Many people often mistake that all Medicare plans are the same. But it is not the case. To find the top high-performing coverage option, you need to check their Medicare star rating

Every year, the CMS gives ratings to each of the Medicare plans. For this purpose, they use a scale called the star rating system. CMS collects feedback from members and health care providers. It ensures the overall performance rate of Medicare health coverage. The ratings range from one to five stars. Where five is the highest, and one is the affordable, rating. 

Each year, only several plans get a 5-star rating in the country. However, CMS considers a plan with 4-star or more to be well-performing. 

On the other hand, if Medicare gives a plan fewer than 3-stars for three years straight, it is marked as low-performing. And if you are an enrollee of such a plan, then you can switch to a better-performing plan. 

  • Plans eligible for Medicare Star Rating: Medicare Advantage, Medicare Cost, and prescription drug plan
  • Plans not eligible for Medicare Star Rating: Medigap

On What Basis Does CMS Calculate the Medicare Star Ratings?

For plans that provide health coverage, such as Medicare Advantage and Medicare Cost, the ratings are calculated based on the following five factors: 

1. Staying Healthy:

How often do the health plan members undergo vaccinations, screenings, and physical tests? It ensures that the plan is keeping its members healthy through regular reminders and beneficial procedures.

2. Managing deep-rooted (chronic) conditions:

 How often do members get tests and treatments for long-term health problems? It ensures that members are taken care of carefully by identifying chronic health problems beforehand.

3. Member complaints & problems: 

How often do members find trouble with the plan and file complaints? It ensures that the health plan services improve over the gap a year.

4. Plan responsiveness & care: 

How members grade their healthcare experiences. It includes appointments with doctors and prescription drugs as well. 

5. Customer service:

 How often the plan provides foreign language interpretation. It also includes the timely enrollments of new coverage options and request processing services. 

As for the Medicare Drug plan (Part D), the rating is calculated based on the above factors. It includes the plan, responsiveness & care, member complaints & problems, and customer service of the drug plan. Along with the addition of: 

Safety of the patient and the drug pricing: 

How often do members get a dosage that is safe and accurate enough to cure their condition? It also measures how true the pricing of prescription drugs is.

For more detailed info on the Medicare Star Rating system, visit the official government Medicare website. Through their Medicare Plan Finder Tool, you can also search the Star Rating of a specific health plan. 

How Often Are CMS Ratings Updated?

Every year, during the fall season, CMS announces the Medicare Star Rating for the upcoming year. It means that in October 2021, the Star Ratings for 2022 will come out. These ratings are updated every year, so they may vary from each year. 

If you are an enrollee of Medicare, then you should review ratings every fall. And decide if you want to switch to a better-performing plan or not. 

Must-knows of the 5-star Special Enrollment Period

If you desire to switch to a 5-star rated Medicare plan, you can do so in the Medicare Special Enrollment Period (SEP).

  • This SEP starts from Dec. 7 of the year before the plan became 5-star rated till Nov. 30 of the next year.
  • You are allowed to only use this SEP service once within the given time limit. 
  • Enrollments made in Dec. come into effect in Jan. While, the enrollments requested from Jan. to Dec. are effective one month later. 

Have any Medicare questions? 

Do you have any Medicare-related questions? We are here to guide you through every matter so you can have a healthier life. Feel free to contact us.