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The Importance of Medicare Star Ratings

Are

Medicare Star Ratings

Important

When You Buy Health Insurance?

Recently, I was looking for a local carpet cleaning company.

As most of us do, the first place I went was to Google to find carpet cleaning companies near me, but more importantly, I wanted to see what type of reviews these companies were receiving.

I decided to hire a company that had over 100 five-star reviews. And sure enough, they did a wonderful job at cleaning my carpets.

BACKGROUND TO STAR RATINGS

The Centers for Medicare & Medicaid Services (CMS) is a federal agency and is part of the Department of Health and Human Services (HHS).

Among other things, they administer the Medicare program, and they work with each state government to administer the Medicaid program as well. CMS works hard and continually analyzes our federal health care systems to find ways to improve them.

They monitor things like fraud and abuse and look for ways to provide better access to coverage and better health care for Americans.

In 2007, CMS began a Star Rating Program so that Medicare beneficiaries (you and me) would have the means to compare the performance of Medicare Advantage and Prescription Drug Plans.

The Star Rating Program uses a five-star quality rating system to provide quality and performance information to Medicare beneficiaries to assist them in choosing their health and drug services during the annual enrollment period (October 15 – December 7).

CMS has a Quality Strategy with a goal to optimize health outcomes by improving quality and transforming the health care programs they administer. The Star Ratings Program is a part of that strategy and reflects six priorities:

1Safety

2Person and Caregiver-centered experience and outcomes

3Care coordination

4Clinical care

5Population/community health

6Efficiency and cost reduction

Start Rating Program Priorities

According to the CMS Medicare 2020 Part C & D Star Ratings Technical Notes (October 2019), Star Ratings include measures applying to five categories:

1Outcomes

This reflects improvements in a beneficiary’s health and are central to assessing the quality of care. In other words, how well did a beneficiary respond to the diagnosis and care provided by the plan? Did their health improve, stay the same, or worse?

2Intermediate outcomes

This reflects actions taken which can assist in improving a beneficiary’s health status. For example, for a diabetic, Blood Sugar Controlled is an example of an intermediate outcome.

3Patient experience

This reflects the beneficiaries’ perspectives of the care they received. Pay attention to surveys you receive from your health plan and participate in them.

4Access

This measure reflects processes and issues that could create barriers to receiving needed care. or example, if an appeal is filed, how well does the plan react to the claim and solve an issue.

5Process

Process measures capture the health care services provided to beneficiaries which can assist in maintaining, monitoring, or improving their health status.

HOW TO UNDERSTAND STAR RATINGS

The Medicare Program rates all health and prescription drug plans each year, based on a plan’s quality and performance. Medicare Star Ratings help you know how good a job each plan is doing. You can use these Star Ratings to compare each plan’s performance to other plans. The two main types of Star Ratings are:

1An Overall Star Rating that combines all the plan’s scores.

2Summary Star Rating that focuses on the medical or the prescription drug services.

Some of the areas Medicare review for these ratings include:

  • How the members in the plan rate the plan’s services and care.
  • How well the doctors in the plan detect illnesses and keep members healthy.
  • How well the plan helps its members use recommended and safe prescription medications.

Each Medicare Advantage and Prescription Drug Plan will be assigned an Overall Star Rating from Medicare. In addition, each plan will be assigned a Summary Star Rating for the health/drug plan services if applicable.

You can find Medicare Star Ratings on Medicare’s website, the plan’s website, and in the enrollment materials provided by the plans.

NumericGraphicDescription
5    Excellent
4   Above Average
3  Average
2 Below Average
1 Poor

In 2020, there are only 23 plans nationwide with a high performing indicator indicating that they earned 5 stars. 21 of them are Medicare Advantage plans, and two are Prescription Drug plans. And approximately 52 percent of Medicare Advantage plans (210 contracts) that are offered in 2020 earned 4 stars or higher for their 2020 overall rating.

CONCLUSION

As you consider Medicare Advantage and Prescription Drug plans, it’s important to evaluate a few different points:

1Do your doctors accept the plan?

2Are all your medications in the plan’s formulary?

3How much is the monthly plan premium and co-pays?

4What are the Star Ratings?

Insurance Professionals of Arizona

Finding a 4-star or higher plan should be easy in most large metropolitan areas. But always talk with a trusted Medicare broker that understands doctor networks and the details of these plans to make sure you are getting a good understanding of how well these plans perform. A good broker will be able to share stories about their clients’ experiences with these plans.

And if you’re lucky enough to live in an area with a 5-star plan, you have an opportunity to enroll in that 5-star plan throughout the year without having to wait for Annual Enrollment. Contact your local broker for assistance.

We’re here to help! Call us today.

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Insurance Professionals of Arizona