Four Key Facts About Medicare Star Ratings

Choosing the right Medicare plan is a critical decision – whether you are new to Medicare or are reevaluating current coverage. Navigating Medicare options can be challenging and sometimes having too many options can prove more difficult than helpful. Medicare costs and coverage are top considerations, but Medicare star ratings should also be factored in.

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.

Learn the four key facts about Medicare star ratings to help with choosing a Medicare Advantage or prescription drug Part D plan.

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

Important considerations when choosing a Medicare plan are cost and coverage. Star ratings can also provide additional points of comparison when choosing between plans with similar costs and coverage. Each plan has a rating for individual chronic conditions – the details of the rating can help identify the best plan. Each plan can also be rated to compare among the results based on the specific chronic condition selected. The comparison ratings reveal how well the plan manages the condition as well as details such as how easy it is to see a specialist. This information is available under the 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.

Overall ratings for Part D plan 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 each of these categories.

3. Using star ratings to select a Medicare plan can help ensure better coverage

Medicare star ratings assist beneficiaries in finding the best plan based on health care needs and financial situations. Enrollment in a Medicare plan that is less than 3 stars is considered poor quality and is likely not providing the most optimal health coverage.

If the Medicare plan has received less than 3 stars for three consecutive years, a notification will arrive through the mail during late October allowing for evaluation of the current plan and the opportunity to switch to a higher rated plan either during Open Enrollment, a Special Enrollment Period, or any time of year if switching to a 5-star plan.

4. There are four Enrollment Periods to join a star-rated Medicare plan

During the Initial Enrollment Period, star rated Medicare and Part D plans are available. These plans are also available during the annual Open Enrollment Period (Oct. 15 – Dec. 7). You can also enroll 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 Dec. 8 and Nov. 30, allowing a 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 Jan. 1 and Dec. 31. If enrolled in a plan that has received a rating from CMS of fewer than 3 stars for three straight years, this period can be used 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).

Note: Both Special Enrollment Periods remove prescription drug coverage if moving from a Medicare Advantage Plan that has drug coverage to a 5-star Medicare Advantage Plan that does not. Another change will not be allowed until the next Open Enrollment Period to get drug coverage and may require payment of a late enrollment penalty.