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What Is the Medicare Star Rating?



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The Medicare Star Rating System evaluates the performance of health insurance providers’ Medicare Advantage — also known as Medicare Part C — and Part D plans. Rated from one to five, with one being “poor” and five being “excellent,” the rating system ensures the quality of services insurance providers offer their clients while providing patients a way to evaluate and compare plans to find the best option for them.

The Star Ratings of participating insurance providers are annually reviewed and updated each fall through the Healthcare Effectiveness Data and Information Set (HEDIS). However, the Star Rating System is also graded against a curve each year, which adds an element of competition.

Furthermore, the measures used to evaluate any insurance plan’s Medicare Star Rating are not static. On the contrary, certain measures get retired while others are added depending on the events of each year and developments in medical care and technology. For example, COVID-19 has prompted various changes in the Medicare Star Rating System to ensure insurance providers respond well to the current health crisis and its ongoing effects.

What Measures Are Included in the Medicare Star Ratings?

The quality measures used to evaluate a plan’s Star Rating are different for Medicare Advantage and Part D. As mentioned, the total number of measures included varies from year to year. In 2021, there were 46 measures used for the Star Rating evaluation — 32 for Medicare Advantage and 14 for Medicare Part D. The measures for each plan are grouped into different subcategories. Moreover, numerous considerations go into the weighting and scoring of each measure.

The subcategories for the Medicare Advantage Plan include:

Staying Healthy (Screenings, Tests and Vaccines): This subcategory includes measures for the percentage of members who had their flu vaccine, underwent cancer screenings for breast and colorectal cancer and went through monitoring for physical activity and average body mass index (BMI).

Managing Chronic (Long Term) Conditions: The measures here include special needs plan (SNP) care management for members who require an assessment of their health needs and risks, care for older adults, which involves medication review, pain assessments and functional status assessments, osteoporosis management in women who have had a fracture, diabetes care and more.

Member Experience With the Health Plan: These include the rate at which members get the care they need, get appointments and care quickly, receive information from the health plan when they need it and more.

Member Complaints and Changes in Plan Performance: The three main measures here are member complaints about the health plan, members choosing to leave the health plan and improvements (if any) in the quality of the health plan’s performance.

Health Plan Customer Services: There are three measures here, including the timeliness of the plan’s appeal decisions, how fairly they review appeals and the availability of foreign language and teletypewriter (TTY) services.

For Part D, which only covers prescription drugs, the subcategories include:

Drug Plan Customer Service: The measures evaluating drug plan customer service mirror the ones for the Health Plan Customer Services subcategory for Medicare Advantage Plans.

Member Complaints and Changes in Plan Performance: These reflect the related subcategory for Medicare Advantage Plans.

Member Experience With the Drug Plan: These measures include members’ rating of the drug plan and the ease of refilling prescription drugs with the plan.

Drug Safety and Accuracy of Pricing: These include accurate drug pricing information on the plan’s website, medication adherence for diabetes medications, blood pressure medications and cholesterol medications, statin use in members with diabetes and the percentage of members enrolled in a Medication Therapy Management (MTM) program who have received a Comprehensive Medication Review (CMR).

How Can You Improve Your Rating?


Given the number of measures involved with evaluating a health plan’s performance and Medicare Star Rating, the first thing you can do to improve your rating is to become familiar with the details of each measure and how they contribute to the overall rating.

However, familiarizing yourself in such a way can be a tedious process, let alone developing a strategy to score well with each measure. With that in mind, it can be extraordinarily helpful to enlist the services of a healthcare consulting firm that can help you develop and execute a strategy for improving your rating.

At ProspHire, we use a phased, data-backed approach to partner with and help healthcare companies develop and execute their star performance improvement strategy. The outcomes we aim to establish include:

  • Assessing each measure and prioritizing those that are most pertinent or likely to affect your star rating and return on investment (ROI)
  • Analysis of ROI and intervention business cases
  • Designing a foundational and operational model that works for you
  • Developing a stars roadmap and implementation plan
  • Delivery plans and strategies for Part D
  • Planning for HEDIS seasons when ratings are reviewed and updated
  • Analyzing and predicting adjustments to the grading scale and developing risk mitigation plans
  • Helping you achieve your goals with a math- and data-backed approach

Read about one of our many success stories in a case study!

Why Would You Want to Improve Your Rating?

There are several reasons why you’d want to improve your Medicare Star Rating when you provide Medicare Advantage and Part D plans, not the least of which is the quality bonus payment (QBP) for high-ranking plans. The Medicare Star Rating system rewards high-ranking plans with three or more stars with annual bonus payments from the Centers for Medicare and Medicare Services (CMS). Note that plans with higher star ratings receive a bigger bonus, so stopping at three stars isn’t necessarily in your best interest, either.

While medical law requires plans to spend the annual bonus on extra benefits for members, the extra benefits increase the attractiveness of the plan to prospective members. This will help draw in more members to the plan, enable you to care for your members more effectively and ultimately increase your profit margin. In other words, improving your Medicare Star Rating is essential to maximizing your rebate potential.

In addition to increasing the attractiveness of your plan, the Medicare Star Rating is a tool for prospective members to compare your health plan against others. While the star rating is not the only relevant factor in comparing the fit of a certain plan for a prospective member, as network considerations, coverage details and premiums come into play, having a high star rating can give your health plan the upper edge on competitors with similar plan structure to yours.

Contact ProspHire to Maximize Your Medicare Star Rating

Both maintaining and improving your Medicare Star Rating is something that requires effort and innovation as the ratings renew and evolve each year. The healthcare management consultants at ProspHire have extensive industry knowledge on Medicare Star Rating trends and are continuously improving their insight to help health plans meet the needs of their clients and strengthen their Medicare Star Rating.

If you’d like to learn more about the Medicare Star Rating and how ProspHire can help you reach the next level, we’d love to hear from you. Let’s start the conversation about how ProspHire can take you where you want to go with your Medicare Star Rating! Fill out our form below.


Let’s have a conversation

Andrew Bell

Senior Manager