Choosing the right Medicare coverage can be daunting, especially if you’re turning 65 and new to Medicare. Many plans include “extra” benefits. There are also restrictions, costs, and coverage limitations. Fortunately, Medicare has implemented a star rating system to help you compare plans and make an informed decision. This article will discuss how to compare Medicare Advantage plans using the Medicare Star Rating System.

 What are Medicare star ratings?

Medicare star ratings are a system that rates Medicare Advantage plans on a scale of 1 to 5, with 5 stars being the highest rating and 1 star being the lowest. The rankings are as follows:

• 5 stars: Excellent
• 4 stars: Above average
• 3 stars: Average
• 2 stars: Below average
• 1 star: Poor

The Centers for Medicare & Medicaid Services (CMS) determine each plan’s rating based on the quality of care provided and measurements of customer satisfaction. To find a plan’s rating, you can use the Medicare plan-finding tool, and 5-star plans have a special star icon in the results list. CMS updates plan ratings annually based on the most recent data, typically released in October unless a plan is new to the Marketplace and has ratings once CMS can collect the necessary data.

Why are Medicare Star ratings beneficial?

The Medicare Star Ratings are essential for two main reasons:

• They provide “apples-to-apples” comparisons

No matter which Star Rating you’re looking at, all plans and providers are judged against the exact measurements. Ratings can be a big help when choosing which hospital you should go to for a specific procedure.

• They hold healthcare providers accountable.

By publicly publishing their rating, providers must decide to improve low-performing areas or risk losing future customers. The Marketplace displays star ratings alongside vital details like each plan’s premiums and deductibles.

Star ratings for Medicare Advantage plans

Medicare Advantage plans, or Medicare Part C plans, are evaluated based on their health coverage in five categories.

The categories used to rate the health coverage of Medicare Advantage plans are as follows:

• Member experience: This category assesses how members rate the ease of seeing specialists and getting timely appointments.
• Plan performance: This category looks at the plan’s complaint history and whether its performance has improved or declined. It also examines whether members are leaving the plan.
• Customer service: This category evaluates how well the plan responds to member requests and appeals.
• Staying healthy: This category assesses whether members have access to checkups, vaccinations, and screening tests that help them maintain good health.
• Chronic conditions: This category examines whether members receive recommended tests and treatments.

In addition to the category ratings mentioned earlier, Medicare Advantage plans are assigned a summary rating for Medicare Part C, a weighted average of their performance on all health plan measures.

Medicare Advantage plans that offer prescription drug coverage are rated on both the Medicare Part C and Medicare Part D measures. These plans receive a summary rating for health plan measures, a summary rating for drug plan measures, and an overall rating for the plan.

Star ratings for Medicare Part D prescription drug plans

The ratings for Medicare Part D plans are determined based on the following four categories:

• Member experience: This category considers how members rate the plan.
• Plan performance: This category looks at the complaint history of the plan and whether its performance has improved or declined over time. It also examines whether members are leaving the plan.
• Customer service: This category evaluates how well the plan responds to member requests and appeals.
• Drug safety and pricing: This category examines the accuracy of the plan’s pricing information and whether members with specific medical conditions are prescribed drugs safely and appropriately.

Each Medicare Part D plan receives a summary rating, a weighted average of all the Medicare Part D measures.

How to compare plans using the Medicare Star Ratings

To evaluate the quality through the star ratings, it is helpful to consider their summary or overall ratings. Plans with 5 stars are considered the best. For reference, the Centers for Medicare & Medicaid Services (CMS) provide data on the average star ratings of plans and the percentage of beneficiaries in plans rated 4 stars or higher.

• For 2023, Medicare Advantage plans with prescription drug coverage have an average overall rating of 4.15 stars. In the same year, approximately 72% of individuals enrolled in such plans have a rating of at least 4 stars. 
• On the other hand, stand-alone Medicare Part D plans have an average summary rating of 3.25 stars for 2023, and only about 9% of beneficiaries enrolled in a stand-alone Part D plan have a rating of at least 4 stars in the same year. 

If you have specific care needs, it may be beneficial to compare plans based on their performance on individual categories or measures, such as diabetes measures in the chronic conditions category. You can find the ratings for individual measures by checking the “Plan Details” when using the Medicare plan-finding tool.

Signing up for 5-star Medicare plans

You have a few options to sign up for a 5-star Medicare Advantage or Part D plan, including 

• your initial enrollment period (around your 65th birthday), 
• the open enrollment period (October 15 to December 7 each year), 
• Or the Medicare Advantage open enrollment period (January 1 to March 31 each year if you already have a Medicare Advantage plan). 

You may also qualify for a special enrollment period. Suppose you want to switch to a 5-star plan outside of these enrollment periods. In that case, you can do so during a special enrollment period from December 8 to November 30 of the following year (almost a full year), but only if a 5-star plan is available in your area. 

Keep in mind that not all areas have 5-star plans available. Additionally, if you’re enrolled in a plan that has received a rating of fewer than 3 stars for three consecutive years, you’re allowed a one-time chance at any time to enroll in a higher-rated plan.

>>Learn more about Medicare Enrollment Periods here.

How often are Medicare Star Ratings updated?

CMS updates its Star Ratings at different times. Ratings for insurance plans are typically released each fall to line up with enrollment periods for Medicare, Medicare Advantage, Medicare Prescription Drug Plan (Part D), and standard health insurance. Changes are made based on feedback, provider recommendations, and the data.

Some are updated even more regularly; CMS’ Nursing Home Compare tool reflects the latest nursing home ratings each month. Others are updated less often — CMS’ hospital quality rating, Hospital Compare, is often refreshed only once yearly.

When using CMS Star Ratings, check how old the ratings are. If you have any questions, ask your provider or carrier for the latest ratings.

FAQS

What is the 5-star special enrollment period?

If you’re enrolled in a Medicare Advantage plan or Part D plan, you may be able to enroll in a five-star plan in your area — if your current plan is rated lower. Medicare allows a once-a-year special enrollment period for those who want to switch to a five-star plan. This switch can only occur after December 8 of the year you selected your plan and before November 30 of your plan year.

If the star rating drops, can I change my Medicare Part D or Medicare Advantage plan?

Yes, you can change your Medicare Part D or Medicare Advantage plan if the star rating drops. The Star Ratings are updated annually and released in the fall to assist consumers in deciding whether to re-enroll in their current plans or switch to another. This means that the rating will stay the same in the middle of your policy year.

When do I get notified of star updates If I have a Part D or Medicare Advantage plan?

The updates are typically released each autumn, but it’s not guaranteed that you’ll be notified. It’s up to the individual to keep track of their plan’s star ratings throughout the enrollment period. If you plan to renew your current plan, check its star rating.

The Bottom Line

There is a significant difference in coverage and expenses between Medicare Advantage Plans and Medicare Part D plans. Check the Medicare Star Rating System so you can get access to information that allows you to make sure you have the best Medicare plan for YOU. 

Need help? Call Health Plans in Oregon: 503-928-6918. Our assistance is at no cost to you