How Medicare Advantage Star Ratings Work: What the Stars Measure

Each fall, CMS posts star ratings for Medicare Advantage plans. A plan can earn 1 star. It can earn up to 5 stars. You see the stars next to the plan name in the Plan Compare tool on Medicare's site. That is the tool most people use to shop in open enrollment. The stars are hard to miss. They are also easy to read the wrong way.

A star rating tells you how a plan has run in the past. It does not promise how the plan will treat you. This guide shows what CMS counts. It shows where the score comes from. It also shows how to use the score with care. Let the score help you. Do not let it pick the plan for you. Our Medicare Advantage hub holds the rest of our guides. It also holds the plan data pages for this section.

What CMS measures

CMS builds the rating from a set of measures. The measures fall into groups. Most shoppers can follow them with ease.

CMS scores each measure on its own first. Each one gets its own star score. Then CMS blends the scores into one overall rating for the contract. The blend gives some measures more weight than others. So a plan can do well in one area. It can still land in the middle overall.

• Staying healthy. These measures check if members get screenings. They check vaccines too. They check tests that catch problems early.
• Care for long term conditions. These measures look at how well the plan helps members. They check blood pressure control. They check blood sugar control. They also check if members get follow-up care. That is the care their doctors order.
• Member experience. CMS asks members to take a survey. The survey asks how easy it was to get care. It asks how plan service felt. It asks members to rate the plan. It asks them to rate their care.
• Complaints and follow-through. CMS counts complaints about the plan. It checks if the plan fixed the problems. CMS also tracks how often members leave the plan.
• Drug measures, for plans with drug cover. These check drug safety. They check if drug list prices are right. They cover other drug checks too.

Ratings belong to contracts, not single plans

Most shoppers miss this part. One firm can sell many Medicare Advantage plans. The plans can span many counties. Yet they may all sit under one contract with CMS. CMS scores the star rating at the contract level. So two plans can share the same overall rating. They can have distinct names. They can have distinct premiums and networks. The shared contract is why the rating matches.

So the rating alone cannot pick your plan. It tells you how the contract has run as a whole. Your care still turns on plan level facts. Is your doctor in the network? What does the drug list hold? What will care cost in your county? Check those facts on the plan's own page. See the UnitedHealthcare page in our insurance section. Check Plan Compare too.

Why some plans show no stars

A contract can show no overall rating at all. This can happen when a contract is new. It can also happen when a contract serves too few members. Then CMS lacks firm data to score it. In the CMS plan files, the rating field says data is short. It does not say zero stars. The plan did not fail a test.

Treat a plan with no rating with care. Do not treat it with fear. You just have less proof of how it runs. Read its costs with extra care. Read its networks with extra care too. Then weigh how much the thin track record matters to you.

The timing problem in every rating

Star ratings rest on old data. By the time you see a rating, the data is one to two years old. The plan you join this fall earned its score in past years. It served other members then. Staff change over time. Networks change too. A plan can earn strong stars and then cut a key hospital. A plan can also fix its worst flaw. But the fix may come after the data window closed.

Open enrollment for next year's plans runs from October 15 to December 7 (ledger row B4). Use that window well. Check the rating and the plan facts side by side. Buy for the year ahead. The stars describe a past year, not that year.

Sample situation

Carol, 68, is picking a Medicare Advantage plan for next year. Two plans serve her county. Plan A shows 4.5 stars. Plan B shows 3.5 stars. Carol's first thought is to take Plan A and stop there.

Then she checks the details. Her heart doctor is in Plan B's network and out of Plan A's. Her two daily drugs sit on a lower tier in Plan B. Plan A's stars came from strong scores on screenings and member surveys across the whole contract, which spans three states.

Carol picks Plan B. The star gap told her Plan A's contract has run well. It did not tell her which plan fits her doctors and her drugs. She also calls Plan B's member line and asks two things: whether her drugs need prior approval, and which hospital near her home takes the plan. Both answers come back fine. She used the stars as one input, in their place, and let her own care needs lead.

How to check a plan's rating

• Go to the Plan Compare tool on Medicare's site. Type in your zip code.
• Find the plan. Read its overall star rating. It sits at the top of the listing.
• Open the rating detail if you want the measure groups. Look for weak spots in the areas you use most. Drug measures count a lot if you take daily drugs.
• Then check the plan level facts. Are your doctors in the plan? Are your drugs on its list? What will you pay?
• Are you torn between Medicare Advantage and a supplement plan? Read our guide to Plan G versus Plan N. It shows the other fork in the road.

Who pays for what

• Medicare: Medicare pays the private firm a set amount each month. The amount is for each member in a Medicare Advantage plan. The firm runs the plan under CMS rules and ratings.
• The plan firm: The firm pays for care the plan covers. It pays doctors and hospitals. It pays drug costs too. The money comes from Medicare funds plus member cost sharing.
• You: You pay the plan premium if the plan has one. You also pay copays and coinsurance when you use care. The plan's own terms set those costs.
• Medicaid: Some people qualify for both programs. For them, Medicaid can help with some Medicare costs. Rules differ by state.

Sources

• https://www.medicare.gov/plan-compare