5-Star Medicare Advantage Plans & Why Star Ratings Matter

There are several factors to consider when enrolling in a Medicare Advantage plan, such as provider network participation and a range of value-added benefits and services. In addition to network and coverage benefits, a Medicare Advantage plan’s Star rating is another aspect that should be taken into consideration when choosing a plan. 

Medicare Advantage and Part D prescription drug plans are graded on a scale of 1-5 stars, with 5 being excellent and 1 being poor. Unlike marketplace healthcare plans, which receive ratings solely from members, Medicare Advantage plans are evaluated annually by the Centers for Medicare and Medicaid Services (CMS). The Star rating system by CMS utilizes a mix of feedback from members, healthcare providers, and CMS staff who examine several different performance measures. While the Star rating isn’t the sole factor to consider when choosing a plan, it can be a good indicator of how well a plan is performing and the quality of the member experience that can be expected as an enrollee. 72% of Medicare Advantage beneficiaries with prescription drug coverage are enrolled in a plan that has a minimum of 4 Stars. 

This article outlines how Medicare Star ratings work and what separates a 5-Star Medicare Advantage plan from others that receive lower scores from CMS. 

What are Medicare Star Ratings?

When CMS evaluates Medicare plans, the rating is based on feedback from members as well as healthcare providers. Medicare updates every plan’s rating each Fall so that beneficiaries can take that score into consideration when selecting a plan for the following year. Rating criteria include the quality of care provided, responsiveness to members and healthcare providers, and overall member satisfaction. 

Plans that receive the 5-Star designation are given the opportunity to enroll new members outside of the formal annual enrollment periods (AEP & OEP) through the use of a Special Election Period – reserved only for the highest-rated plans. 

Beneficiaries can use the 5-Star Special Enrollment Period just once, between December 8th of the current year and November 30th of the following year, once a 5-Star Medicare Advantage plan becomes available in their area. 

What is a 5-Star Medicare Plan? 

CMS assigns Star ratings to 3 types of Medicare plans:

1) Medicare Advantage plans with prescription drug coverage (MA-PD)

2) Medicare Advantage plans without prescription drug coverage (MA-only)

3) Standalone Part D prescription drug plans (PDP)

CMS uses a number of different performance measures across several rating categories that are aggregated into an overall Star rating of 1-5 (including half-stars, such as 3.5 out of 5). MA-PD contracts are rated on 38 performance measures, MA-only on 28, and PDP on 12. 

To determine whether a plan has achieved a 5-Star rating, CMS examines quality and performance measures, such as: 

• How quickly members can get appointments and necessary care 
• Ease of care coordination
• Customer service
• How many members complain about the plan 
• Member retention 
• Member ratings of care quality 

Plans are also rated on their ability to adhere to clinical measures and guidelines designed to encourage healthy behaviors and utilization of preventive care, such as: 

• Comprehensive coverage of diabetes care
• Cancer screenings, namely breast and colorectal cancers
• Rheumatoid arthritis management
• Ability to get necessary prescription drugs
• Annual flu shots
• Medication adherence assistance for cholesterol and diabetes medications
• Monitoring physical activity

Benefits of a 5-Star Medicare Plan 

Medicare Advantage plans achieve a 5-Star rating by consistently helping their members find the right care at the right place and time. To do this, many plans establish care coordination programs that are designed to encourage members to stay healthy through the use of preventive care benefits covered by the plan. These programs also help to remove barriers to  care and prescription drugs.  

5-Star plans have also received top marks in customer service, which means they make it easier for members to get the information they need, receive fewer complaints, and offer a more consistently high level of customer satisfaction than lower-rated plans in their market. 

As mentioned earlier, because these plans offer the highest levels of quality and customer satisfaction, they are given the opportunity to enroll members year-round. This makes 5-Star plans an attractive option for beneficiaries who are unhappy with their current plan and are looking to switch plans outside of the Annual Enrollment Period. 

How to Find a 5-Star Medicare Plan 

Finding Medicare Advantage plans is very easy with numerous online resources, such as Medicare’s Plan Finder tool.

A licensed Medicare agent can also show you how to find and compare Medicare Advantage plans. Recommendations from friends and family are also a common place many people start, in addition to online communities and resources for Medicare beneficiaries. 

How Much Does a 5-Star Medicare Plan Cost? 

All Medicare Advantage plans have a range of costs associated with them, from premiums and deductibles, to member cost-share payments – and 5-Star plans are no different. Premiums for 5-Star plans can be as low as $0, and some plans offer more comprehensive benefits or have lower out-of-pocket costs than lower-rated plans. However, the availability and benefits offered by a plan can vary greatly, so it’s important to research the specific plans that are offered in your area. 

Myths of 5-Star Medicare Advantage Plans

One persistent myth about 5-Star Medicare Advantage plans is that they are only for beneficiaries that are in excellent health, and anyone with a pre-existing condition will not qualify for coverage. This is a false assumption. Medicare Advantage plans cannot deny anyone based on health status, and this includes 5-Star Medicare plans.  

Another myth is the notion that 5-Star plans automatically cost more than plans that receive a lower star rating. This is also false. 5-Star Medicare plans receive bonus dollars from CMS that they use to enhance their benefit offerings, which often results in lower costs and better benefits for their members. So, while the cost of a 5-Star plan varies by carrier and by service area, these plans frequently offer some of the best value in a given market. 

Baylor Scott & White Health Plan offers 5-Star rated HMO plans in North and Central Texas. Contact us today for more information on our 5-Star Medicare Advantage plans. A Baylor Scott & White licensed insurance agent is prepared to help review your coverage needs and find a plan that’s right for you.