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Medicare Insurance Comparison

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What is the Medicare Star Ratings System and How Does it Work?

Just the Essentials…

  • A Medicare plan’s star ranking is a measure of a plan’s overall quality, as determined by the government.

  • You may switch from your current Medicare plan to a 5-Star Medicare plan outside of the normal enrollment periods, but only once per coverage period.

  • While 5-star plans are usually preferable, your unique circumstances may make lower rated plans more appealing.

How well-rated is your health plan?

It’s tempting to ignore Medicare star ratings, especially with how meaningless the five-star scale seems to have become for most things. How often have you just been asked to rate something five stars, like an app, or a service? Medicare Advantage star ratings have to be similar… right?

Wrong. Unlike your average Amazon product or Uber driver, Medicare Advantage star ratings are determined by the Centers for Medicare and Medicaid Services (CMS), not the consumer. They also represent a much broader range of statistics instead of a vague customer satisfaction metric. These star ratings are like a report card, aggregating how well a given plan performs. They also have an enormous impact on how your plan operates, including how much you pay, and when you can enroll.

What are CMS star ratings?

five gold stars sitting near an Apple Keyboard

When you compare Medicare Advantage plans, whether you’re going through a licensed agent, using our free Medicare plan finder, or looking somewhere else entirely, you’ll see a five-star rating system associated with every Medicare Part C and Part D plan. Those ratings aren’t determined by the vendor, the insurance provider, or the customers. They come directly from the CMS, the government agency responsible for the Medicare program. Moreover, while they are helpful for choosing between different plans, they’re primarily meant for the providers themselves, as a way to push them to improve and reward them for providing excellent service.

CMS’s star rankings are determined by looking at various metrics, including preventive care, chronic illness management, customer service, and overall customer satisfaction. 

When these metrics are aggregated, a 1-5 star rating is issued to the plan, giving an idea of its overall quality.

⭐: A poor quality plan. The number of one-star plans has steadily dropped since the rating system was introduced.

⭐⭐: A below-average plan. 

⭐⭐⭐: An average, middle-of-the-road plan.

⭐⭐⭐⭐: An above-average plan. Plans of this level and above receive bonus funding from the CMS to encourage further improvement.

⭐⭐⭐⭐⭐: An exceptional plan: 5-star plans are eligible for Special Enrollment periods. 

 

Plans can have half-stars, but 4 and 5-star benefits only come into effect once a plan reaches the full-star rating. In addition, it is possible for a plan to have no star rating: this simply means the plan is new, and hasn’t generated enough data to be rated yet. 

Medicare Part D plans also have star ratings, but have a larger focus on drug accuracy and pricing. However, the core principles are the same.

So I should always go for 5-star plans, right?

Hand selecting the five star option from a floating checklist

Not necessarily. While these rankings take quality into account, it’s better to consider it similar to a hotel’s star rating rather than a product review.  

In the hotel business, the number of stars a hotel has refers to its various amenities: a 1-star hotel is a room with a bed, while a 5-star hotel contains luxuries like a concierge service and spa. That 5-star hotel is definitely nicer, but sometimes factors conspire to make it suboptimal. For instance, maybe you’re traveling with pets, and the luxury hotel doesn’t allow animals, but a 3-star hotel does. In that case, allowing pets is more valuable to you than having access to room service. 

Medicare plans work similarly. A star rating does not indicate the existence of any additional benefits. A plan can have five stars and provide identical services to Original Medicare. It would provide those services exceptionally well, but it wouldn’t provide the extra benefits you’d expect from a Medicare Advantage plan. 

When you compare Medicare Advantage plans, you must review the benefits. Don’t just blindly click on a plan because it has five stars! For instance, depending on your needs, you may want to choose a Special Needs Plan. This is common for residents of nursing homes and assisted living communities, which tend to offer Medicare Advantage plans tailored to their residents. 

While these plans may not have a 5-star rating, they may be the only plan your institution accepts. Even if they’re not, the convenience of having an I-SNP can outweigh the benefits of an extra star or two.

Of course, the hotel analogy starts to fall apart when we discuss price. Unlike a five-star hotel,  5-Star Medicare plans aren’t extravagantly expensive. They may be less expensive than lower-rated plans. This is because 4-star or higher plans receive additional funding from CMS to encourage high performance. This allows insurers to lower premiums and cost-sharing obligations to attract further enrollment. 

In short, you should typically go for a higher-rated plan, provided it falls within your budget and provides the benefits you need. 

What is a 5-Star Special Enrollment Period?

A Medicare Enrollment Form, with several $100 bills on it.

Because CMS wants high-quality care to be as accessible as possible, it allows for a Special Enrollment Period (SEP) when a 5-star plan is available in your area.

Ordinarily, there are only a few times you can enroll in a Medicare plan.

  • When you first become eligible, either due to age or a health condition
  • During Annual Enrollment from October 15 – December 7
  • During Open Enrollment from January 1 – March 31 (only if you are currently enrolled in a plan)
  • If you lose coverage, move, or experience another qualifying life event

The 5-Star SEP is an exception to this rule. If a 5-star plan is available in your area, you can switch from your current plan to the 5-star plan with no penalty at any time from December 8 – November 30, though you can only do so once per coverage period. This applies whether or not the plan is newly available or if it has already existed.

Be Aware: If your current plan includes Medicare Part D Prescription Drug coverage, you risk losing drug coverage and paying a Part D Late Enrollment penalty if you switch to a plan that lacks this benefit. To enroll in a standalone Medicare Part D plan during this SEP, it must also have a 5-star rating.

If you’re curious about 5-star plans in your area, we can help. Our licensed insurance agents can help you compare Medicare plans and answer any questions. Call us today at (800) 950-0608 or enter your zip code below to begin your search today!

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