protections, and the governance structure (UM Committee) that approves all UM policies. UM performance is assessed through the ODAG (Organisation Determination, Appeals, and Grievances) audit programme area.

Prerequisites: What Must Be in Place Before Building the Programme

Designated QM and UM programme leads

Each programme must have a named accountable leader: a Quality Director or Medical Director for QM and a UM Medical Director for UM. CMS programme audits expect documented accountability. A programme without a named lead has no clear ownership for audit findings and corrective actions.

A UM Committee constituted to 42 CFR 422.137 requirements

The UM Committee must include a majority of practicing physicians, at least one independent physician free of conflict, at least one physician with expertise in elderly or disabled care, and members representing various clinical specialties. This committee must be in place and operating before any UM policy can be used. No UM policy used on or after January 1, 2024 is compliant without UM Committee approval.

HEDIS-certified data systems and CAHPS survey vendor

Plans with 600 or more enrollees in July of the prior year must contract with a CMS-approved CAHPS vendor and submit HEDIS data to CMS in the format required by NCQA specifications. Plans without certified data systems and approved CAHPS vendors cannot meet the QM submission requirements and will receive zero scores on HEDIS and CAHPS measures.

Documented chronic care improvement programme criteria

Under 42 CFR 422.152(c), the plan must develop written criteria for a Chronic Care Improvement Programme covering how it identifies members with multiple or severe chronic conditions, what interventions it deploys, and how it measures outcomes. This must be documented before the programme can be reported to CMS. Undocumented programmes have no audit defence.

Step-by-Step: Building and Running the QM and UM Programme

Constitute and operate the UM Committee under 42 CFR 422.137

What to do: Establish the UM Committee with the required composition: majority practicing physicians, at least one independent physician (document the conflict-of-interest review process), at least one physician expert in elderly or disabled care, and representatives across clinical specialties including primary care and behavioural health. Schedule regular meetings (at minimum annually, with ad hoc meetings for policy changes). Document all decisions in writing and retain documentation for CMS review on request.

Why it matters: Every UM policy the plan uses must have UM Committee approval. From January 1, 2024, any prior authorisation policy in use without UM Committee approval is non-compliant under 42 CFR 422.137(b). CMS programme auditors verify UM Committee composition and meeting records in the ODAG audit area. A missing or non-compliant committee creates systemic ODAG deficiencies across every policy it should have reviewed.

What the standard requires: 42 CFR 422.137 requires that the committee meet the composition standards, review all UM policies annually, revise policies as necessary to comply with coverage criteria requirements, and document its decisions in writing. The 2025 Final Rule added a health equity expert requirement, from the applicable contract year, the committee must include a member with expertise in health equity. Source: 42 CFR 422.137

Align all prior authorisation criteria with Medicare coverage standards

What to do: Review every prior authorisation requirement for basic benefits against national Medicare coverage determinations (NCDs) and local coverage determinations (LCDs). Where CMS guidance exists on coverage criteria, the plan’s prior authorisation criteria must not be more restrictive than the applicable NCD or LCD. Where CMS guidance is silent, the plan may develop internal coverage criteria, but those criteria must be reviewed and approved by the UM Committee annually.

Why it matters: The 2024 Final Rule (effective January 1, 2024) codified the Internal Coverage Criteria (ICC) requirement: plans may not apply more restrictive coverage criteria than Medicare’s when making coverage decisions for basic benefits. Applying internal criteria that are stricter than NCDs or LCDs is a coverage denial, a plan is withholding a Medicare-covered benefit from an enrolled member. This generates ODAG deficiencies and, if systemic, can trigger CMS corrective action.

What the standard requires: 42 CFR 422.101(c)(1) requires that MA plans cover all services that Original Medicare covers and that their coverage criteria are consistent with applicable Medicare coverage determinations. Source: CY2024 MA Final Rule, Internal Coverage Criteria Requirements

Build and submit the HEDIS quality measurement programme

What to do: Contract with a HEDIS-certified organisation to collect, validate, and submit HEDIS measures. Identify which HEDIS measures are included in the plan’s Star Ratings calculation. Develop a data improvement plan for each measure where performance is below the 4-star threshold. Prioritise measures with the highest weighting in the Star Ratings calculation, clinical effectiveness measures carry more weight than administrative measures, particularly following CMS’s removal of 11 administrative measures from the 2025 Star Ratings.

Why it matters: HEDIS measures are the primary driver of Star Ratings performance. CMS increased measure-level cut points for 2025 Star Ratings, meaning plans must achieve higher performance to maintain the same star level. With 11 administrative measures removed, plans that previously relied on high administrative scores to compensate for weaker clinical HEDIS performance now have no buffer, their Star Rating reflects clinical performance directly. Source: CMS: 2025 Star Ratings Fact Sheet

What the standard requires: 42 CFR 422.152(b) requires MA plans to collect and submit HEDIS data to CMS using NCQA specifications. Plans with 600 or more enrollees must use NCQA-certified data collection approaches. Failure to submit valid HEDIS data results in a zero score for the affected measures. Source: 42 CFR 422.152(b)

Contract with a CMS-approved CAHPS vendor and drive member experience scores

What to do: Select a CMS-approved CAHPS survey vendor and ensure the survey is fielded in accordance with CMS specifications each year. Treat CAHPS survey scores as operational metrics, not just compliance submissions. Identify the specific CAHPS domains with the lowest scores, Getting Care Quickly, Getting Needed Care, Customer Service, Rating of Health Care Quality, and build member services interventions targeted at those domains. CAHPS scores are driven by operational decisions in member services, care coordination, and provider access, not by survey strategy.

Why it matters: CAHPS scores are directly included in the Star Ratings calculation and carry significant weighting. A plan with strong HEDIS scores but poor CAHPS scores cannot reach 4 stars. Member experience is a real-time operational output, poor CAHPS scores reflect prior year service failures that have already cost the plan in member satisfaction. Improvement requires changing operational behaviour now to be reflected in next year’s survey.

What the standard requires: 42 CFR 422.152(b)(5) requires plans with 600 or more enrollees to contract with approved CAHPS vendors and submit survey data to CMS annually in accordance with CMS specifications. Source: 42 CFR 422.152(b)(5)

Operate the Chronic Care Improvement Programme

What to do: Develop and document the CCIP criteria including: the method for identifying members with multiple or sufficiently severe chronic conditions who would benefit from the programme; the interventions deployed (care coordination, disease management, health coaching); and how outcomes are measured and reported. The CCIP must be operational, documented, and producing measurable outputs, not a paper programme.

Why it matters: The CCIP is a mandatory component of the QM programme under 42 CFR 422.152(c). CMS programme auditors verify that the CCIP is operational, that its criteria are documented, and that the plan can produce evidence of programme activity. A CCIP that exists as a written policy but has no documented operational activity is a compliance deficiency, the standard requires the plan to actually identify and serve chronic condition members, not just to have a policy saying it will.

What the standard requires: 42 CFR 422.152(c) requires all MA organisations to develop CCIP criteria, identify eligible members, deploy interventions, and measure outcomes. Source: 42 CFR 422.152(c)

Conduct the annual UM policy review and health equity analysis

What to do: The UM Committee must review all UM policies at least annually. Beginning with the 2025 requirements, this annual review must include a health equity analysis: the plan must assess whether its prior authorisation policies disproportionately affect dual-eligible or LIS members compared to the general enrolled population. Document the analysis, findings, and any policy adjustments made as a result. Retain all documentation for CMS review.

Why it matters: The health equity UM review is a new requirement that creates a documented audit trail, plans that conduct it and find disparities have an obligation to remediate them. Plans that do not conduct it cannot demonstrate compliance with the 2025 requirement. The 2027 Health Equity Index reward further raises the stakes: plans whose UM policies produce equity disparities will not perform well on the HEI, directly affecting their competitive position and quality bonus eligibility.

What the standard requires: 42 CFR 422.137 requires annual UM Committee review of all policies. The 2025 Final Rule added the health equity expert requirement to the UM Committee composition and the plan-level health equity review of prior authorisation policies. Source: 42 CFR 422.137; 2025 MA Final Rule

Monitor and close Star Ratings performance gaps continuously

What to do: Track performance on every Star Ratings measure monthly, not annually. For HEDIS measures, identify the gap between current performance and the prior year’s 4-star cut point. For CAHPS measures, monitor member service operational metrics (hold times, resolution rates, grievance rates) as leading indicators. Report to executive leadership monthly. Escalate any measure where the plan is at risk of falling below 4 stars before the end of the measurement year, once the year closes, the performance is locked.

Why it matters: Star Ratings cut points are recalculated each year based on how all plans perform. The 2025 Star Ratings saw cut points increase across many measures, plans that held the same performance as the prior year found themselves at a lower star level because the threshold moved up. Plans that only look at Star Ratings after they are published have no opportunity to intervene. Continuous in-year monitoring is the only operational model that gives a plan time to act before measurement closes. Source: CMS 2025 Star Ratings Fact Sheet

What the standard requires: 42 CFR 422.152(a) requires MA organisations to have an ongoing quality improvement programme. Ongoing means continuous monitoring and improvement activity, not annual review.

Compliance Checklist: QM and UM Programme Readiness

UM Committee and Policy Governance

UM Committee constituted with required composition under 42 CFR 422.137

Health equity expert added to UM Committee (2025 requirement)

All UM policies reviewed and approved by UM Committee (mandatory from Jan 2024)

Annual health equity analysis of prior authorisation policies completed and documented

UM Committee meeting minutes retained and available for CMS review

Prior Authorisation and Coverage Criteria

All PA criteria for basic benefits reviewed against applicable NCDs and LCDs

No PA criteria applied that are more restrictive than applicable NCD or LCD

Medical necessity reviews performed by physicians with appropriate specialty expertise

Continuity of care requirements met for members transitioning to new providers

PA denial rates tracked and reviewed quarterly for outlier patterns

Quality Measurement and Reporting

HEDIS data collected and submitted using NCQA-certified approach

CMS-approved CAHPS vendor contracted and survey fielded annually

CCIP criteria documented, programme operational, and outcomes tracked

QI projects documented with baseline, intervention, and outcome data

Health Equity Index baseline data collected for 2027 Star Ratings preparation

Star Ratings Monitoring

Monthly performance tracking against prior year 4-star cut points for every measure

Clinical HEDIS measures prioritised following removal of 11 administrative measures

CAHPS-driving operational metrics (hold times, resolution rates) tracked monthly

At-risk measures escalated to executive leadership before measurement year closes

QBP eligibility modelled at current performance levels quarterly

Troubleshooting: Common QM and UM Programme Failures

Problem: HEDIS scores are stagnant despite quality improvement activity

Root cause: QI projects are targeting the wrong population or using the wrong intervention. HEDIS measure performance is determined by whether the right members receive the right services, if the plan’s outreach is reaching members who would have received the service anyway, the marginal impact is zero. Fix: Stratify the HEDIS-eligible population by their likelihood of not receiving the service without intervention (claims history, provider engagement, demographic patterns). Target outreach to the low-compliance segment first. Track intervention-to-compliance conversion rates, not just outreach volume.

Problem: UM Committee was constituted but UM policies were not formally approved

Root cause: The committee met but did not formally vote on and document approval of each UM policy. Having a committee and having approved policies are two different compliance requirements. Fix: Conduct a retroactive policy review session where the UM Committee formally votes on and approves all current UM policies. Document the approval in meeting minutes with the policy name, version, and vote date. Going forward, no new or revised UM policy should take effect without a dated UM Committee approval vote in the minutes.

Problem: CAHPS scores are low on “Getting Needed Care” despite adequate network

Root cause: Members cannot get appointments with listed providers (phantom listings, closed panels) or prior authorisation denials are blocking access to approved services. A structurally adequate network that is operationally inaccessible produces low CAHPS Getting Needed Care scores. Fix: Cross-reference CAHPS low-score domains against grievance data on access complaints and provider directory accuracy findings. If PA denial rates are elevated for specific service types, review those PA criteria against NCDs/LCDs for ICC compliance. If provider access is the issue, run active panel status verification outreach for providers in the affected counties.

Problem: CCIP exists on paper but CMS audit found no evidence of operational activity

Root cause: The CCIP policy was written to satisfy the documentation requirement but the operational workflows for member identification, outreach, and care coordination were never built or staffed. Fix: Build the CCIP as an operational programme, not a compliance document. Define the specific chronic conditions targeted, the claims-based identification query, the outreach workflow, the care coordination intervention, and the outcome metric. Produce quarterly reports showing: number of members identified, number contacted, number enrolled in the programme, and outcome data. Without this operational evidence trail, the CCIP is a paper programme that fails audit review.

Key Takeaways

Every UM policy used without UM Committee approval is non-compliant from January 2024 forward

42 CFR 422.137(b) is unambiguous: no UM policy for basic or supplemental benefits may be used on or after January 1, 2024 without UM Committee review and approval. This is not a process recommendation, it is a compliance requirement. Plans that were using prior authorisation criteria before the January 2024 deadline without having them approved by a constituted UM Committee have been non-compliant since that date. The fix is a retroactive approval session followed by a governance process that prevents any new or revised policy from taking effect without UM Committee action.

Star Ratings cut points rise every year, holding performance flat means falling behind

CMS recalculates Star Ratings cut points annually based on how all plans perform. In 2025, cut points increased across many measures, plans that maintained the same level of clinical performance as the prior year found themselves at a lower star level because the threshold moved. The practical implication is that a QM programme that is not driving performance improvement is losing ground relative to the market. Holding at 4 stars requires improving performance year over year, not maintaining it.

QM and UM are operationally linked, a non-compliant UM programme suppresses QM scores

When a prior authorisation policy is more restrictive than Medicare’s coverage criteria, it denies members services they are entitled to. Those denied services include preventive care and chronic condition management services that are also HEDIS measures. A plan whose UM policies block access to diabetes monitoring, cancer screening, or cardiovascular care is simultaneously generating ODAG audit findings (for improper denials) and suppressing HEDIS performance scores (because members are not receiving the services being measured). The path to fixing both programmes starts at the same place: aligning PA criteria with Medicare coverage standards and getting UM Committee approval for every policy in use.

Frequently Asked Questions

What is required in the Medicare Advantage UM Committee under 42 CFR 422.137?

The UM Committee must include a majority of practicing physicians; at least one independent practicing physician who is free of conflicts of interest relative to the MA organisation and plan (with a documented conflict-of-interest review process); at least one practicing physician with expertise in elderly or disabled care; and members representing various clinical specialties, specifically including primary care and behavioural health. From the applicable contract year under the 2025 Final Rule, the committee must also include a member with expertise in health equity. The committee must meet, vote on, and document approval of all UM policies, and those records must be available for CMS review. Source: 42 CFR 422.137

What does the Internal Coverage Criteria requirement mean for prior authorisation policies?

The ICC requirement, codified in 42 CFR 422.101(c)(1) and clarified in the CY2024 Final Rule, means that when an MA plan applies coverage criteria for a basic benefit and CMS has issued a National Coverage Determination or applicable Local Coverage Determination for that service, the plan’s PA criteria must not be more restrictive than the NCD or LCD. If the plan’s internal criteria require something that Medicare’s coverage determination does not require, an additional test, a longer trial period, a more restrictive diagnosis threshold, that is a non-compliant PA criterion. Where CMS guidance is silent on coverage criteria, plans may develop internal criteria, but those must be reviewed and approved by the UM Committee. Source: CY2024 MA Final Rule, Internal Coverage Criteria

Which HEDIS measures have the most impact on Star Ratings?

Star Ratings weights differ across measure types. Under the current weighting structure, clinical quality improvement measures carry the highest individual weights. Following CMS’s removal of 11 administrative measures from the 2025 Star Ratings, the relative weight of clinical HEDIS and CAHPS measures increased, the removal concentrated scoring on clinical performance. High-impact HEDIS measure categories include effectiveness of care measures (preventive screenings, chronic disease management, medication adherence), which are typically triple-weighted. Plans should identify which of their measures fall in the triple-weight tier and prioritise QI activity accordingly. Source: Greenspace Health: CMS Star Ratings Strategic Guide (2025)

What is the Chronic Care Improvement Programme and what must it include?

The CCIP is a mandatory QM programme component under 42 CFR 422.152(c) requiring MA plans to identify members with multiple or sufficiently severe chronic conditions who would benefit from targeted intervention and to deliver that intervention. At minimum, the CCIP must include: a documented method for identifying eligible members (claims-based criteria, risk stratification); a description of the interventions deployed (care coordination, disease management, health coaching); and a method for measuring and tracking outcomes. CMS programme auditors verify that the CCIP is operational, that members are being identified, contacted, enrolled in interventions, and tracked. A written CCIP policy without documented operational activity fails audit review. Source: 42 CFR 422.152(c)

How does the Health Equity Index affect the MA QM programme from 2027?

The Health Equity Index (HEI) reward, launching with 2027 Star Ratings (based on Measurement Years 2024 and 2025), will recognise plans that perform well for members with social risk factors: dual-eligible members, LIS members, and members with disabilities. The HEI is separate from the overall Star Rating, it provides an additional reward for plans that demonstrate equitable performance across these populations. Plans that want to perform well on the HEI must begin stratifying their QM data by dual-eligibility and LIS status now (in Measurement Years 2024 and 2025) to build the evidence base. Plans whose UM policies produce access disparities for these populations will face HEI penalties that compound their Star Ratings exposure. Source: Greenspace Health: Health Equity Index and 2027 Star Ratings

What is the financial impact of the Quality Bonus Payment for Star Ratings?

Under 42 CFR Part 422 Subparts D and F, MA plans with 4 or more stars receive a 5% Quality Bonus Payment added to their benchmark. Plans with 4.5 or more stars also receive a 70% rebate share (versus 65% at 4.0 stars), which increases the amount the plan retains from the difference between the benchmark and the bid for supplemental benefits. For a 50,000-member plan at a $1,000 PMPM benchmark, the 5% QBP represents approximately $30 million per year. The transition from 3.5 to 4.0 stars is the single most financially significant Star Ratings movement, it is the step from receiving no quality bonus to receiving the full bonus. Source: Quality Health: Star Ratings Financial Stakes (2026)

What happens if a plan’s HEDIS or CAHPS data fails audit validation?

Under 42 CFR 422.152(b) and CMS’s data integrity requirements, if a plan’s HEDIS or CAHPS data fails audit validation, due to a failure to adhere to reporting requirements, data integrity issues, or errors in data processing, CMS assigns a score of zero for the affected measures. A zero score on any HEDIS or CAHPS measure has a direct negative impact on the overall Star Rating. For plans near the 4-star threshold, a single zero measure score from a data validation failure can cause a plan to fall below 4 stars and lose the Quality Bonus Payment for the affected contract year. Source: CMS: 2025 Star Ratings Technical Notes

Sources

Government and Regulatory Sources

42 CFR 422.137, Medicare Advantage Utilization Management Committee: the primary regulatory requirement for UM Committee composition, the January 1, 2024 mandatory policy approval requirement, and the annual UM policy review and documentation obligations.
42 CFR 422.152, Quality Improvement Programme: the QM programme requirements including HEDIS submission (422.152(b)), CAHPS vendor contracting (422.152(b)(5)), and Chronic Care Improvement Programme criteria (422.152(c)).
Federal Register: CY2024 MA Final Rule (April 12, 2023): source for the Internal Coverage Criteria requirement, UM Committee mandatory policy approval requirement effective January 1, 2024, and additional continuity of care requirements.
CMS: 2025 Medicare Advantage and Part D Star Ratings Fact Sheet: source for the 2025 Star Ratings cut point increases, the removal of 11 administrative measures, and CMS’s statement that contracts must achieve higher performance to maintain the same star level.
CMS: 2025 Star Ratings Technical Notes: source for data integrity requirements, zero-score assignment for failed HEDIS/CAHPS validation, and HEDIS audit designation procedures.

Industry Sources

Greenspace Health: Mastering CMS Medicare Star Ratings (July 2025): source for the HEDIS measure structure and CAHPS/HOS relationship to Star Ratings, and the 2027 Health Equity Index reward description covering dual-eligible, LIS, and disabled member performance requirements.
Quality Health: Star Ratings Cut Points and Financial Stakes (2026): source for the QBP financial model (5% of benchmark, 50,000-member example = $30M/year), the 4.5-star 70% rebate share, and the analysis of the 3.5-to-4.0 star transition as the single largest revenue upgrade in MA.