When choosing a Medicare plan, you’re probably focused on costs and coverage—but there’s a crucial quality factor you might be overlooking. Plans rated below 3 stars could actually harm your healthcare experience, while 5-star plans unlock special enrollment opportunities most people don’t know about.
Key Takeaways
- CMS Star Ratings are a 1-5 star system that rates Medicare Advantage and Part D prescription drug plans based on quality and performance measures
- Medicare Advantage plans are evaluated on up to 40 measures across five categories including member experience, customer service, and chronic condition management
- Star ratings are updated annually each October and can unlock special enrollment opportunities for switching plans
- Plans with 3 or more stars indicate acceptable quality, while 5-star plans offer the highest level of performance and care
When choosing a Medicare plan, quality matters just as much as cost and coverage. The Centers for Medicare & Medicaid Services (CMS) created the Star Ratings system to help Medicare beneficiaries make informed decisions about their healthcare coverage by providing clear, easy-to-understand quality measurements.
CMS Star Ratings Are Medicare’s Quality Report Card
CMS Star Ratings function as Medicare’s official quality report card, rating both Medicare Advantage (Part C) and prescription drug (Part D) plans on a straightforward 1-5 star scale. A rating of 1 represents the lowest quality, while 5 stars indicates excellent performance. This system was designed to improve healthcare quality and accountability across the Medicare program.
The ratings focus on measurable outcomes that directly impact beneficiaries’ healthcare experiences. Rather than relying on marketing claims or promotional materials, the star system uses concrete data about customer satisfaction, clinical outcomes, and plan performance. Official Medicare resources provide detailed information to help beneficiaries understand these ratings and make informed coverage decisions.
Plans earning fewer than 3 stars are considered poor quality and may not provide the best healthcare options for beneficiaries. Beneficiaries enrolled in plans with fewer than 3 stars for three consecutive years have a special enrollment period to switch plans. In contrast, 5-star plans represent the gold standard, demonstrating consistently excellent performance across all measured categories.
How Medicare Advantage Plans Earn Their Stars
Medicare Advantage plans receive their overall star rating based on performance across five distinct categories, each containing multiple quality measures that reflect real-world healthcare experiences. Medicare Advantage Prescription Drug (MA-PD) contracts are rated on up to 40 measures, while MA-only contracts are rated on up to 30 measures.
1. Member Experience with the Health Plan
This category captures how satisfied members are with their overall plan experience. CMS surveys actual plan members about their healthcare experiences, including how easy it is to get care, communication with healthcare providers, and overall satisfaction with the plan’s services. These firsthand accounts provide valuable insights into the day-to-day reality of being enrolled in each plan.
2. Customer Service Performance
Customer service ratings evaluate how effectively plans handle member inquiries, complaints, and appeals. This includes response times, problem resolution rates, and the overall helpfulness of customer service representatives. Plans that consistently provide prompt, accurate, and courteous service earn higher ratings in this category.
3. Plan Performance and Problem Resolution
This category examines how often Medicare identifies problems with a plan and how frequently members encounter issues. It also tracks whether plans show improvement over time in addressing identified problems. Plans that proactively resolve issues and demonstrate continuous improvement receive better scores.
4. Managing Chronic Conditions
Plans are rated on how well they help members manage long-term health conditions like diabetes, heart disease, and hypertension. This includes ensuring members receive recommended tests, treatments, and follow-up care. Effective chronic disease management can significantly improve health outcomes and quality of life for Medicare beneficiaries.
5. Preventive Care and Staying Healthy
This category measures whether members receive important screening tests, vaccinations, and preventive check-ups. Plans that actively promote preventive care and make it easily accessible to members typically earn higher ratings. Preventive care helps catch health problems early when they’re most treatable.
How Part D Drug Plans Get Rated
Medicare Part D prescription drug plans undergo evaluation across four key categories, with each category containing specific measures that assess different aspects of drug coverage and service quality.
1. Member Experience with the Drug Plan
Similar to Medicare Advantage plans, Part D ratings include member surveys about their experiences with prescription drug coverage. This includes satisfaction with the plan’s formulary, ease of obtaining medications, and overall experience with drug benefits.
2. Customer Service for Drug Coverage
This category evaluates how well Part D plans handle member questions about drug coverage, prior authorization requests, and appeals for coverage decisions. Effective customer service is vital when members need help navigating complex drug coverage rules and procedures.
3. Plan Performance and Improvements
Part D plans are assessed on complaint rates, Medicare’s findings during plan oversight, and whether plans show improvement over time. Plans that maintain low complaint rates and address identified issues promptly receive better ratings.
4. Drug Safety and Pricing Accuracy
This category measures how accurately plans provide pricing information and whether they follow clinical guidelines for safe prescribing. Plans must ensure members with certain conditions receive appropriate medications while avoiding potentially harmful drug interactions.
Up to 12 Measures Total
Part D plans are evaluated on up to 12 specific measures across these four categories. While fewer than Medicare Advantage plans, these measures focus on the most critical aspects of prescription drug coverage that directly impact member health and satisfaction.
Finding and Using Star Ratings
Medicare beneficiaries can easily access current star ratings through official Medicare resources and use this information to compare plans during enrollment periods.
Using Medicare Plan Finder Tool
The Medicare Plan Finder tool on Medicare.gov displays star ratings for all available plans in a beneficiary’s area. Five-star plans are prominently marked with a special star icon, making it easy to identify the highest-quality options. The tool allows users to filter and sort plans by star rating alongside other important factors like cost and coverage.
Annual Updates Released Each October
CMS releases updated star ratings each October, reflecting the most recent data on plan performance. These ratings appear on the Medicare Plan Finder for the following year’s open enrollment and impact quality bonus payments for the year after that. New plans entering the Medicare market will not have ratings until they’ve operated long enough for CMS to collect sufficient performance data.
Special Enrollment Opportunities with Star Ratings
Star ratings unlock unique enrollment opportunities that allow beneficiaries to switch plans outside the standard enrollment periods, providing flexibility based on plan quality.
5-Star Plans: December 8 to November 30 Switch Window
The 5-Star Special Enrollment Period allows beneficiaries to switch to any available 5-star plan once per year between December 8 and November 30. This opportunity extends well beyond the standard Open Enrollment Period, giving beneficiaries access to the highest-quality plans when they become available.
Low-Rated Plan Exit: January 1 to December 31
Beneficiaries enrolled in plans with fewer than 3 stars for three consecutive years can use the Special Enrollment Period for Disenrollment to switch to higher-rated plans anytime between January 1 and December 31. This protection ensures members aren’t stuck with persistently poor-performing plans.
Why 3+ Stars Matter for Your Medicare Choice
The 3-star threshold represents more than just a numerical cutoff—it indicates whether a Medicare plan meets acceptable standards for quality and performance. Plans below this threshold consistently demonstrate problems with member satisfaction, customer service, or clinical care that could negatively impact beneficiaries’ healthcare experiences. Plans with 4 or more stars receive bonus payments from CMS, though a plan’s star rating should not be the only factor when making a final decision.
Choosing a plan with 3 or more stars helps ensure access to quality healthcare services, responsive customer support, and effective management of both routine and complex medical needs. While cost and coverage remain important factors, star ratings provide vital insight into whether a plan will deliver on its promises when beneficiaries need care most.
Plans with higher star ratings often demonstrate better coordination of care, more effective chronic disease management programs, and superior customer service—all factors that contribute to better health outcomes and member satisfaction. The rating system empowers beneficiaries to make informed decisions based on objective performance data rather than marketing claims alone.
Page content independently curated and maintained by David W. Bynon, Medicare Technical Operator, using a standardized, data-driven methodology designed for accurate, non-commercial Medicare plan interpretation and resolution.