Medicare Star Ratings Explained: What They Can and Can't Tell You

When you start comparing Medicare Advantage or Part D prescription drug plans, you'll notice that each one shows a number of stars. It's tempting to look at those stars and stop there. They're useful, but they only tell part of the story.

With the Annual Enrollment Period starting tomorrow, October 15, and running through December 7, here's a clear look at what star ratings are, how they're measured, and how to use them alongside the things that matter most to you here in Mooresville, Iredell County and around Lake Norman.

Every year, Medicare evaluates plans based on a 5-star rating system.

What Medicare star ratings are

Medicare rates Medicare Advantage plans and Part D drug plans on a scale of 1 to 5 stars. Five stars is rated "excellent," and one star is rated "poor." The ratings are updated each fall for the coming plan year, so the stars you see during enrollment apply to next year's plans.

You can see a plan's rating in the Medicare Plan Finder on Medicare.gov, and plans often include it in their materials.

What the stars measure

The ratings are built from many quality and performance measures. For plans that cover health care, the categories include:

• Staying healthy, such as screenings, tests and vaccines
• Managing chronic (long-term) conditions
• Member experience with the plan
• Member complaints and changes in the plan's performance
• Customer service

For drug coverage, Medicare also looks at drug plan customer service, member complaints, member experience, and drug safety and the accuracy of drug pricing. A plan that covers both health care and drugs gets an overall rating that reflects both sides.

In short, the stars try to answer a general question: how well has this plan performed for its members as a whole?

What the stars don't tell you

Here's the part that's easy to miss. A star rating is a measure of the plan overall, not a measure of how well it fits you. A highly rated plan may still be a poor match if:

• Your primary care doctor or a specialist you see in Huntersville or Charlotte isn't in its network
• One of your prescriptions isn't on its drug list, or sits on a costly tier
• Your pharmacy isn't in network, or isn't a preferred pharmacy
• Its copays, deductibles or out-of-pocket maximum don't fit your budget
• You travel or spend part of the year outside North Carolina, and its network is local

A plan with fewer stars could be a better fit for one person, and a plan with more stars could be a better fit for another. Your doctors, your medicines and how you use care should come first. Stars are a helpful tiebreaker and a good prompt for questions, not the whole decision.

The 5-star Special Enrollment Period

There's one way star ratings can open a door. If a plan with a 5-star overall rating is offered where you live, you can generally use a Special Enrollment Period to switch into it one time between December 8 and November 30. That means you aren't limited to the fall enrollment window if a 5-star plan becomes available in your area.

Not every area has a 5-star plan, and the plans that qualify can change from year to year. Rules may vary, so it's worth confirming your options before you make a change.

Plans with low ratings over time

Medicare.gov may flag plans that have received low ratings for several years in a row. If you're in one of those plans, you may be able to switch to a different plan outside the usual enrollment windows. You can call 1-800-MEDICARE to ask whether that applies to you.

If your current plan's rating dropped this year, that alone doesn't mean you need to leave it. It's a good reason to take a closer look at your Annual Notice of Change and compare your options.

How to use star ratings during enrollment

Here's a simple order that keeps the focus where it belongs:

1. Narrow your list to plans that include your doctors, hospitals and pharmacy.
2. Check that your prescriptions are covered, and at what cost.
3. Compare total yearly costs, not just the monthly premium.
4. Then look at star ratings to compare the plans still on your list.
5. If an extra benefit like dental, vision or hearing matters to you, read the details, since benefits vary by plan.

If you'd like a fuller checklist, see what to review before Medicare Annual Enrollment. If you're still deciding between the two main paths, Original Medicare vs. Medicare Advantage walks through how they differ.

Talk it through with a local broker

I'm Matt MacMillan, a licensed independent broker based in Mooresville. I can pull up the star ratings for the Medicare Advantage plans I represent in your area, and, more importantly, check your doctors and prescriptions against each one before you decide. There's no fee for my help, and you're never under any obligation. You can learn more on my Medicare page, the Iredell County Medicare Advantage guide or Medicare Advantage in Mooresville.

When you're ready, call me at (704) 802-2523 or request a call below, and we'll go through your options at your pace.

We do not offer every plan available in your area. Currently we represent 8 organizations which offer 1,210 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options. The MacMillan Agency is not connected with or endorsed by the U.S. government or the federal Medicare program. Plan availability, benefits and costs vary by county and plan.