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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 36 different topics in 5 categories:
        • Staying healthy: screenings, tests, and vaccines: Includes whether members got various screening tests, a yearly flu shot, 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, problems getting services, and improvement in the health plan’s performance: Includes how often Medicare found problems with the plan and how often members filed complaints against the plan and choose to leave the plan.  Includes how much the plan’s performance has improved (if at all) over the last two years.
        • Health plan customer service: Includes how well the plan handles calls from members, makes decisions about member appeals for health coverage, and handles new enrollment requests in a timely way.
    • For plans covering drug services, the overall score for quality of those services covers 15 different topics in 4 categories:
        • Drug plan customer service: Includes how well the plan handles calls from members, makes decisions about member appeals for drug coverage, and handles new enrollment requests in a timely way.
        • Member complaints, problems getting services, and improvement in the drug plan’s performance: Includes how often Medicare found problems with the plan and how often members filed complaints against the plan and choose to leave the plan.  Includes how much the plan’s performance has improved (if at all) over the last two years.
        • Member experience with plan’s drug services: Includes ratings of member satisfaction with the plan.
        • Patient safety and accuracy of drug pricing: Includes how well the plan provides accurate pricing information for the Medicare website. Includes information on how often members with certain medical conditions get prescription drugs that are considered safer and clinically recommended for their condition. Includes information on whether members are taking certain medications as directed.
    • For plans covering both health and drug services, the overall score for quality of those services covers all of the 48 topics listed above.
Summary Rating of Prescription Drug Plan Quality
This summary rating gives an overall score on the drug plan’s quality and performance in 15 different topics in 4 categories:
    • Drug plan customer service: Includes how well the plan handles calls from members, makes decisions about member appeals for drug coverage, and handles new enrollment requests in a timely way.
    • Member complaints, problems getting services, and improvement in the drug plan’s performance: Includes how often Medicare found problems with the plan and how often members filed complaints against the plan and choose to leave the plan. Includes how much the plan’s performance has improved (if at all) over the last two years.   
    • Member experience with the plan’s drug services: Includes ratings of member satisfaction with the plan.
    • Patient safety and accuracy of drug pricing: Includes how well the plan provides accurate pricing information for the Medicare website. Includes information on how often members with certain medical conditions get prescription drugs that are considered safer and clinically recommended for their condition. Includes information on whether members are taking certain medications as directed.
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, or on results from Medicare’s regular monitoring activities.
 
Why is the summary rating important?
The summary rating makes it easy to compare drug plans based on quality and performance.  
In addition to using the summary rating:
    • You can look up the plan’s rating in each of the 4 categories that make up the summary rating.
    • You can also look up how well the plan is doing in the 18 different topics that make up the rating in those 4 categories.
Drug Plan Customer Service
This category shows how each plan performs in the following customer service areas:
    • How quickly and how well the plan handles appeals made by members. An appeal is a special kind of request you file if you disagree with a decision made by your plan about what prescriptions the plan will cover or how much it will pay. As an extra protection for members, sometimes an outside panel of experts (the independent reviewer) reviews the decisions made by plans. This category tells how quickly the plan handles appeals and whether the plan’s decisions are upheld by the independent reviewer.
    • How long pharmacists wait on hold when they call the plan’s pharmacy help desk.
    • How often TTY/TDD services and foreign language interpretation are available for members.  
    • Whether the plan handles new enrollments within 7 days.
Availability of TTY Services and Foreign Language Interpretation When Prospective Members Call the Drug Plan
Percent of the time that the TTY services and foreign language interpretation were available when needed by prospective members who called the drug plan’s prospective  enrollee customer service phone number.
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, Problems Getting Services, and Improvement in the Drug Plan’s Performance
This category shows how each plan performs in the following areas:
    • How many complaints, for every 1,000 members, Medicare got about the plan from its members.
    • How often members in each plan chose to leave the plan.
    • How many problems Medicare found when it has done audits and other types of reviews to check on how well the plan is following rules set by Medicare.
    • How much the plan’s performance has improved or declined from one year to the next year.
Complaints about the Drug Plan (more stars are better because it means fewer complaints)
How many complaints Medicare received about the drug plan.
Problems Medicare Found in Members’ Access to Services and in the Plan’s Performance (more stars are better because it means fewer serious problems)
To check on whether members are having problems getting access to services and to be sure that plans are following all of Medicare’s rules, Medicare conducts audits and other types of reviews. Medicare gives the plan a lower score (from 0 to 100) when it finds problems. The score combines how severe the problems were, how many there were, and how much they affect plan members directly. A higher score is better, as it means Medicare found fewer problems.
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 2012. (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 each plan performed in Medicare’s member satisfaction survey. It includes scores in the following areas:
    • How often the plan provides information or help when members need it.
    • How members rate the plan overall.
    • How often members could get prescriptions filled easily using 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.
Patient Safety and Accuracy of Drug Pricing
This category shows how each plan performs in the following drug price and safety areas:
    • Whether the plan provides accurate drug pricing information for this Web site (the Medicare Plan Finder Web site).
    • Whether members 65 and older are taking certain drugs with a high risk of side effects, when there may be safer drug choices.
    • Whether members with diabetes who also have high blood pressure are given a type of blood pressure medication that is recommended for people with diabetes.
    • Whether members are taking certain medications as directed.
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, or a DPP-IV inhibitor. 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 on the plan’s quality and performance on 36 different topics in 5 categories:
    • Staying healthy: screenings, tests, and vaccines. Includes whether members got various screening tests, a yearly flu shot, 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, problems getting services, and improvement in the health plan’s performance: Includes how often Medicare found problems with the plan and how often members filed complaints against the plan and choose to leave the plan. Includes how much the plan’s performance has improved (if at all) over the last two years.
    • Health plan customer service. Includes how well the plan handles calls from members, makes decisions about member appeals for health coverage, and handles new enrollment requests in a timely way.
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. It includes whether plan members get regular breast cancer screening with mammograms; regular screening for colon cancer and high cholesterol; a yearly flu shot; glaucoma testing. It also includes whether members get checked to see if they are at a healthy weight.
Breast Cancer Screening
Percent of female plan members aged 40-69 who had a mammogram during the past 2 years.
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.
Glaucoma Testing
Percent of senior plan members who got a glaucoma eye exam for early detection.
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.
 
If you have a chronic health condition such as diabetes, high blood pressure, or arthritis, this information may be especially important to you. It includes whether people with diabetes are getting certain types of 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).
Yearly Review of All Medications and Supplements Being Taken (Special Needs Plans only)
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 (Special Needs Plans only)
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 (Special Needs Plans only)
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 satisfaction survey. It includes 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 also includes 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, Problems Getting Services, and Improvement in the Health Plan's Performance
Are there problems at the plan? How much has the plan’s performance improved since last year?
 
This category shows how each plan performs in the following areas:
  • How many complaints, for every 1,000 members, Medicare got about the plan from its members.
  • How often members in each health plan chose to leave the plan.  
  • How many problems Medicare found when it has done audits and other types of reviews to check on how well the health plan is following rules set by Medicare.  
  • How much the health plan’s performance has improved or declined from one year to the next year.
Complaints about the Health Plan (more stars are better because it means fewer complaints)
How many complaints Medicare received about the health plan.
Problems Medicare Found in Members’ Access to Services and in the Plan’s Performance (more stars are better because it means fewer serious problems)
To check on whether members are having problems getting access to services and to be sure that plans are following all of Medicare’s rules, Medicare conducts audits and other types of reviews. Medicare gives the plan a lower score (from 0 to 100) when it finds problems. The score combines how severe the problems were, how many there were, and how much they affect plan members directly. A higher score is better, as it means Medicare found fewer problems.
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 2012. (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' calls and appeals and processing new enrollment request?
 
This category shows how each plan performs in the following customer service areas:
  • How quickly and how well the plan handles appeals made by members.  An appeal is a special kind of request you file if you disagree with a decision made by your plan about what care the plan will cover or how much it will pay.  As an extra protection for members, sometimes an outside panel of experts (the independent reviewer) is asked to review the decisions made by plans.  This category tells how quickly the plan handles appeals and whether the plan's decisions are upheld by the independent reviewer.
  • Whether the plan handles new enrollment requests within 7 days.
  • How often TTY/TDD services and foreign language interpretation are available for 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.)
Availability of TTY Services and Foreign Language Interpretation When Prospective Members Call the Health Plan
Percent of the time that the TTY services and foreign language interpretation were available when needed by prospective members who called the health plan’s prospective enrollee customer service phone number.