READ ABOUT OTHER ASPECTS OF MEDICARE ADVANTAGE
Medicare uses a five-star rating system to inform the public about the quality of private Medicare Advantage plans and to provide the plans with financial incentives to perform well. The stars are based on more than 40 measures that track whether enrollees are receiving appropriate preventive care and how well their chronic diseases are controlled. The composite score, which is published on the Medicare Plan Finder website, also includes administrative measures, such as a plan’s timeliness in responding to appeals of coverage decisions, and enrollees’ plan ratings.
The star ratings play an outsized role in determining a plan’s future. Plans that fail to achieve three or more stars for three consecutive years can be terminated. The ratings also affect payment levels: plans with four or more stars can submit their bids to deliver Medicare benefits against a higher benchmark, typically 5 percent higher than projected local spending in the fee-for-service program. High-performing plans in urban counties where fee-for-service spending is low and Medicare Advantage enrollment is high do even better. They are eligible for a “double bonus” that can increase the benchmark by as much as 10 percent. In 2021, these quality bonuses reached $11.6 billion — accounting for more than 3 percent of federal payments to Medicare Advantage plans that year.
The star-rating system also affects the size of the rebates that plans receive when their bids fall below a county-level benchmark. Because rebates are used to subsidize premiums, reduce copayments and deductibles, or finance enhanced benefits (such as vision and dental), plans that get higher rebates enjoy a competitive advantage in attracting new enrollees.
Given the importance of the Medicare Advantage star-rating system, we asked experts to reflect on what is working well and which reforms may be needed.