If you’re new to Medicare or want to purchase a private Medicare insurance plan, you’ve probably heard about Medicare’s star rating system.
This article will help you understand Medicare Star Ratings, how these scores are calculated, why they are essential, and how to use them to find a great plan in your area.
The Centers for Medicare and Medicaid Services (CMS) releases its Star Ratings in October each year.
The Medicare Star Rating System scores:
Health insurance companies that offer private Medicare plans
Medicare Advantage with prescription drug coverage
Star Ratings provide:
A simple measure of the quality of MA, MA-PD, and PDP plans.
A reflection of the experiences of Medicare beneficiaries on different insurance plans.
A way of comparing performance and services between Medicare plans and companies.
Meaningful information about private Medicare services alongside details about benefits and costs.
Original Medicare (Traditional Medicare) is health insurance run by the federal government that offers Part A (hospital insurance) and Part B (out-of-hospital medical insurance) cover.
Medicare Advantage (formerly called Medicare Part C) are private health care policies that offer the same coverage as Original Medicare. They also provide additional benefits, such as fitness perks and coverage for vision, dental, and hearing medical expenses.
There are three categories of private Medicare plans:
MA-PD (Medicare Advantage with Prescription Drug Cover) plans cover inpatient, outpatient, and prescription drug expenses. They also offer added health benefits and additional medical cover.
MA (Medicare Advantage only) plans cover Part A and B expenses, have added benefits, but do not offer cover for prescription drugs.
PDP (Medicare Prescription Drug Plans), also known as standalone Part D drug plans, covers expenses for self-administered prescribed drugs.
Medicare plans are rated on a scale of one to five stars, with each star representing the quality and level of service provided. Medicare plans and health care insurance companies can also receive half-stars.
There is also a number score between 1 and 5, which gives beneficiaries a more accurate look at a company or plan's performance.
Here’s what the different stars mean:
⭐: Poor Performance
⭐⭐: Below Average Performance
⭐⭐⭐: Average Performance
⭐⭐⭐⭐: Above Average Performance
⭐⭐⭐⭐⭐: Excellent Performance
For example, a plan can receive ⭐⭐⭐⭐ and have a score of 4.1 stars or receive ⭐⭐⭐ and have a score of 3.4 stars.
Star: A measure of the quality for health insurance companies and private Medicare (Part C and D) plan performance.
Score: The rated level of service and performance for health insurance companies and plans which is shown as a number — for example, a Star Rating Score of 4.3.
Summary Star Ratings: This is the score or rating for a specific Medicare Advantage or Part D plan.
Overall Star Rating: This is the rating that private health insurance companies get from the CMS.
For example, Medicare Advantage plans in Texas will get a summary star rating, while a health insurance company in Texas will get an overall star rating.
The star rating system looks at five categories when scoring Medicare providers and plans:
Outcomes: What are the improvements in Medicare plans beneficiaries’ physical health?
Intermediate outcomes: What actions have health care plans taken to assist in improving their beneficiaries health statuses?
Patient experience: What do beneficiaries think about the care they receive?
Access: What processes and issues can prevent a beneficiary from receiving care?
Processes: What health care services plans provide beneficiaries to assist with maintaining, monitoring, and improving their health?
But this is not how you’d see the information in the CMS annual report, which uses a complicated structure to evaluate plans and companies.
Their rating system looks at specific benefits, processes, and services (known as measures) and categories of measures (called domains).
A quality measure is a particular process, service, or area of focus, such as how well does the plan review appeals decisions or how easy it is for beneficiaries to get appointments and care quickly.
A domain is a group of quality measures, such as “Managing Chronic Conditions” and “Health Plan Customer Service.”
For example, “Managing Chronic Conditions” is a domain or category, and in this category, there are many measures.
Take a look at this example to understand how domains and measures work together.
Medicare Star Rating Scores are calculated based on the different measures in each domain
While it can be confusing, domains are a helpful way of looking at a company or plan’s strengths and weaknesses.
One person might want a plan with an excellent score for managing chronic conditions, while another might value how their provider deals with their complaints and concerns.
The Medicare Star Rating System’s domains can help you quickly understand what benefits a company or plan offers and if it meets your medical needs, preferences, and expectations.
For MA-Only plans (Medicare Advantage without Prescription Drug Cover), there are five domains.
For PDPs (Prescription Drug or Part D plans), there are four domains.
For MA-PDs (Medicare Advantage with Prescription Drug Cover), the CMS looks at both MA-Only Plans (five) and PDPs domains (four). All nine domains are considered.
MA Plans (Medicare Advantage without prescription drug coverage) are scored in five areas (domains), and MA-PD (Medicare Advantage with prescription drug coverage) health plans are scored in nine areas (domains).
Medicare uses data from:
Health care companies
Enrollees/members through surveys.
CMS Contractors (Companies paid by the CMS to look at performance and services).
CMS Administrative Data (Information that the CMS collects).
The CMS uses this data to calculate how these plans performed in the different measures and then gives each a score.
Scores for each measure are combined to get to a star rating for plans, companies, and the national average for all Medicare plans and companies.
For example, one measure of performance that the CMS uses is “Complaints about the plan.” The CMS will go through the number of complaints a plan gets (per 1,000 members) and determine how well the plan performed in that area.
Medicare Star Ratings give Medicare beneficiaries a view of how plans and companies have performed in the previous year.
They are especially helpful to someone who is new to Medicare or thinking about changing their Medicare Advantage plan.
Always check the Medicare Star Rating for plans and providers, as this will give you an idea of the services you can expect after you join.
If you need more advice or help, our team of licensed Medicare agents can assist you with finding the most highly rated plans and providers in your area.
5-star rated plans score very well in the Medicare Star Rating for a particular year. These are plans that offer their members excellent services and benefits.
You can visit the Medicare.gov website and search for your plan’s score. You will be able to see if your plan received five stars in the previous year by looking for this special icon:
In 2021, the star ratings for Medicare Advantage and PDPs increased, and 87 plans received a 5-star rating.
Overall, the CMS estimated that 42% of people are enrolled in a PDP plan rated 4 stars or higher and that 90% of MA-PD enrollees were members of plans that received a 4-star rating or more for 2022.
Here’s an overview of 5-star rating distributions for different types of plans in 2021.
|The Type of Plan||Number of Plans That Received a 5-Star Rating|
|Medicare Advantage with Prescription Drug Cover (MA-PDs)||74|
|Medicare Advantage without Prescription Drug Cover (MA-only Plans)||3|
|Prescription or Part D Drug Plans (PDPs)||10|
Members of any Medicare Advantage plan and Prescription Drug plan can change to a 5-star rated plan. If you want to move to a 5-star rated plan, you’ll be able to use your 5-Star Enrollment Period.
You can do this at any time in the year. However, if you are thinking about switching to a 5-Star Medicare plan, remember that:
You can only do this once each year.
The plan must be available in your area.
Star ratings change every year, which means a 5-star plan might get a lower score in the future.
If you’re considering switching to a five-star rated Medicare plan, speak with a licensed Medicare consultant to determine if you’re making the right choice.
CMS defines poor performance as a plan that receives an overall rating of three stars or less for three years.
If you are a member of a poor-performing plan, you will receive two notices.
These notices will tell you:
If you have received a notice like this or are unhappy with your current policy, you should consider switching to a different Medicare Advantage plan.
If you have any questions about changing Medicare Advantage plans, speak to an experienced consultant at PolicyScout to get one-on-one assistance.
If a plan doesn’t have a star rating, this doesn’t mean that it’s poor-performing.
In some cases, Medicare plans or health insurance companies will not receive a star score or rating because they are too new or have insufficient data to provide a reliable score.
For example, if a company has only offered a plan for 6 months, it can’t be fairly compared to a company that has been offering a plan for 12 months.
If you are thinking about joining a Medicare plan that doesn’t have a star rating, feel free to send us an email to Help@PolicyScout.com or call us on 1-888-912-2132 to speak with a Medicare consultant about benefits and options you should consider.
Location: Make sure that your preferred provider has plans in your area, and if they don’t find out which health insurance companies are available.
Price: Check your plan’s costs to see if you can pay the monthly premiums, deductibles, copayments, and coinsurance.
Experience: Look at the company’s number of members and how long they’ve been offering Medicare health insurance.
Coverage: Read through the benefits, terms, and conditions of coverage before signing on.
The Medicare Star Ratings System is a good way of understanding how Medicare providers and plans perform. However, you may want to do your research or look at different sources for information.
Here are some other ways of getting information about private Medicare plans and healthcare providers:
Talk to friends and family - Ask people who have Medicare which plan they have, and their experience.
Speak with a licensed Medicare agent to look at the benefits and costs associated with the plan you’re interested in.
If you’re interested in learning about Medicare costs, benefits, coverage, and penalties, PolicyScout’s Medicare hub is an excellent place to learn more about Medicare and health cover for over-65s.
You’ll also be able to learn more about Star Ratings by visiting the CMS website and downloading their annual fact sheet and technical data for ratings.