What is the Medicare Advantage and Medicare Part D Plan Star Rating System?

The Medicare Advantage Plan’s Star Rating System rates Medicare Advantage and Medicare Part D plans offered by private insurance companies. These plans have been approved by the Federal Government and are rated on a scale of One to Five stars. A Five Star Plan has demonstrated the highest quality of service. The Star Rating System is based on two different methods and the methodology used is based upon what the plan offers. First, a plan is rated based on its quality of service for medical services. This would include the Medical Advantage (also known as “MA Plans”) plans which offer medical coverage only. The plan is scored based on its overall quality of services for thirty-six different topics in five categories. With regard to Medicare Advantage Plans with a built in Prescription Drug Plan (also known as “MAPD Plans”), the plan is scored based on overall quality of services for seventeen different topics in four categories. Medicare Part D Drug Plans (also known as “PDP Plans”) are also scored.

How Medicare Advantage and Part D Plans are Scored on the Five Star System

The Five Star Rating System has actually been used for many years to assist in plan comparison and examine how the plan’s quality scores will interact with plan payments. By utilizing the Five Star Rating System a plan is encouraged to provide quality of care. The 2010 health reform law authorized Medicare to pay plans bonuses beginning in 2012 if they receive four or five stars based on Medicare’s review of the plan. The overall basis for the star rating to ensure quality of care and reward plans that earn a four or five star rating based on the scoring methods. The method in which a plan is rated is based on the type of plan offered. Specifically, a plan is rated on the overall quality of service for the medical services provided. However, if a plan offers prescription drug coverage, it is rated based on the quality of service with regard to the prescription drug coverage as well. This does not mean that a plan that offers a built in prescription drug plan, or a MAPD, automatically is given more stars, but ensures that the star rating assigned is based on overall quality of service for both the medical services and the prescription drug coverage parts of the plan. However, the Center for Medicare Services (also known as “CMS”) recently began allowing more plans to receive bonuses and increased the plans bonuses to further encourage the plan to maintain or improve their rating.

The five main topics and thirty-six subtopics for rating Medicare Advantage Plans which are reviewed and scored include the following:

Staying health

What screenings, tests and vaccines does the plan offer to the Medicare beneficiary? This includes how often members, or Medicare beneficiaries, utilized the screening tests, vaccines, and other check-ups that help them stay healthy offer by the plan.

Managing chronic or long term medical conditions

This part of the scoring process is based on how often members of the plan with chronic or long term medical conditions utilized the tests and treatmentoffered by the plan that help them manage their medical condition(s).

Rating of health plan responsiveness and care

This part of the Five Star Scoring System rates the plan based on member satisfaction, or dissatisfaction, with the plan.

Health plan member complaints and appeals

This part of the scoring process takes into consideration the number of member complaints and appeals. In other words, how often did members file a complaint against the plan? A complaint, or a grievance, is when a member is dissatisfied with actions of the plan, or customer service provided by the plan. An appeal is filed by a member when he or she disagrees with a decision regarding coverage of a treatment and requests reconsideration of the decision.

Health plan telephone customer service

This part of the scoring process scores the plan based on how well the plan handles calls from its members, regardless of the issue that initiated the member to call the plan. The plan is rated based on its overall responsiveness to a call from a plan member. The information regarding a plan’s customer service is obtained through member surveys performed by Medicare, information from clinicians, information submitted by the plans and results from Medicare’s regular monitoring of activities of the plan.

With regard to Medicare Advantage plans with a built in Prescription Drug Plan, or MAPD plans, the scoring system is based on four categories, which include seventeen subtopics. These plans are scored based on the following:

Drug plan customer service

The plan is scored based on how well the drug plan handles calls and makes decisions about member appeals. Again, appeals are filed when a member does not agree with the plan’s decision regarding coverage of a medical service and requests reconsideration of the decision.

 Drug plan member complaints and Medicare audit findings

This part of the scoring process is based on how often members filed a complaint about the drug plan and the findings by Medicare’s audit of the plan. In other words, did Medicare find evidence justifying the reasoning of the complaint filed by a member?

Member experience with Medicare Part D drug plan

This part of the scoring process is based on member information regarding satisfaction, or dissatisfaction, of the plain in which they are enrolled.

Drug pricing and patient safety

This part of the scoring process includes how well the drug plan prices prescriptions and how the often the plan provides updated information on the Medicare website. The plan is also scored based on how often members with certain medical conditions get prescription drugs that are considered safer and clinically recommended for their medical condition.

The Five Star Scoring System for MAPD plans includes review of all of the topics listed above, for an overall combined score based on medical care services in combination with the scores based on the review of the issues related to the plan’s prescription drug coverage that is built into the plan. The information used for scoring a MAPD is obtained from Medicare’s regular monitoring activities, review of bills and other information that plans submit to Medicare, as well as member surveys done by Medicare.