Medicare Star Ratings help consumers compare healthcare plans.
Providers and plans receive an overall Star Rating based on several different measurements.
Five stars is the highest rating, while one is the lowest rating.
DeductiblesA deductible is an amount you pay out of pocket before your insurance company covers its portion of your medical bills. For example: If your deductible is $1,000, your insurance company will not cover any costs until you pay the first $1,000 yourself., premiumsA premium is a fee you pay to your insurance company for health plan coverage. This is usually a monthly cost., provider networksA provider network is a group of doctors, hospitals and other specialists who agree with an insurance company to treat its clients. It's usually less expensive for you to see a doctor within your provider network.–the details you need to consider each year when choosing your Medicare plan can be dizzying. To help, the Medicare Star Ratings can be a guiding light. GoHealth has put together an easy-to-follow guide to help make sense of it all.
Find a local Medicare plan that fits your needs
The purpose of the Medicare Star Ratings is to help consumers make educated decisions when purchasing their health insurance plans. The Centers for Medicare & Medicaid Services (CMS) assigns a star rating of 1 to 5 based on ratings across designated performance areas. More stars mean better performance.
CMS provides ratings in several vital areas for customers who are 65 and older, including:
The Medicare Star Ratings are essential for two main reasons:
They provide “apples-to-apples” comparisons
No matter which Star Rating you’re looking at, all plans and providers are judged against the same measurements. Ratings can be a big help when you’re looking to pick which hospital you should go to for a specific procedure.
They hold the healthcare providers accountable
By having their rating published publicly, providers must decide to improve low-performing areas or risk losing future customers. The Marketplace displays star ratings alongside vital details like each plans’ premiums and deductibles.
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CMS updates its Star Ratings at different times. Ratings for insurance plans are typically released each fall to line up with enrollment periods for Medicare, Medicare Advantage, Medicare Prescription Drug Plan (Part D), and standard health insurance. Changes are made based on feedback, provider recommendations and the data itself.
Some are updated even more regularly; CMS’ Nursing Home Compare tool reflects the latest nursing home ratings each month. [i] Others are updated less often — CMS’ hospital quality rating, Hospital Compare, is often refreshed only once per year. [i]
When using CMS Star Ratings, make sure to check how old the ratings are. If you have any doubt, ask your provider or carrier to see the latest ratings.
CMS Star Ratings always range from one to five stars, with five stars being the highest rating. Consider this as a guide:
- Five stars: Best
- Four stars: Above average
- Three stars: Average
- Two stars: Below average
- One star: Worst
To help consumers even more, CMS applies half-star ratings. A three-and-a-half star rating, for example, is higher than just three stars.
What extra benefits and savings do you qualify for?
Each Star Rating calculation is separate for the type of plan and coverage. For example, Star Ratings for health plans are different than those for hospitals.
Ratings are developed from feedback and outcomes CMS gathers throughout the year. To Illustrate, here’s an example of two fictional health plans:
Plan No. 1
- 4.5 stars: Screenings, vaccines and tests
- 4 stars: Long-term conditions
- 4 stars: Member familiarity with plan
- 5 stars: Member complaints/changes
- 5 stars: Customer Service
Overall: 4.5 stars
Plan No. 2
- 2 stars: Screenings, vaccines and tests
- 4 stars: Long-term conditions
- 2.5 stars: Member familiarity with plan
- 3.5 stars: Member complaints/changes
- 3 stars: Customer Service
Overall: 3 stars
The Medicare Star Ratings provide an in-depth analysis. The Overall Star Ratings above appear to be made up of five areas. In reality, each of those five areas is broken down even further.
For example, each plan’s “Screenings, vaccines and tests” Star Rating calculates ratings in specific areas such as Breast Cancer Screenings, Colorectal Cancer Screenings and flu shots.
Think of it like your school grade point average; you take tests and complete assignments (individual measurements) in different classes (areas). The grades you receive in those classes all feed into your GPA (overall Star Rating).
That means you may be able to find Star Ratings that are surprisingly useful for your specific need.
Have your own ratings
The CMS Star Ratings can be an invaluable tool when searching for insurance plans and providers. They shouldn’t, however, be your only resource when making decisions. When researching your choices, make sure you’re searching for the services and facilities you need, or may need in the future–seeing a provider’s rating in these specific areas may be more important to you than just the plan’s overall Star Rating.
Also, make sure to seek out other opinions. Several other organizations have ratings of their own, and some use different criteria. If you need personal help, GoHealth’s team of licensed insurance agents can break down your individual healthcare choices and their Star Ratings.
What is the 5-star special enrollment period?
If you’re enrolled in a Medicare Advantage plan, Part D plan, or both, you may be able to enroll in a five-star plan in your area–if your current plan is rated lower. Medicare allows a once-a-year special enrollment period for those that would like to switch to a five-star plan. This switch can only occur after Dec. 8 of the year you selected your plan, and before Nov. 30 of your plan year. [i]
Can I change my Medicare Part D or Medicare Advantage plan if the star rating drops?
Yes, you can. The Star Ratings are released each fall to help consumers as they decide whether to re-enroll in their existing plans or find another. Because Star Ratings for health plans are updated once a year, it won’t drop in the middle of your policy year.
When do I get notified of star updates If I have a Part D or Medicare Advantage plan?
These updates will be released each fall but you may not be notified–it’s up to the consumer to monitor their plan’s stars during the enrollment period. If you plan to simply re-enroll in your plan, be sure to check the star rating before you do.