All Medicare Advantage Plans (Part C) and stand alone Prescription Drug Plans (Part D) are rated on a scale from 1 to 5 stars. The rating is assigned by CMS, which is the Center for Medicare and Medicaid Services, the governing body of Medicare. The intent of the star rating is to help guide agents and Medicare Beneficiaries in choosing a plan based on higher quality services and accessible coverage in their area. However, what do the ratings really mean, and should it have a large impact on what plan you choose? Read on for a better understanding of the Medicare Star Rating.
Data Collection
The data used to determine a plan’s star rating comes from member surveys, provider surveys, CMS Contractor data and CMS Administrative data. Right away, we notice these terms are quite vague and broad. A concern would also be how accurate the ratings are if a large portion is based on member and provider surveys. How many times have you as a consumer ignored a survey offering? Also, it has been my experience that only people who have had a negative experience tend to fill out a survey, skewing results. One could also assume based on time constraints that there is even less of a chance of a provider (ie Doctor, Nurse, Therapist, Medical Equipment Supplier, Nursing Home Admin, etc.) completing a survey. Contractor data and administrative data do have finite numbers and statistics to pull from. This includes medical claims data, appeal records and resolutions, clinical outcomes and fiduciary compliance. Plans should be well represented in the star rating when you combine the qualitative information from surveys with the vast amount of quantitative information found in the administrative data.
The factors considered
Of all the data available from the sources listed above, CMS focuses on six overlapping categories to factor into the plan’s star rating. The six categories are as follows:
Staying Healthy – pertaining to only Part C or Advantage Plans. This includes annual mammogram usage, colorectal screenings, recommended vaccinations and other preventive offerings and screenings.
Managing Long Term Chronic Illness – this is again in relation to Advantage Plans. This would include how well the plan manages diabetes care, blood sugar control, osteoporosis management and other conditions.
Member Complaints and Plan Changes – this is for both Part C and Part D, prescription drug plans. CMS takes into account the number of complaints to the plan and how often members change or leave the plan.
Member Experience – this includes Advantage Plans and Part D plans. The member surveys are likely critical to this metric. CMS looks at customer satisfaction, speed of getting appointments with specialists and getting care.
Health Plan Customer Service – affects both Advantage Plans and Part D plans. This includes timely and fair appeal outcomes, availability of interpreter services and hearing impaired accommodations.
Drug Safety and Pricing – this metric only factors into the stand alone prescription drug plans or Part D plans. CMS reviews things like accurate drug costs and appropriate prescribing history for specific diagnoses.
the 5 star plan
Star Ratings are assigned each year, and the list is constantly changing. A 5 Star rating is a very rare occurrence where plans have achieved the highest status in their assessed quality measures. It is so rare that there is a special enrollment that beneficiaries can take advantage of in a market if a 5 Star plan exists. You can switch to that plan anytime from a lower-rated one instead of waiting for Open Enrollment in the fall.
should a star rating matter?
How much should a plan’s star rating affect your decision making? As a trained and licensed agent, I would honestly say, not much. Typically, agents start with a review of prescription drugs costs, formulary, network inclusion and medical cost share. We also look at ancillary benefits such as Dental, Vision and Hearing. These are items that affect Medicare Beneficiaries’ use of their plan every day. As for customer service, the fact that you use a local Independent Agent means you have an advocate who can help you navigate issues and be the ‘go-between’ to get answers from your plan. In this case, you don’t necessarily need to rely on the plan for customer service. However, there are some instances where two plans line up nearly equal in costs, benefits and network. This is where I may touch on the star rating to make that final call between the two options. So bottom line, it is good to understand the ratings, but it shouldn’t be the first or only metric you rely on in deciding on a best fit plan.
CDI is here to help you manage your healthcare costs and find the best options for your unique situation. We can meet in person or virtually. Reach out if you would like more information. Email carrie@cdi-cares.com or check out www.cdi-cares.com for a contact page and other helpful blogs.
Resources:
https://www.cms.gov/newsroom/fact-sheets/2025-medicare-advantage-and-part-d-star-ratings
