5 things to know about Medicare Star Ratings

Medicare Star Ratings help you learn which plans perform best in areas you find important. The federal government (the Centers for Medicare and Medicaid Services, also known as CMS) gives an annual rating to Medicare Advantage and prescription drug plans (Part D), based on categories such as:

• Customer service
• Member complaints
• Quality of care

Each plan gets one to five stars, with five being the best and one being the worst.

Every plan is evaluated against the same set of criteria. So you have a good way of seeing how the plans available in your area compare to one another.

“A consumer can clearly and appropriately take that as a good objective measure of how one plan stacks up against another,” says Alan Roberts, vice president and head of Star Ratings for Aetna, who works to ensure Aetna delivers benefits, care and service to members in the best way possible. “The beauty of the program is that it takes the complicated health care delivery landscape and sets all of the health plans against the same standards, across a broad set of measures, and so ultimately it’s all very transparent.”

Whether you’re evaluating plans for yourself or a loved one, here are five facts to consider. 

1. Subcategory ratings matter, too

Plans receive an overall performance rating. They also receive ratings in a few subcategories. This helps you see if the plan performs well in a specific area that‘s important to you.

The “staying healthy” category includes whether members got their annual flu shot and reported improvements in their physical health over a two-year period. 

The “managing chronic conditions” category measures how well plans help members with long-term conditions such as diabetes, rheumatoid arthritis and high blood pressure. It’s calculated from a few data points.These include things like how often patients with diabetes receive recommended screenings and are able to see a specialist. Or if patients with rheumatoid arthritis were prescribed proper medications.

“Maybe you don’t have a lot of clinical conditions to manage, but health care is very confusing to you. Then for you, having a very high degree of service may be top of mind. But, for other individuals wrestling with multiple chronic conditions, understanding how the plan that they’d choose can help support them in their health may be of most interest,” Roberts adds.

2. Stars aren’t everything

Star Ratings are helpful. But keep in mind that health plans are not one-size-fits-all. “If you just went and looked at the plans available in your service area and decided solely on Star Ratings, you may end up with a plan that doesn’t fit your needs,” says Roberts.

A higher performing plan may not be a good match if:

• It doesn’t offer the right mix of doctors 
• Can’t be used if you travel out of state or
• Doesn’t offer your prescription drugs

3. The Star Ratings can help you decide

Once you’ve narrowed down your options, Roberts says the Star Ratings can be a “useful barometer” in deciding what plan to choose.

“Clearly if you’re deciding between a 4.5-star plan that has your doctors in-network and has your drugs, versus a similar 3-star plan, the Star Ratings can help make the final decision,” says Roberts.

4. High-performing plans get a bonus

The Star Ratings system rewards higher-performing plans. This means that those with three or more stars receive annual bonus payments from the CMS. The higher the rating, the higher the bonus.

Plans are required by law to spend this bonus money on extra benefits for members, such as vision, hearing or dental coverage. “Generally speaking, plans with a higher Star Rating, especially plans that are four stars or higher, are likely going to have more benefits than a lower-rated plan. So for the consumer, that means your out-of-pocket medical costs could be less in a highly rated plan.” 

5. Fall is ratings season