4 Key Facts About Medicare Star Ratings

September 25, 2017

by: The My Medicare Matters Team

Whether you’re new to Medicare or re-evaluating your current coverage, you want to find the best plan for your needs. But sometimes having too many options can prove more difficult than you may expect.

Say you choose to evaluate your options using the Medicare Questionnaire and find 3 or 4 plans that all fit in your budget and cover your health care needs. How will you decide which plan to choose? Using the Medicare star rating system can help.

Medicare star ratings are a quality rating system created by the Centers for Medicare & Medicaid Services (CMS) for Medicare Advantage (MA) and prescription drug (PDPs or Part D) plans. The rating scale ranges between 1 and 5 (5 being the highest) and is based on measurements of customer satisfaction and quality of care the plan delivers. CMS conducts a yearly review of these measures, and takes into consideration the reliability of the measures, clinical recommendations, feedback received from stakeholders, and additional data that plans submit to Medicare.

Before you get started, here are four things you should know about Medicare star ratings when choosing your next Medicare Advantage or prescription drug Part D plan.

1. Star ratings can be a useful tool in comparing plans with similar costs and coverage

How much you’ll pay for your plan/prescriptions, and whether it covers your needed services and drugs are important considerations when choosing a Medicare plan. But star ratings can also provide additional points of comparison when choosing between plans with similar costs and coverage. For instance, if you have a chronic condition(s) and often see a specialist, you can review each plan’s rating for chronic condition management, which is a measure of how easy it is to see a specialist.  Comparing the scores on chronic condition management may help identify which plan might be best for you.  (This information is available under the Your Plan Detail page of Medicare Plan Finder.)

2. Medicare Advantage and Part D plan star ratings use separate categories for ranking

A Medicare Advantage plan’s overall rating is determined by 5 categories: staying healthy, managing chronic (long-term) conditions, member experience with the health plan, member complaints and changes in the health plan’s performance, and health plan customer service.

Part D plans’ overall ratings are determined by 4 categories: drug plan customer service, member complaints and changes in the drug plan’s performance, member experience with the plan’s drug services, and drug safety and accuracy of drug pricing.

For plans covering both health and drug services (Medicare Advantage plan with prescription drug coverage), the overall rating for quality and performance covers all of the topics above.

3. Using star ratings to select a Medicare plan can help ensure you don’t enroll in a subpar plan

Medicare star ratings assist beneficiaries in finding the best plan for them based on their health care needs and financial situation. If you are enrolled in a Medicare plan that is less than 3 stars it’s considered poor quality and is likely not providing you with the most optimal health coverage. If your Medicare plan has received less than 3 stars for three consecutive years you will be notified via mail during late October so you can consider re-evaluating your coverage and switching to a higher rated plan either during Open Enrollment, a Special Enrollment Period, or any time of year if you are switching to a 5-star plan.

4. There are 4 different Enrollment Periods in which you can join a star rated Medicare plan

If you are new to Medicare you can enroll in a star rated Medicare Advantage or Part D plan during your Initial Enrollment Period. If you are already enrolled in Medicare, you can enroll in or switch Part D and Medicare Advantage plans during the annual Open Enrollment Period (October  15 – December 7), or during two Special Enrollment Periods—the 5-Star Special Enrollment Period, and a Special Enrollment Period for Disenrollment from lower-rated plans.

The 5-Star Special Enrollment Period can be used only once per year between December 8 and November 30, during which you can switch to a plan that has a 5-star overall rating.

The Special Enrollment Period for Disenrollment from lower-rated plans is available once per calendar year between January 1 and December 31. If you are enrolled in a plan that has received a rating from CMS of fewer than 3 stars for three straight years, you can use this period to switch to a plan that is rated 3-stars or better or a plan with no rating (since some plans are too new to rate).

Please note, for both Special Enrollment Periods you may lose your prescription drug coverage if you move from a Medicare Advantage Plan that has drug coverage to a 5-star Medicare Advantage Plan that doesn’t. You’ll have to wait until the next Open Enrollment Period to get drug coverage, and you may have to pay a late enrollment penalty.

Now you have a great start on the information you need about Medicare star ratings to make an informed decision regarding your next healthcare plan enrollment. You can call your local State Health Insurance Assistance Program (SHIP) for federally-funded Medicare counseling or compare Medicare plans online using our Medicare Questionnaire, which generates a personalized report on your options. In order to view a plan’s star rating on the Medicare Questionnaire, simply choose the Medicare plans you would like to see and select compare. The star rating will appear on the row labeled CMS Rating.