How to improve Medicare Star Ratings in 2025
Organizations are realizing the importance of these performance measures and can take concrete steps to raise their ratings.
The Medicare Star Ratings system measures the quality of health and drug services provided to consumers. These ratings — determined by factors such as member experience, preventive care and chronic disease management — influence reimbursements, enrollment and market reputation.
Despite their critical role, Star Ratings in the United States are declining, with only 40 percent of Medicare Advantage plans receiving four-star ratings in 2024, down from 42 percent in 2023. Health insurance companies prioritize quality improvement initiatives, member engagement and provider collaboration to meet performance benchmarks.
High ratings improve compliance, create competitive advantages, attract members and foster trust, positioning insurers for sustained growth in a value-driven market.
Why Star Ratings matter
Turning 65 grants senior citizens access to Medicare health plans, but choosing the right plan can be challenging because of varying individual needs and numerous plan options.
This is where Medicare Star Ratings help. The Centers for Medicare & Medicaid Services (CMS) assess Part D prescription drug plans and Medicare Advantage plans annually, rating them from one star (poor) to five stars (excellent) to improve the quality of care and accountability of physicians, hospitals and other providers. These ratings are available to enrollees via a Medicare Plan Comparing Tool to view and evaluate how local Advantage and Part D prescription plans measure up.
Medicare Advantage plans’ Star Ratings are based on five major categories.
Screenings, tests and vaccines. This is the percentage of eligible participants who get breast and colorectal cancer screenings and the yearly flu vaccine.
Managing chronic conditions. How well does the plan handle care for people with certain chronic conditions, such as osteoporosis, diabetes and heart disease? Healthcare providers may also monitor physical activity, review medications and perform pain assessments.
Member experience. Members rate their plan on the ease of booking appointments and seeing specialists, whether they receive care quickly and the quality of a plan’s services.
Member complaints and changes in a plan’s performance. This is the percentage of members who file grievances or leave a plan.
Customer service. This rating measures the timeliness of a plan’s decision about appeals, the fairness of those decisions based on an independent review and the availability of services in other languages or for deaf and hard-of-hearing people.
Medicare Part D (prescription drug) plans are rated based on the following four categories.
Member experience with the drug plan. This is based on members’ reviews of the Part D plan.
Customer service. This measurement assesses how well the plan manages member complaints and claim appeals.
Plan performance. This focuses on member complaints and plan changes. It includes how often Medicare found problems with the plan, how frequently members reported issues and how much the plan’s performance has improved (if at all) over time.
Drug safety and pricing. This category measures the accuracy of the plan’s pricing information and the frequency with which people with specific medical conditions are prescribed drugs in a safer and clinically recommended way.
The significance of Star Ratings
The Star Ratings system rewards higher-performing plans. Plans with four or more stars receive higher reimbursements and annual bonuses, which must be invested into member benefits, such as vision, hearing, or dental coverage.
Plans with fewer than four stars face reduced CMS payments, marketing restrictions during the special enrollment period, increased regulatory scrutiny, possible penalties and reputational damage. For instance, CVS Health’s Aetna National PPO plan dropped from 4.5 to 3.5 stars in 2023, resulting in a 40 percent drop in operating income in the second quarter of 2024, compared with the same quarter in 2023.
Strategies for improving Star Ratings
Insurers can improve Star Ratings and deliver superior outcomes that align with CMS’s vision of high-quality, equitable healthcare by focusing on the following.
Member engagement. Strengthening relationships with members is crucial for enhancing patient experience and Star Ratings. If a plan provides unsatisfactory care, members are more likely to choose another option during open enrollment. So how can plans do better? One way is to provide virtual telehealth visits so patients can access care more efficiently and remotely. Biochemistry Research International showed that 86 percent of patients found telehealth easy to understand, and the overall patient satisfaction with telehealth was 87.9 percent. Plans can offer user-friendly digital tools such as health portals, through which patients access health information and request medication refills. Also, developing and implementing case management programs provide personalized support to members with complex health needs to enhance care coordination, control costs and boost overall health outcomes.
Preventive care and chronic disease management. Encouraging and incentivizing providers to conduct annual wellness visits facilitate early detection of health risks and chronic conditions. Even simple patient-focused interventions can help providers manage chronic conditions and reduce hospital readmissions. One study documented a 55 percent decline in hospital readmission among patients who received automated check-in text messages from their primary care team.
Data analytics streamlining and integration. Data analytics help identify high-risk patient populations, facilitating targeted interventions and improved management of chronic conditions. For example, health plans can use analytics to identify members not receiving statin therapy for cardiovascular disease or those needing additional diabetes education and lifestyle management resources.
Medication adherence. Developing digital health programs helps members adhere to their medication and treatment plans and empowers them to understand their health and act to protect it. Through digital health programs, members can access tools to take measurements, submit updates to their care teams, and receive essential directions from their providers. Members can also track their progress while following step-by-step care plans, which their providers manage.
Customer service optimization. Analyzing customer service metrics, such as call center performance and responsiveness, can highlight areas to enhance member experience and satisfaction. Companies can invest in training programs, real-time feedback systems and advanced technologies like artificial intelligence chatbots to improve customer service ratings.
Insurers and providers will continue to collaborate as they seek innovative ways to improve patient health. One thing is for sure — a shift from fee-for-service to value-based care models is a necessary step toward rewarding providers based on patient outcomes and satisfaction. Providers and plans also will look at factors influencing health outcomes (social determinants of health), such as economic stability, education access and neighborhood conditions. Insurers and healthcare providers will receive better ratings when patients remain at the center of everything they do.
Mayur Chauhan is a systems analyst, senior advisor and Agile lead with more than 18 years of experience in IT, specializing in the U.S. healthcare domain. He has expertise in system analysis, solution design and tools like FACETS. He can be contacted on LinkedIn.