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Star Ratings

MEASURE DEFINITION
Overall Star Rating The Overall Star Rating combines scores for the types of services each plan offers: What is being measured? For plans covering health services, the overall score for quality of those services covers many different topics that fall into 5 categories:
  • Staying healthy: screenings, tests, and vaccines: Includes whether members got various screening tests, vaccines, and other check-ups that help them stay healthy.
  • Managing chronic (long-term) conditions: Includes how often members with different conditions got certain tests and treatments that help them manage their condition.
  • Member experience with the health plan: Includes ratings of member satisfaction with the plan.
  • Member complaints and changes in the health plan’s performance: Includes how often Medicare found problems with the plan and how often members had problems with the plan. Includes how much the plan’s performance has improved (if at all) over time.
  • Health plan customer service: Includes how well the plan handles member appeals.
    For plans covering drug services, the overall score for quality of those services covers many different topics that fall into 4 categories:
  • Drug plan customer service: Includes how well the plan handles member appeals.
  • Member complaints and changes in the drug plan’s performance: Includes how often Medicare found problems with the plan and how often members had problems with the plan. Includes how much the plan’s performance has improved (if at all) over time.
  • Member experience with plan’s drug services: Includes ratings of member satisfaction with the plan.
  • Drug safety and accuracy of drug pricing: Includes how accurate the plan’s pricing information is and how often members with certain medical conditions are prescribed drugs in a way that is safer and clinically recommended for their condition.
    For plans covering both health and drug services, the overall score for quality of those services covers all of the topics above.
Summary Rating of Prescription Drug Plan Quality This summary rating gives an overall score on the drug plan’s quality and performance in many different topics that fall into 4 categories:
  • Drug plan customer service: Includes how well the plan handles member appeals.
  • Member complaints and changes in the drug plan’s performance: Includes how often Medicare found problems with the plan, and how often members had problems with the plan. Includes how much the plan’s performance has improved (if at all) over time.
  • Member experience with the plan’s drug services: Includes ratings of member satisfaction with the plan.
  • Drug safety and accuracy of drug pricing: Includes how accurate the plan’s pricing information is and how often members with certain medical conditions are prescribed drugs in a way that is considered safer and clinically recommended for their condition.
  This information is gathered from several different sources. In some cases it is based on member surveys. In other cases, it is based on reviews of billing and other information that plans submit to Medicare results from Medicare’s regular monitoring activities.
Drug Plan Customer Service This category shows how each plan performs in customer service areas. For example, it shows how quickly and how well the plan handles appeals made by members.
Drug Plan Makes Timely Decisions about Appeals Percent of plan members who got a timely response when they made an appeal request to the drug plan about a decision to refuse payment or coverage.
Fairness of Drug Plan’s Appeal Decisions, Based on an Independent Reviewer This measure/rating shows how often an Independent Reviewer thought the drug plan’s decision to deny an appeal was fair. This includes appeals made by plan members and out-of-network providers. (This rating is not based on how often the plan denies appeals, but rather how fair the plan is when they do deny an appeal.)
Member Complaints and Changes in the Drug Plan’s Performance This category shows how often member have problems and how often they chose to leave the plan. It also shows how much a health plan’s performance has improved (if at all) over time.
Complaints about the Drug Plan (more stars are better because it means fewer complaints) How many complaints Medicare received about the drug plan.
Members Choosing to Leave the Plan (more stars are better because it means fewer members are choosing to leave the plan) The percent of plan members who chose to leave the plan in 2013. (This does not include members who did not choose to leave the plan, such as members who moved out of the service area.)
Improvement (if any) in the Drug Plan’s Performance This shows how much the drug plan’s performance has improved or declined from one year to the next year. To calculate the plan’s improvement rating, Medicare compares the plan’s previous scores to its current scores for all of the topics shown on this website. Then Medicare averages the results to give the plan its improvement rating.
  • If a plan receives 1 or 2 stars, it means, on average, the plan’s scores have declined (gotten worse).
  • If a plan receives 3 stars, it means, on average, the plan’s scores have stayed about the same.
  • If a plan receives 4 or 5 stars, it means, on average, the plan’s scores have improved.
Keep in mind that a plan that is already doing well in most areas may not show much improvement. It is also possible that a plan can start with low ratings, show a lot of improvement, and still not be performing very well.
Member Experience with the Drug Plan This category shows how well each plan performed in Medicare’s Member Experience Survey. This survey may include items such as members’ ratings about the ease of getting prescriptions filled, getting needed information from the plan, and members’ overall rating of the plan. When comparing plans on this topic, it’s better to look at and compare star ratings than to compare plans using the star details (the percentages, times, or other numbers for measures). The star ratings are better because they capture more statistical information while keeping it easy to make comparisons.
Members’ Rating of Drug Plan Percent of the best possible score the plan earned from members who rated the prescription drug plan.
Ease of Getting Prescriptions Filled When Using the Plan Percent of the best possible score the plan earned on how easy it is for members to get the prescription drugs they need using the plan.
Drug Safety and Accuracy of Drug Pricing This category shows how each plan performs in drug safety and the accuracy of their drug pricing. It includes how accurate the plan’s pricing information is and how often members with certain medical conditions are prescribed drugs in a way that is safer and clinically recommended for their condition.
Plan Provides Accurate Drug Pricing Information for This Website A score comparing the prices members actually pay for their drugs to the drug prices the plan provided for this Website (Medicare’s Plan Finder Website). (Higher scores are better because they mean the plan provided more accurate prices.)
Plan Members 65 and Older Who Received Prescriptions for Certain Drugs with a High Risk of Side Effects, When There May Be Safer Drug Choices The percent of plan members who got prescriptions for certain drugs with a high risk of serious side effects, when there may be safer drug choices.
Using the Kind of Blood Pressure Medication That Is Recommended for People with Diabetes When people with diabetes also have high blood pressure, there are certain types of blood pressure medication recommended. This tells what percent got one of the recommended types of blood pressure medicine.
Taking Diabetes Medication as Directed One of the most important ways you can manage your health is by taking your medication as directed. The plan, the doctor, and the member can work together to find ways to help the member take their medication as directed. Percent of plan members with a prescription for diabetes medication who fill their prescription often enough to cover 80% or more of the time they are supposed to be taking the medication. (“Diabetes medication” means a biguanide drug, a sulfonylurea drug, a thiazolidinedione drug, a DPP-IV inhibitor, an incretin mimetic drug, or a meglitinide drug. Plan members who take insulin are not included.)
Taking Blood Pressure Medication as Directed One of the most important ways you can manage your health is by taking your medication as directed. The plan, the doctor, and the member can work together to find ways to help the member take their medication as directed. Percent of plan members with a prescription for a blood pressure medication who fill their prescription often enough to cover 80% or more of the time they are supposed to be taking the medication. (“Blood pressure medication” means an ACE (angiotensin converting enzyme) inhibitor, an ARB (angiotensin receptor blocker), or a direct renin inhibitor drug.)
Taking Cholesterol Medication as Directed One of the most important ways you can manage your health is by taking your medication as directed. The plan, the doctor, and the member can work together to find ways to help the member take their medication as directed. Percent of plan members with a prescription for a cholesterol medication (a statin drug) who fill their prescription often enough to cover 80% or more of the time they are supposed to be taking the medication.
Summary Rating of Health Plan Quality This summary rating gives an overall score of the plan’s quality and performance on many different topics that fall into 5 categories:
  • Staying healthy: screenings, tests, and vaccines. Includes whether members got various screening tests, vaccines, and other check-ups that help them stay healthy.
  • Managing chronic (long-term) conditions. Includes how often members with different conditions got certain tests and treatments that help manage their condition.
  • Member experience with the health plan. Includes ratings of member satisfaction with the plan.
  • Member complaints and changes in the health plan’s performance: Includes how often Medicare found problems with the plan and how often members had problems with the plan. Includes how much the plan’s performance has improved (if at all) over time.
  • Health plan customer service. Includes how well the plan handles member appeals.
  This information is gathered from several different sources. In some cases it is based on member surveys, information from clinicians, or information from plans. In other cases, it is based on results from Medicare’s regular monitoring activities.
Staying Healthy: Screenings, Tests and Vaccines Does the plan do a good job detecting and preventing illness? This category addresses how well each plan works to detect and prevent illness, and improve or maintain the physical and mental health of its members. For example, it may include whether plan members get regular screenings for certain types of cancer or conditions and whether plan members get certain vaccines.
Colorectal Cancer Screening Percent of plan members aged 50-75 who had appropriate screening for colon cancer
Cholesterol Screening for Patients with Heart Disease Percent of plan members with heart disease who have had a test for “bad” (LDL) cholesterol within the past year.
Cholesterol Screening for Patients with Diabetes Percent of plan members with diabetes who have had a test for “bad” (LDL) cholesterol within the past year.
Annual Flu Vaccine Percent of plan members who got a vaccine (flu shot) prior to flu season.
Improving or Maintaining Physical Health Percent of all plan members whose physical health was the same or better than expected after two years.
Improving or Maintaining Mental Health Percent of all plan members whose mental health was the same or better than expected after two years.
Monitoring Physical Activity Percent of senior plan members who discussed exercise with their doctor and were advised to start, increase or maintain their physical activity during the year.
Checking to See if Members Are at a Healthy Weight Percent of plan members with an outpatient visit who had their “Body Mass Index” (BMI) calculated from their height and weight and recorded in their medical records.
Managing Chronic (Long Term) Conditions Does the plan do a good job caring for people who have long-lasting or chronic conditions? This category addresses how well each plan helps people with chronic or long lasting health conditions. It includes whether people with certain conditions, such as diabetes or high blood pressure, are getting recommended care. For example, it may include whether people with diabetes are getting recommended care, whether people with high blood pressure are able to maintain a healthy blood pressure, whether people with bone fractures are tested for brittle bones, and whether people with arthritis are taking drugs to manage their condition. It also has information about how often members are readmitted to the hospital (if this happens very often, it is a cause for concern). If you have a chronic health condition such as diabetes, high blood pressure, or arthritis, this information may be especially important to you.
Members Whose Plan Did an Assessment of Their Health Needs and Risks The percent of members whose plan did an assessment of their health needs and risks in the past year. The results of this review are used to help the member get the care they need. (Medicare collects this information only from Medicare Special Needs Plans. Medicare does not collect this information from other types of plans.)
Yearly Review of All Medications and Supplements Being Taken Percent of plan members whose doctor or clinical pharmacist has reviewed a list of everything they take (prescription and non-prescription drugs, vitamins, herbal remedies, other supplements) at least once a year. (This information about a yearly review of medications is collected for Medicare Special Needs Plans only. These plans are a type of Medicare Advantage Plan designed for certain types of people with Medicare. Some Special Needs Plans are for people with certain chronic diseases and conditions, some are for people who have both Medicare and Medicaid, and some are for people who live in an institution such as a nursing home.)
Yearly Assessment of How Well Plan Members Are Able to Do Activities of Daily Living Percent of plan members whose doctor has done a “functional status assessment” to see how well they are able to do “activities of daily living” (such as dressing, eating, and bathing). (This information about the yearly assessment is collected for Medicare Special Needs Plans only. These plans are a type of Medicare Advantage Plan designed for certain types of people with Medicare. Some Special Needs Plans are for people with certain chronic diseases and conditions, some are for people who have both Medicare and Medicaid, and some are for people who live in an institution such as a nursing home.)
Yearly Pain Screening or Pain Management Plan Percent of plan members who had a pain screening or pain management plan at least once during the year. (This information about pain screening or pain management is collected for Medicare Special Needs Plans only. These plans are a type of Medicare Advantage Plan designed for certain types of people with Medicare. Some Special Needs Plans are for people with certain chronic diseases and conditions, some are for people who have both Medicare and Medicaid, and some are for people who live in an institution such as a nursing home.)
Osteoporosis Management Percent of female plan members who broke a bone and got screening or treatment for osteoporosis within 6 months.
Eye Exam to Check for Damage from Diabetes Percent of plan members with diabetes who had an eye exam to check for damage from diabetes during the year.
Kidney Function Testing for Members with Diabetes Percent of plan members with diabetes who had a kidney function test during the year.
Plan Members with Diabetes whose Blood Sugar is Under Control Percent of plan members with diabetes who had an A-1-C lab test during the year that showed their average blood sugar is under control.
Plan Members with Diabetes whose Cholesterol Is Under Control Percent of plan members with diabetes who had a cholesterol test during the year that showed an acceptable level of “bad” (LDL) cholesterol.
Controlling Blood Pressure Percent of plan members with high blood pressure who got treatment and were able to maintain a healthy pressure.
Rheumatoid Arthritis Management Percent of plan members with Rheumatoid Arthritis who got one or more prescription(s) for an anti-rheumatic drug.
Improving Bladder Control Percent of plan members with a urine leakage problem who discussed the problem with their doctor and got treatment for it within 6 months.
Reducing the Risk of Falling Percent of plan members with a problem falling, walking or balancing who discussed it with their doctor and got treatment for it during the year.
Readmission to a Hospital within 30 Days of Being Discharged (more stars are better because it means fewer members are being readmitted) Percent of senior plan members discharged from a hospital stay who were readmitted to a hospital within 30 days, either for the same condition as their recent hospital stay or for a different reason. (Patients may have been readmitted back to the same hospital or to a different one. Rates of readmission take into account how sick patients were when they went into the hospital the first time. This “risk-adjustment” helps make the comparisons between plans fair and meaningful.)
Member Experience with Health Plan How do the plan’s members rate the plan?   This category shows how well each plan performed in Medicare’s member experience survey. This survey may include items such as members’ ratings about the ease of getting appointments and care, getting needed information from the plan, and the plan’s coordination of members’ health care services. It may also include members’ overall ratings of the plan.  When comparing plans on this topic, it’s better to look at and compare star ratings than to compare plans using the star details (the percentages, times, or other numbers for measures). The star ratings are better because they capture more statistical information while keeping it easy to make comparisons.
Ease of Getting Needed Care and Seeing Specialists Percent of the best possible score the plan earned on how easy it is for members to get needed care, including care from specialists.
Getting Appointments and Care Quickly Percent of the best possible score the plan earned on how quickly members get appointments and care.
Health Plan Provides Information or Help When Members Need It Percent of the best possible score the plan earned on how easy it is for members to get information and help from the plan when needed.
Member's Rating of Health Care Quality Percent of the best possible score the plan earned from members who rated the quality of the health care they received.
Member's Rating of Health Plan Percent of the best possible score the plan earned from members who rated the health plan.
Coordination of Members' Health Care Services Percent of the best possible score the plan earned on how well the plan coordinates members’ care. (This includes whether doctors had the records and information they need about members’ care and how quickly members got their test results.)
Member Complaints and Changes in the Health Plan's Performance Are there problems with the plan? How much has the plan’s performance improved over time? This category shows how often members have problems and how often they chose to leave the plan. It also shows how much a health plan’s performance has improved (if at all) over time.
Complaints about the Health Plan (more stars are better because it means fewer complaints) How many complaints Medicare received about the health plan.
Members Choosing to Leave the Plan (more stars are better because it means fewer members are choosing to leave the plan) The percent of plan members who chose to leave the plan in 2013. (This does not include members who did not choose to leave the plan, such as members who moved out of the service area.)
Improvement (if any) in the Health Plan’s Performance This shows how much the health plan’s performance has improved or declined from one year to the next year. To calculate the plan’s improvement rating, Medicare compares the plan’s previous scores to its current scores for all of the topics shown on this website. Then Medicare averages the results to give the plan its improvement rating.
  • If a plan receives 1 or 2 stars, it means, on average, the plan’s scores have declined (gotten worse).
  • If a plan receives 3 stars, it means, on average, the plan’s scores have stayed about the same.
  • If a plan receives 4 or 5 stars, it means, on average, the plan’s scores have improved.
Keep in mind that a plan that is already doing well in most areas may not show much improvement. It is also possible that a plan can start with low ratings, show a lot of improvement, and still not be performing very well.
Health Plan Customer Service Does the plan do a good job handling members' appeals and processing new enrollment requests? This category shows how each plan performs in customer service areas. For example, it shows how quickly and how well the plan handles appeals made by members.
Health Plan Makes Timely Decisions about Appeals Percent of plan members who got a timely response when they made an appeal request to the health plan about a decision to refuse payment or coverage.
Fairness of the Health Plan’s Appeal Decisions, Based on an Independent Reviewer This measure/rating shows how often an Independent Reviewer thought the health plan’s decision to deny an appeal was fair. This includes appeals made by plan members and out-of-network providers. (This rating is not based on how often the plan denies appeals, but rather how fair the plan is when they do deny an appeal.)