Understanding Medicare Star Ratings

Buying a Medicare Advantage Plan or a prescription drug plan to accompany your Original Medicare plan requires you to compare plans and healthcare providers to determine which one can best meet your needs. That is not easy to do. Medicare plans are complex. There’s no way to know what you can expect from the drug coverage or the healthcare providers until you have a plan, right?

That’s where Medicare star ratings come into play. Each year, the Centers for Medicare & Medicaid Services (CMS) public star ratings, which are a basic star rating for each of the available policies. They are meant to give you some insight into what you are buying and what you can expect.

The Medicare Part D Star Ratings and Medicare Advantage (Medicare Part C) ratings can help you to learn the quality of health and drug services. The system allows you to compare the quality of Medicare health and drug plans so you can make a better decision to fit your needs down the road.

Let’s explain how they work and what these ratings should mean to you.

You are in the market to purchase a Medicare Advantage plan. Or, you may be planning to purchase a Medicare Part D prescription drug plan if you have Original Medicare. Most people want a low cost for the health insurance they select, but there is no point in purchasing health insurance that does not meet your needs. Finding that balance between affordable and quality Medicare insurance is your priority.

Who Sells These Plans?

Medicare Part D and Medicare Advantage plans are not sold or offered through Medicare. Rather, they are from private insurance companies. However, CMS monitors these plans and the companies on behalf of consumers. They gather information and align it to a simple 5-star system. That allows you to compare the plans for:

• How well they perform
• Their quality of coverage
• Member satisfaction

To be clear, you should not purchase a Medicare healthcare plan that does not meet your individual needs just because it has 5 stars. You still need to make sure the coverage aligns with your specific needs and goals.

What Are the Medicare Star Ratings?

Here is how the Medicare star ratings breakdown:

• 1 star rating – Poor service noted
• 2 star rating – Below average service noted
• 3 star rating – Average among all policies compared
• 4 star rating – Above average rating
• 5 Start – Excellent coverage, the best option for quality, performance, and service

That makes the entire process simple enough, but not everyone wants to pay the highest price for a 5 star plan if a 4 star plan is more affordable and offers the coverage you need. So how do you choose?

Learn How Medicare Star Ratings Work

When you need to purchase a prescription drug plan or a Medicare Advantage plan, you can compare several healthcare provider options on the CMS website. There, you will see the Medicare star rating listed.

The CMS calculates this rating based on the measurements of customer satisfaction and plan quality of care that it receives. These star ratings will change every year – that is one of the reasons you will want to compare policies annually to determine which one fits your goals and not just stick to the same plan each year.

The CMS uses the most recently available data to produce these ratings. Most of the time, it releases the star ratings in October before the launch of open enrollment periods for most people. There are some situations in which the star rating may be listed before or after this, generally when the healthcare coverage is a new policy to the marketplace that year. They may not have any rating that initial year because no members have provided that information just yet.

Medicare Advantage Plan Star Ratings

Medicare Advantage, also known as Medicare Part C, has its own set of factors that CMS uses to determine the quality of the policies and how well they meet the needs of consumers. To determine this information, the CMS looks at the following data:

• Member Experience: In this area, they consider how well the members of the health insurance plan benefit from it, specifically related to how easy it is to see a specialist if they need care. They also note how hard it is for members to get an appointment for the care they need in a short period of time.
• Plan Performance: They also look at the complaint history of the health insurance plan. Here, they want to determine if the performance of the plan – the good and bad of it as reported by members – is getting better or if it is worsening over time. They also track if members are leaving the plan as a determining factor in how well the plan fits their needs.
• Customer Service: This is a big one for most consumers. The CMS takes a look at what people are saying about the plan. Specifically, how well do members get the help they need when they have a member request? What happens during the appeals process?
• Staying Healthy: The next factor that plays a role in star ratings for Medicare Advantage plans is the access members have to the services they need to stay healthy. Is it easy to get checkups and routine care? Are screening tests paid for and available to the member? They also want to verify the access to vaccinations, and other needs members have.
• Chronic Condition Care: For many seniors and those on disability, chronic condition management is a big factor in choosing a plan. The CMS looks at the information available, including the availability of testing and lab work for various conditions. They also look at the treatment options available. Would members recommend the plan for those who have the same conditions they do?

Most Medicare Advantage Plans will have a prescription drug coverage component. CMS rates the Medicare Advantage Plan based on all components of the coverage it provides.

Medicare Part D Drug Plan star ratings

For those who are just purchasing a Medicare Part D drug plan, you will need to have insight into how well that healthcare plan works to meet your needs. The star ratings from CMS are a bit different here than they are for Medicare Advantage plans. Here is how they break down.

• Member Experience: This is still a big factor in the overall rating. How do members who have the plan rate it? Good or bad?
• Plan Performance: CMS looks at what is happening with the plan over time. This includes any history of complaints members filed against the plan as well as how the ratings for the plan have improved or worsened over time. They also look at why and how often members are leaving the plan.
• Customer Service: In this area, the CMS considers how well members report receiving quality service from the plan. They take a look at factors like how member requests are handled and how many appeals occur (including how they are treated).
• Drug Safety and Pricing: The final component is a consideration for pricing. How accurate is the pricing of the plan? Do those who have specific medication needs prescribed by their doctors able to get that care and can be prescribed drugs appropriately?

Each of the Medicare Part D plans will have a summary rating, which is an overall weighted average based on all of the factors that Medicare Part D measures.

Medicare Star Ratings: How to Use Them to Choose a Medicare Advantage and Part D Plan

Now that you have some idea about a plan’s star rating, you next need to consider how this information can impact your decision when choosing health care providers. The more information you have about health coverage before you find it – including healthcare effectiveness data – the more prepared you can be in choosing a policy that really meets your needs. The star rating system is one tool to help you in the process of choosing a health plan.

How to use the rating system and plan ratings for your needs

When you are within your open enrollment period, or you are making an enrollment request, you will want to gather information on the star rating from the one to five stars the plan has.

Look at all of the health plans to determine what their overall star rating is. Most of the time, you will want to use the summary rating to make a decision. Most often, on a scale of one to five stars, you’ll want to choose those policies with five stars. These are considered the best health plans.

Need more information? That’s great because the more insight you have into the performance measures and the health plan itself, the better.

Take into consideration what ratings range people typically sign up for. For the 2023 enrollment period, about 72% of all beneficiaries enrolled in a health plan with an overall star rating of at least a 4 when they enrolled in Medicare Advantage Plans.

The overall star rating for stand-alone Medicare Part D plans was 9% - meaning that about 9% of those who signed up chose a plan with at least a 4 star rating.

Don’t stop there when considering a plan’s performance. Instead, look at how well the plan works to meet the individual needs of those who have the same type of medical needs as you do, especially for chronic conditions.

To do this, you can look at the data for the measurement period about the plan’s performance based on other people who have the same health needs as you do. If you have diabetes, for example, you can look at how other people with diabetes say the plan met or did not meet their health needs. You can choose which type of chronic health conditions to look at based on the plan ratings.

You can do this using the Medicare Plan-Finding Tool. There, go under the “plan details” table, where you can select the chronic conditions you are facing.

When Can You Enroll in a 5 Stars Plan?

Medicare star ratings provide you with a tool to comparison shop, but when can you choose one of the prescription drug coverage plans?

You will need to sign up for a plan that meets your needs when you are eligible for open enrollment. You may be able to sign up for this information whenever you meet the requirements for eligible Medicare beneficiaries.

• Initial Enrolment Period: Most people will sign up for Medicare prescription drug coverage during their initial enrollment period. This period typically spans seven months. It starts three months before your 65th birthday and runs for three months after your birth month. It includes the month of your birthday as well. If you are new to Medicare prescription drug coverage, you likely will sign up at this period.
• Open Enrollment Period: After that first period, you can also sign up for a health plan during the Open Enrollment Period. This occurs each year from October 15th through December 7th. During this period, Medicare beneficiaries can choose the Medicare Plan right for them. The prescription drug plan they choose will then become active on January 1st of the following year.
• Special Enrollment Period: You may also be able to enroll during a special enrollment period. Medicare beneficiaries may qualify for a special enrollment period if they become diagnosed with a medical condition that meets the requirements for disability.

Another time when you may be able to switch occurs when you want to move from the policy you have now to a 5 star plan. If the star ratings for your existing plan are low, you may be able to switch to one with a 5 star rating. This is a one time special enrollment period – which means Medicare beneficiaries can only do this one time. This period runs from December 8th through November 30th. You can only switch from a low performing plan to a 5 star plan one time during that period.

What if you do not purchase MA plans during the right time of the year? If you sign up outside the enrollment period allowable, you may have to pay a late enrollment penalty. That penalty will carry on over the lifetime of your coverage and may impact the plan’s pricing.

When Will Medicare Star Ratings Be Updated?

Star ratings do not update in real time. Rather, the star ratings will be updated in the fall, prior to the next year. This data comes from member satisfaction surveys completed in the year before. Consumer assessment like this is very valuable, but the overall rating only changes once time a year.

For this reason, when you need to purchase Medicare Part D drug plans or a Medicare Advantage Plan, you will want to look at star ratings that are most up to date. Prescription drug plans of all types should be compared, but start ratings are not all that you need to consider.

How to Choose the Best Medicare Part D Drug Plans or Medicare Advantage Plan for You

Star ratings are one component of the factors that you need to consider. When looking at Medicare Part D plans and Medicare Advantage star ratings, you will need to consider a range of data.

What medical conditions do you have?

When choosing any plan, you want to know how people who have the same medical needs as you have received care from the drug plans. List those conditions you have that are important to you, such as heart disease or diabetes.

What is the plan's pricing information?

Always choose a health plan that fits your needs. Yet, it is not logical to think that the plan's pricing information does not matter. While you may not want to choose a plan with fewer than three stars just for a lower price, you do want to consider the overall benefits the plan offers.

Drug pricing information is available during open enrollment. Before selecting one, you should always know the cost of the Medicare Part D prescription drug plan or the Advantage plan.

What additional cost is involved?

Though it can occur for many reasons, including changing costs over time, you should know what to expect for all costs. That includes things like types of treatment that may not be covered or medications the policy does not cover.

Is your doctor in the network?

As you consider star ratings, be sure that you also consider how well the policy fits into your life right now. You certainly have the right to make a switch to a new doctor if you want to do so, but you may not want to do that. For that reason, make sure the Advantage plan or prescription drug plans cover the medical providers, hospitals, and other care that you need. You want to be sure that the plan helps you in staying healthy and meet your healthcare needs over time.

Are your preferred cost-sharing pharmacies present in your area?

Also, look at the plan's ability to meet your current prescription medication requirements. Does the pharmacy you want to use have coverage under the plan? Choosing prescription drug plans with high star ratings can be a good thing, but only if the coverage you need for your medications is included.

What member complaints are there?

Most people know the importance of choosing a policy that fits their needs. The plan's rating can matter, too. You also need to consider member complaints or any information you find about the policy. That could be very important in situations where member complaints have driven down the plans star ratings. Those with fewer than three stars, for example, may have significant consumer complaints. You should know about that before you choose them. Also, consider any improvement measures the organization has taken to improve the plan's pricing information, drug safety, and other factors alongside the plan's quality.

Answering Your Star Ratings Questions

Do you have questions about any Medicare plans? Be sure to reach out. Don’t assume you know what is covered or what is not – that could cost you significantly over time. Here are some common questions.

My plan has a low star rating. I want to switch because I’m frustrated with it. Do I have to wait until open enrollment?

No, you do not. Each year, you are given a special enrollment period. This is outside of what the normal enrollment periods are. This tends to have for special reasons. If you are awarded that period, you are then able to enroll in another plan, generally a five-star plan, that better meets your needs.

When will the star ratings for Medicare plans and prescription drug plans update?

There is no specific date that this is done. It happens one time a year. Most of the time, it occurs in the fall, usually before the open enrollment period begins. That way, you can compare policies and be able to learn as much as possible about the health plan before you make the decision to switch.

Will it cost me more if I switch from one plan to the next?

Not necessarily. When it is time for you to pick a new plan, wait until the Centers for Medicare & Medical Services updates the star rating and drug pricing information. Then, start comparing. You are able to see how much a new plan will cost you right there. You may find that it costs less to switch to a new plan than to stay with the old one. Other times, you may want to switch because of the plan’s rating or because you want a different type of coverage. That may mean paying more.

There is no penalty to you when it comes to switching providers every year, especially if you do so during the open enrollment period. You can also switch from a stand alone Part D prescription drug policy to Advantage plans during this time, too. There’s no higher fee for doing so.