Healthcare Educators


What Do Medicare’s Star Ratings Mean

by | Nov 14, 2022

Every fall the Centers for Medicare and Medicaid Services (CMS) releases its Star Ratings for Medicare Advantage and Part D plans. This timeline coincides with Medicare’s Annual Open Enrollment period when you are making decisions about your healthcare coverage for the following year. But what do these ratings mean, and how should they factor into your decisions when choosing a plan? Here’s what you need to know.

What the 5-Star Rating System Means

CMS developed the 5-star rating system to help you compare plan options in your area, based on quality and performance. The 5-star rating system is used by CMS to monitor plans to ensure that they meet Medicare’s quality standards. They are updated every year. The higher the star rating the better the plan performed.

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

A strong star rating is good indicator of an insurance carrier with experience and stability. It shows the plan provides good customer service, has satisfied its members, is well managed and provides effective health care across a range of needs.

CMS rewards high performing plans with annual bonus payments. Plans use this extra revenue for additional benefits such as vision, dental and hearing. You are likely to find more of these benefits with higher rated plans.

A plan is considered below average if it is rated fewer than three stars for three consecutive years. CMS will flag these plans and alert its members to let them know their plan is performing below average. CMS can block new enrollees from joining a low performing plan until their ratings improve.

What the 5-Star Rating System Measures

CMS uses the same criteria for all plans to measure their quality and performance. There are more than 40 measures that fall into the following categories:

  • Staying Healthy- measures whether members had access to preventive services such as physicals, vaccines, and screenings
  • Managing Chronic Conditions- measures care coordination and services received by members with long term health conditions
  • Member Experience- rates plans on their overall member experience including satisfaction with their providers and access to care
  • Member Complaints- measures how frequently members submitted complaints, whether they had issues getting needed services, and how frequently members left the plan
  • Customer Service- rates plans on the quality of their call center experience, including providing accurate information, processing appeals and new enrollments in a timely manner
  • Drug Safety and Drug Pricing- this measurement is based on how accurate the plans drug pricing information is and how often drugs are prescribed in a way that is safe and is clinically recommended for specific conditions

5-Star Special Enrollment Period

Many people do not realize there are opportunities to change plans mid-year if you are enrolled in a low performing plan or your circumstances have changed, and you need to find a plan that better fits your needs. One of these opportunities is the 5-Star Special Enrollment Period (SEP). During this SEP from December 8 through November 30, you may switch plans once to a 5-Star Medicare Advantage, 5-Star Medicare Cost Plan, or 5-Star Medicare Prescription Drug Plan available in your area. You can use Medicare’s search tool to look for 5-star plans in your zip code.  Look for the 5-star special symbol, which is a yellow triangle with a white star that has the number 5 inside of it.

What Do Medicare’s Star Ratings Mean

There is More to Consider When Choosing a Plan

Star ratings should be just one of the factors you consider when looking for the right plan. Affordability and coverage are also important considerations. A 5-star plan is not necessarily more expensive since star ratings do not determine premiums. But a higher performing plan may not be the best choice for you if your doctors are not in the network, or if you will have higher out of pocket costs for frequently used benefits including your prescription drugs.

If you are just enrolling in a Medicare plan, or think you need to change plans, contact us today. Our experienced and knowledgeable team is here to help you review all your options.