Ratings – JustCare

2025: Fewer Medicare Advantage plans get five stars

To encourage insurers to perform well and help people choose a Medicare Advantage plan, The Centers for Medicare and Medicaid Services (CMS), which administers Medicare, rates the performance of insurers offering Medicare Advantage plans through a five-star rating system. Based on this year’s star-ratings, Medicare Advantage plan performance is worsening. Susan Morse reports for HealthCare Finance that CMS gave five star ratings for just seven insurer Medicare Advantage contracts (1.79 percent of contracts), down from 38 in 2024.

The government’s star-rating system should help people appreciate the quality of different MA plans but it is largely a farce because it misleads people into believing that they can choose a high-quality plan. In truth, CMS does not have the data to distinguish among MA plans effectively. Its ratings are based on insufficient data that lumps together lots of different MA plans offered by an insurer under one government contract, even though the MA plans can have different networks and different rules and processes for covering care.

As it is, MA plans with five stars can have high rates of inappropriate delays and denials of care, particularly for people needing hospital, skilled nursing and rehab services, inadequate networks, and high mortality rates. The star-rating system won’t help people pick plans that meet their current and future needs.

CMS is working to improve its star-rating system. But, it doesn’t yet have enough complete, accurate and timely date from the Medicare Advantage insurers to deliver effective ratings. The insurers offering the plans don’t release the data that CMS would need or don’t release reliable data. As a result, at best, the star-rating system tells people which plans to avoid. Don’t consider enrolling in a plan that has three or fewer stars.

Here are the MA plans that got five stars: Alignment Health Plan; HealthSun Health Plans by Elevance Health; Highmark Blue Cross Blue Shield; Leon Health; MCS Advantage Classicare; Network Health Medicare Advantage Plans; and Optimum HealthCare by Elevance.

UnitedHealthcare, which covers the largest number of Medicare Advantage enrollees, lost its five star ratings this year and has sued the government. So has Humana, which in 2025 only has 25 percent of its enrollees in four or five-star plans, down from 94 percent in 2024.

CMS gave the Medicare Part D prescription drug plans even lower ratings, with only 40 percent of them receiving four or five stars. People should know that Part D insurers often charge higher copays for drugs on their formularies than the full cost of the drug through Costco or Mark Cuban, and they often don’t cover the drugs that your doctor prescribes.

Here’s more from Just Care:

October 14, 2024

McKinsey weighs in on how Medicare Advantage plans can maximize profits

In a new report, McKinsey offers insurers advice on how Medicare Advantage plans can maximize profits. McKinsey focuses on “star” power, keeping Medicare Advantage star ratings at four or higher, and paying more hospitals and physicians fixed rates rather than for each service performed. Make no mistake, this advice will help insurers, not Medicare Advantage enrollees.

The star-ratings in Medicare Advantage remain a farce for several reasons. Most important, the star-ratings do not capture high denial rates or high mortality rates, two indicia of poor performance and high risk for anyone joining a Medicare Advantage plan. The stars also do not capture basic metrics, such as network adequacy at the Medicare Advantage plan level, but only at the MA insurer contract level, which includes multiple plans. Consequently, a network could look very good at the contract level and deliver a high score to some Medicare Advantage plans, which have poor networks.

It’s easy for Medicare Advantage insurers to game the star-rating system. And, so long as they get a four or five-star rating, they get additional money from the federal government.

When insurers pay their network providers a fixed capitated rate rather than fee-for-service, as McKinsey recommends, it can lead to poor care for enrollees. Physicians have a powerful incentive to reject patients with complex conditions, because they cost the physicians too much money. Physicians also have a powerful incentive to not refer patients to costly specialists, because that too can cost them money.

We still have little clue of the health outcomes for people in Medicare Advantage plans who have complex and costly conditions; the data we do have is troubling. The data show higher disenrollment rates from Medicare Advantage and widespread inappropriate delays and denials of care.

McKinsey, health insurers, and many others use the Orwellian term “value-based” care to describe the capitated payment system. But, value is made up of quality and costs. And, Medicare Advantage plans have never shared the complete, accurate and timely data that would allow outside independent experts to assess their quality. Moreover, we know that Medicare Advantage plans’ costs to the Medicare program are significantly higher than Traditional Medicare’s.

Based on the overall quality unknowns of Medicare Advantage, the available data that too often shows delays and denials of care and its high cost, you could say that Medicare Advantage value-less care. Don’t tell us about your performance, Medicare Advantage plans, don’t hide your data, show us what you do, and outside independent experts will report on your performance.

Here’s more from Just Care:

August 20, 2024

Low-income communities are particularly at risk in Medicare Advantage

Insurers offering Medicare Advantage plans too often delay and deny care inappropriately. If you happen to live in a low-income community, you are more likely to be forced to join a Medicare Advantage plan that does not cover the care to which you are entitled under Medicare, according to a new analysis by Avni Gupta et al. published in JAMA. This analysis adds to the mountains of evidence that insurers are fostering health inequities among Black, Hispanic and other vulnerable Americans in Medicare Advantage.

To be clear, you should not assume that if you are a middle-class white American in a Medicare Advantage plan that you will get the care you need. Even Medicare Advantage plans with five-star ratings delay and deny care inappropriately. And, there is no way for you to know which ones do.

You are better off in traditional Medicare if you get sick and need costly and complex care. You can choose your physicians and you will get the care you need in a timely manner without bureaucratic hassle. But, you will need Medicare supplemental insurance or Medigap, to protect you from financial risk. With Medigap you will have few out-of-pocket costs, but it will cost you around $2,500 a year. While Medicare Advantage plans have an out-of-pocket cap, your out-of-pocket costs for in-network care alone can be as high as $8,850 this year, depending upon the Medicare Advantage plan you join. If you go out-of-network, your costs will be even higher.

But, if you live in a low-income community, you are more likely to have fewer choices of Medicare Advantage plans with five-star ratings. And, it is fair to assume that plans with one, two, three and four-star ratings should be avoided. If a plan is not able to earn a five-star rating, there’s likely something wrong with its performance.

Put differently, it is harder to enroll in a Medicare Advantage plan with a five-star rating if you live in a community with greater poverty and unemployment. As a result, you are likely to experience worse health outcomes. Specifically, you are more likely to receive poorer chronic care management and less likely to receive screenings and vaccinations. Customer service is more likely not to be good. And, if your Medicare Advantage plan inappropriately denies the care you need, it could be harder to challenge that denial.

Here’s more from Just Care:

July 30, 2024

Medicare will recalculate Medicare Advantage star ratings

Now two court cases in which insurers prevailed are leading the Centers for Medicare and Medicaid Services to raise star ratings for some Medicare Advantage plans, without data to show they’ve earned a higher rating. Both SCAN Health Plan and Elevance Health both won their legal challenges against the government’s reductions in their Medicare Advantage star ratings. So, the government is going to recalculate 2024 star ratings and only implement changes if the ratings increase, reports Anna Wilde Matthews for the Wall Street Journal.

Don’t trust the Medicare Advantage star ratings–or, for that matter, the Medicare skilled nursing home and hospital star ratings. They have never been reliable. And, now the Medicare Advantage star ratings will be even less reliable.

So, how do you choose a Medicare Advantage plan? There’s no meaningful way to make a choice. The best you can do is avoid plans that do not have 5 stars and pray that your 5-star Medicare Advantage plan will not force you to deal with excessive and unfounded prior authorization requirements or deny and delay your care inappropriately. There’s no way to know in advance.

To date, the star ratings for Medicare Advantage plans do not capture whether the plan forces people to wait long periods for approval of their treatments, makes them go through too many unnecessary hoops to get care or inappropriately denies them care. It also does not capture a Medicare Advantage plan’s mortality rates, even though, according to one study, the bottom five percent of worst performing MA plans are responsible for tens of thousands of unnecessary deaths each year.

Still, having a four or five-star rating results in Medicare Advantage plans getting additional payments from the government. These payments should reflect that the Medicare Advantage plans deliver quality care. But, they do not.

Instead, these bonus payments are given to plans that might be delivering poor care. And, they allow these plans the resources to enhance benefits and attract more members.

SCAN reports that the recalculation of its star rating will earn it an additional $250 million in 2025. Elevance will also see more money from the government. But, the ruling in its case only bears on one Elevance plan. Elevance claims it would have lost $310 million in bonus payments had it not won its lawsuit. Humana could have lost $150 million or so and UnitedHealth $70 million if CMS were not recalculating the star ratings

SCAN projects that the Centers for Medicare and Medicaid Services will end up paying out an additional $1 billion to insurers serving about one million enrollees, as a result of its lawsuit.

Here’s more from Just Care:

June 17, 2024

Scan Health plan wins suit against CMS on Medicare Advantage star ratings

If you’re shopping for a Medicare Advantage plan, you might look at the number of stars the government has given it. Any Medicare Advantage plan with fewer than four stars should be avoided. But, a plan with four or five stars might also not meet your needs.

The government awards four and five stars to Medicare Advantage plans with high denial rates and high mortality rates. Plans with excessive rates of prior authorization requirements can also get four or five stars. And, of course, you want to avoid those plans.

Because the Medicare Advantage star ratings are terribly misleading, the star-rating program needs an overhaul. But, the insurers have so much power that it might never happen. The Centers for Medicare and Medicaid Services (CMS) tried to adjust star ratings to better capture quality, and Scan Health Plan sued, claiming that it did so inappropriately. Emily Olsen reports for Healthcare Dive on Scan’s recent legal victory, preventing the government from giving it a 3.5 star-rating and reducing payments to Scan by $250 million.

Currently, CMS awards star-ratings based on enrollee complaint rates and hospital readmission rates, among other factors. Those plans with a four or five-star rating get tens of millions of dollars in additional funding from CMS. Moreover, even if an insurers’ score drops a lot, CMS can’t change the rating significantly from one year to the next.

Scan is not the only insurer to sue CMS over the star-rating calculations. Elevance also brought a lawsuit that a judge has yet to rule on. CMS has no comment.

The best thing about the star-rating system is that it requires CMS to drop contracts with plans that have a star rating of three stars or less for three years running. It’s a non-discretionary penalty. Politics can’t get in the way.

But, unless CMS can change the star-rating program significantly and include important data in the metrics, which it currently excludes, the star-rating program is of little value. In fact, it’s terribly misleading. People mistakenly believe that if they enroll in a Medicare Advantage plan with a four or five-star rating, they will get the care they need.

Here’s more from Just Care:

June 10, 2024

Sen. Warren and Rep. Jayapal urge CMS to end Medicare Advantage overpayments, punish bad actors

Ahead of the Centers for Medicare and Medicaid Services’ (CMS’) release of proposed payment policy for Medicare Advantage plans, Senator Elizabeth Warren and Representative Pramila Jayapal sent a letter to the Centers for Medicare and Medicaid Services detailing ways the administration could wipe out a projected $100 billion in overpayments to MA plans this year alone. Among other things, the letter proposes ending contracts with MA plans that violate their duty to cover Medicare benefits.

“It is imperative for [Medicare] to rein in these abuses and protect Medicare coverage for the seniors and people with disabilities who rely on it,” say Warren and Jayapal. Last month, Senator Warren wrote CMS to start collecting critical data needed to oversee the Medicare Advantage plans.

Thirty-one million older adults and people with disabilities are enrolled in Medicare Advantage plans. These health plans cost taxpayers $500 billion last year. But, substantial evidence indicates that the government overpays insurers offering these plans tens of billions of dollars each year; and, some, if not many, of these MA plans inappropriately deny and delay care to their enrollees, especially care for people with complex and costly conditions.

The Biden administration has taken some steps to end some of the overpayment abuses. But, many experts believe there’s a lot more to be done. Mark Miller, former director of the Medicare Payment Advisory Commission, says “If [the Centers for Medicare and Medicaid Services] backs down … then the beneficiary and taxpayer lose.”

CMS gave the insurers immunity from overpayments detected over seven years of audits. CMS now plans to conduct more auditing of MA plans’ billing processes. Warren and Jayapal are looking for payment policy changes as well as audits. For example, they want the government to adjust payments to MA plans because their enrollees are healthier than enrollees in Traditional Medicare.

The five-star quality rating system for MA plans also needs an overhaul. People cannot rely on the star-rating system as an indicator of whether an MA plan inappropriately denies care or has a narrow network that undermines their ability to get good care. Yet, the government pays insurers more for MA plans with a 4 or 5 star-rating.

Moreover, some data show that some MA plans provide their enrollees fewer benefits than they would get in Traditional Medicare, even though they are legally required to cover the same benefits. CMS has not penalized plans that inappropriately deny care. Warren and Jayapal want CMS to hold them accountable and end their contracts.

In some instances, UnitedHealth Group has denied rehab care to patients in critical need of rehab, based on computer algorithms, to the detriment of their enrollees’ health and well-being. Even though CMS said it may punish insurers who violate their contracts by wrongly denying care, it has yet to do so.

CMS has ended contracts with Centene Medicare Advantage plans in Arizona and North Carolina because their star-ratings were three or below for three years running.

Here’s more from Just Care:

January 31, 2024

Elevance Health sues to undo changes to Medicare Advantage star-rating system

For years, the Centers for Medicare and Medicare Services (CMS) has been giving additional money to Medicare Advantage plans that get four and five-star ratings. The goal was to promote quality, but the reality is that the five-star rating system is a farce and needs an overhaul. CMS has taken some steps to overhaul it but Jackob Emerson reports for Becker’s that Elevance Health is suing HHS for “unlawful, and arbitrary and capricious” methodology changes to how Medicare Advantage and Part D star ratings are calculated.

Don’t be misled by the government’s Medicare Advantage star-rating system. As of now, Medicare Advantage plans with four and five stars could have high denial rates, high mortality rates, endless prior authorization requirements and narrow networks that undermine access to care.

CMS uses 40 quality measures to rate Medicare Advantage plans, but these measures don’t give you a good clue as to whether a Medicare Advantage plan will actually cover the care you need, when you need it from physicians and hospitals you want to use.

CMS has gotten a bit stricter in giving out four and five-star ratings. And, Elevance says it is losing revenue because fewer of its Medicare Advantage plans are getting at least four stars.

For reasons that are unclear to me, CMS cannot change MA plan star-rating scores more than five percent from one year to the next. Somehow, Elevance claims that CMS did not abide by this restriction. Elevance therefore asks the court to require CMS to recalculate all scores for purposes of star-ratings for 2024.

Here’s more from Just Care:

January 9, 2024

Seven questions you should be asking this Medicare Open Enrollment period

During this Medicare Open Enrollment period, ask yourself these seven questions. And, please know that you can always call the Medicare Rights Center at 1-800-333-4114 or your SHIP (State Health Insurance assistance Program) for free, unbiased advice on any of your Medicare questions.

Q. What’s the biggest difference between traditional Medicare and a Medicare Advantage plan? To ensure you have good coverage for both current and unforeseeable health needs, you should enroll in traditional Medicare. In traditional Medicare, you and your doctor decide the care you need, with no prior approval. And, you have easy access to care from almost all doctors and hospitals in the United States with no incentive to stint on your care. In a Medicare Advantage plan, a corporate insurance company decides when you get care, often requiring you to get its approval first. Medicare Advantage plans also restrict access to physicians and too often second-guess your treating physicians, denying you needed care inappropriately. The less care the Medicare Advantage plan provides, the more the insurance company profits. You will pay more upfront in traditional Medicare if you don’t have Medicaid and need to buy supplemental coverage, but you are likely to spend a lot less out of pocket when you need costly care. Regardless of whether you stay in traditional Medicare or enroll in Medicare Advantage, you still need to pay your Part B premium.
Q. Should I trust an insurance agent’s advice about my Medicare options? No. Unfortunately, insurance agents are paid more to steer you away from traditional Medicare and into a Medicare Advantage plan, even if it does not meet your needs. While some insurance agents might be good, you can’t know whom to trust. Keep in mind that while Medicare Advantage plans tell you that they offer you extra benefits, you still need to pay your Part B premium, and extra benefits are often very limited and come with high out-of-pocket costs; be aware that many Medicare Advantage plans won’t cover as much necessary medical and hospital care as traditional Medicare. For free independent advice about your options, call the Medicare Rights Center at 1-800-333-4114 or a State Health Insurance Assistance Program (SHIP).
Q. Why can’t I rely on my friends or the government’s star-rating system to pick a good Medicare Advantage plan? Unlike traditional Medicare, which gives you easy access to the physicians and hospitals you use from everywhere in the US and allows for continuity of care, you can’t count on a Medicare Advantage plan to cover your care from the health care providers listed in their network or to cover the medically necessary care that traditional Medicare covers. Even if your friends say they are happy with their Medicare Advantage plan right now, they are gambling with their health care. The government’s five-star rating system does not consider that some Medicare Advantage plans engage in widespread inappropriate delays and denials of care, and other Medicare Advantage plans engage in different bad acts that can endanger your health. So, while you should never sign up for a Medicare Advantage plan with a one, two or three-star rating, Medicare Advantage plans with four and five-star ratings can have very high denial and delay rates.
Q. If I’m enrolled in a Medicare Advantage plan, can I count on seeing the physicians listed in the network and lower costs? Unfortunately, provider networks in Medicare Advantage plans can change at any time and your out-of-pocket costs can be as high as $8,300 this year for in-network care alone. You can study the MA plan literature, and you can know your total out-of-pocket costs for in-network care. But, you cannot know whether the MA plan will refuse to cover the care you need or delay needed care for an extended period. This year alone, dozens of health systems have canceled their Medicare Advantage contracts, further restricting access to care for their patients in MA, because MA plans make it hard for them to give people needed care.
Q. Doesn’t the government make sure that Medicare Advantage plans deliver the same benefits as traditional Medicare? No. The government cannot protect you from Medicare Advantage bad actors. The insurers offering Medicare Advantage plans can decide you don’t need care when you clearly do, and there’s no one stopping them; they are largely unaccountable for their bad acts. In the last few years there have been multiple government and independent reports on insurance company bad acts in Medicare Advantage plans.
Q. If I join a Medicare Advantage plan, can I disenroll and switch to traditional Medicare? You can switch to traditional Medicare each annual open enrollment period. However, depending upon your situation, where you live, your income, your age and more, you might not be able to get supplemental coverage to pick up your out-of-pocket costs and protect you from high costs. What’s worse, you could incur thousands of dollars in out-of-pocket costs in Medicare Advantage.
Q. If I have traditional Medicare and Medicaid, what should I do? If you have both Medicare and Medicaid, traditional Medicare covers virtually all your out-of-pocket costs. You will get much easier access to physicians and inpatient services in traditional Medicare than in a Medicare Advantage plan if you need costly health care services or have a complex condition.

For free independent advice about your options, call the Medicare Rights Center at 1-800-333-4114 or a State Health Insurance Assistance Program (SHIP).

Here’s more from Just Care:

November 9, 2023

Medicare Advantage plans have little reason to address people’s long-term health needs

Nearly half of all Medicare Advantage members leave their Medicare Advantage plans within five years of enrolling, according to a recent study by David Meyers et al. at the Brown University School of Public Health published in the JAMA Network. Most of them are locked out of traditional Medicare because they are unable to get supplemental coverage, so they switch to other Medicare Advantage plans. Because insurers offering Medicare Advantage plans know they are not likely to hold on to their members over the long-term, they have little reason to address people’s long-term health care needs.

The government pays Medicare Advantage (MA) plans a fixed rate per enrollee, regardless of the amount of money the MA plans spend on each enrollee. The thought is that these generous payments would lead the insurers offering MA plans to invest in the long-term heath and care outcomes of their members. But, the data suggests otherwise. The researchers suggest that their findings provide a strong reason for looking at long-term MA disenrollment rates when measuring MA performance as a means of helping to ensure MA plans do not disregard their members’ long-term health care needs.

Researchers studied 82 377 917 individuals enrolled in a Medicare Advantage plan any time from 2011 to 2020. Of those, overall, nearly half (48 percent) left their MA plan within five years of joining. One-third left their MA plan within three years of joining. Disenrollment rates varied substantially by Medicare Advantage plan.

These findings adds support to the case that Medicare Advantage plans are likely not invested in the long-term health and care management of their members, as hoped. Data on inappropriate denial rates in Medicare Advantage, particularly for people in hospital and people in need of post-hospital care also suggests that Medicare Advantage plans, as a whole, have little or no interest in ensuring the health and well-being of their members. Rather, the denial data suggests that once their members get sick and need costly care, the MA plans want them to leave.

The researchers at Brown have found that people enrolled in Medicare Advantage plans who have complex and costly needs disenroll from their plans at higher frequency than people who are in relatively good health. Now, these researchers find that, over time, half of people disenroll from their Medicare Advantage plans. The researchers did not study why, but there’s a compelling argument that these people disenrolled because they were dissatisfied with their plans.

The researchers further found that Black Medicare Advantage enrollees disenrolled from their Medicare Advantage plans at higher rates than enrollees of other races. Nearly 15 percent of them disenrolled from their Medicare Advantage plans within one year of enrolling.

Of note, a smaller portion of people enrolled in plans with five-star ratings disenrolled within five years as people enrolled in four- and three-star plans.

In sum, the researchers report three key findings from their work, in addition to their finding that 48.3 percent of people enrolled in Medicare Advantage plans who do not also have Medicaid left their Medicare Advantage plans within five years.

Black enrollees in Medicare Advantage left their Medicare Advantage plans at higher rates than people of other races.
Different Medicare Advantage plans had very different rates of disenrollment, though the researchers do not disclose which Medicare Advantage plans have the highest disenrollment rates over the five-year period. Disenrollment rates over one year did not correlate with disenrollment rates over five years.
Medicare Advantage plans with five stars had lower disenrollment rates than those with fewer stars.

The researchers conclude that Medicare Advantage plans “may financially benefit by increasing coding intensity in a short period while avoiding interventions to address chronic conditions in which potential benefits may take time to materialize and accrue to competing insurers.”

Here’s more from Just Care:

September 13, 2023

New study finds you can’t meaningfully choose among Medicare Advantage plans

You’ve probably heard me say this before, but I’ll say it again: The less corporate health insurers spend on your care, the more of your premium dollars they can keep. What’s worse is that states and the federal government generally do not begin to have the resources to protect Americans from health plans that inappropriately refuse to cover needed care. Not surprisingly, there’s a new report out from the Urban Institute finding that the federal government’s star-rating system for Medicare Advantage plans neither promotes quality nor helps people distinguish effectively among their Medicare health plans choices.

In other words, if you’re in a Medicare Advantage plan or thinking about enrolling in one, keep in mind that the insurance companies offering these plans have both a financial incentive to inappropriately delay and deny your care and the ability to do so with near impunity.

The Health and Humans Services’ Office of the Inspector General has now issued two reports finding that many Medicare Advantage plans engage in inappropriate delays and denials of care and coverage. The federal government, through the Centers for Medicare and Medicaid Services (CMS), is charged with overseeing these health plans and helping you make an informed choice among them. But, it is not disclosing important information you need to make an informed choice.

What should you do to avoid unnecessary delays and denials of care and coverage? If you can afford traditional Medicare, you should not face barriers to care or inappropriate delays and denials of coverage. There is no corporate health insurer coming between you and your doctors. But, if you don’t have Medicaid or supplemental retiree insurance to fill gaps in your Medicare coverage, you will need to buy “Medigap” supplemental coverage.

If you opt for a Medicare Advantage plan to save the cost of supplemental insurance, keep in mind that a health plan with a five star rating may inappropriately delay or deny your care. Here’s why, according to the Urban Institute’s latest report:

The rating system is based on an overall assessment of several Medicare Advantage plans an individual corporate health insurer offers. So, if one of those plans is terrible, it could still get a four or five-star rating if others of the plans are deemed to offer good care.
The Centers for Medicare and Medicaid Services (CMS) does not take account of certain deficiencies with Medicare Advantage plans in its star ratings, including rates of inappropriate delays and denials of care and coverage.
CMS inflates its scores, giving high star ratings too often.
CMS does not focus its star-rating measures on whether Medicare Advantage plans meet the needs of people with costly and complex conditions. Because health insurance is about protecting people from unforeseen health problems, this is a serious flaw.

Keep in mind that insurance should be about covering your unforeseen health care needs. if you get sick and need costly care, your out-of- pocket costs in a Medicare Advantage plan can be as high as $8,300 for in-network care, this year alone.

Advocates are working hard to get CMS to publish delay and denial rates of individual Medicare Advantage plans. Some plans, we are told, have problematically high denial rates. For sure, those health plans should be avoided and the government should have a duty to, at the very least, let you know about them, as well as to penalize them heavily. If Medicare Advantage plan are jeopardizing the health and well-being of their enrollees, the government should be canceling their contracts.

Here’s more from Just Care:

July 12, 2023

Tag: Ratings