How to use the Medicare Star Ratings System
The Centers for Medicare & Medicaid Services (CMS) created a Star Rating system to help beneficiaries and their families compare plan performance and quality for Medicare Advantage plans, Medicare Prescription Drug Plans, and Medicare Cost plans.
Comparing Medicare Advantage Plans and Medicare Part D drug plans means taking a look at prescription drug coverage, co-pays, and coinsurance costs, the plan’s network of doctors, and service area. But there’s another metric you should consider when making your decision: the plan’s star rating.
As with most rating systems, the Medicare star rating helps rank plans from best (5 stars) to worst (1 star). Again, the ratings are generated by the Centers for Medicare and Medicaid Services, or CMS. These ratings are based on the plan’s quality of care and measurements of customer satisfaction. You can find a plan’s rating with the Medicare Plan Finder medicare.gov.
This metric usually changes each year, as CMS reviews and updates ratings based on plan changes. Ratings are released in October unless plans are new to the marketplace (in which case, they won’t have ratings yet).
Medicare Advantage Plans
Medicare Advantage ratings are based on the following five categories:
- Staying healthy: Plans are rated on whether members had access to preventive services to keep them healthy. This includes physical examinations, vaccinations like flu shots, and preventive screenings.
- Chronic conditions management: Plans are rated for care coordination and how frequently members received services for long-term health conditions.
- Member experience: Plans are rated for overall satisfaction with the health plan.
- Member complaints: Plans are rated on how frequently members submitted complaints or left the plan, whether members had issues getting needed services, and whether plan performance improved from one year to the next.
- Customer service: Plans are rated for quality of call center services (including TTY and interpreter services) and processing appeals and new enrollments in a timely manner.
Medicare Part D prescription drug plans
Medicare Part D plan ratings are based on the following four categories:
- Member experience: How do members rate the plan?
- Plan performance: What is the complaint history of the plan, and has its performance gotten better or worse over time? Are members leaving the plan?
- Customer service: How well does the plan respond to member requests and appeals?
- Drug safety and pricing: How accurate is the plan’s pricing information? Are members with specific medical conditions prescribed drugs appropriately and safely?
Enrolling in a 5-star plan
You can enroll in a 5-star Medicare Advantage or Part D plan during the following enrollment periods:
Initial Enrollment period (when you’re new to Medicare — three months before you turn 65, the month you turn 65, and the three months after that month).
Open Enrollment period (Oct. 15 to Dec. 7 each year).
Medicare Advantage Open Enrollment period (Jan. 1 to March 31 each year, if you already have an MA plan).
Special Enrollment Periods are described below.
No matter what your current plan is rated, if you want to enroll in a 5-star Medicare Advantage or Part D plan, you can switch to one during a Special Enrollment period — which exists for just this purpose — from Dec. 8 to Nov. 30 of the following year. You may do this only once during this time, and it’s possible only if a 5-star plan is available in your area. (Not all areas have 5-star plans available.)
If you’re enrolled in a plan that’s been rated less than 3 stars for three years in a row, you’re allowed a one-time chance at any time to enroll in a better plan.
The overall rating gives a quick summary of a plan’s performance, but you can also look up how the plan scored for individual areas within the above main categories. For more information on the criteria, Medicare considers when rating its plans, visit Medicare.gov.
For questions about Medicare plans and other Medicare issues, contact Medicare at 1-800-MEDICARE (1-800-633-4227) or visit Medicare.gov.
For help choosing the plan that fits your needs the best contact an Ashford Insurance Agent or call our Hurst office at 817-952-3153.
