Understanding the Medicare Star Ratings System in 2026

What determines a plan’s rating, what higher or lower stars actually mean, and how to use the system when comparing coverage.

Prepared by Mark Garrett, AJ Health and Wealth — serving Pace, Milton, Pensacola, Jay, Gulf Breeze, and surrounding Northwest Florida communities.

Introduction

Browse Medicare Advantage or Part D plans and you’ll see a rating from one to five stars next to each one. It’s tempting to read that as a simple scoreboard — more stars, better plan. That’s often true, but the Star Ratings system is measuring far more than most people realize: preventive care, chronic-condition management, prescription safety, customer service, complaints, and appeals all feed into a single number.

For Medicare beneficiaries across Pace, Milton, Pensacola, and the rest of Northwest Florida, understanding what’s actually behind that rating makes plan comparisons easier — and helps you avoid a common mistake: assuming the highest-rated plan is automatically the right plan for you. Your doctors, prescriptions, hospitals, and out-of-pocket costs still matter just as much.

What Is the Medicare Star Ratings System?

Each year, the Centers for Medicare & Medicaid Services (CMS) publishes Star Ratings for Medicare Advantage and Part D plans so consumers can compare quality and performance. The system applies to:

• Medicare Advantage plans without drug coverage
• Medicare Advantage Prescription Drug (MA-PD) plans
• Standalone Part D prescription drug plans
• Certain Medicare Cost and Private Fee-for-Service plans

Original Medicare isn’t rated this way, and Medicare Supplement plans don’t receive CMS Star Ratings at all — they offer standardized benefits rather than actively managing your care.

One detail that trips people up: CMS assigns ratings at the insurance contract level, not the plan level. Several plans from the same carrier can share one CMS contract — and therefore one Star Rating. That rating can reflect the combined performance of multiple plans and service areas, not necessarily your exact local plan.

What Does Each Star Rating Mean?

CMS can also assign half-star increments — so on Medicare Plan Finder you’ll often see plans listed as 3.5, 4, or 4.5 stars rather than a clean whole number.

How Many Measurements Go Into a Star Rating?

For 2026, MA-PD plans are evaluated on as many as 43 individual quality and performance measures. Medicare Advantage plans without drug coverage may be rated on up to 33 measures, and standalone Part D plans on up to 12.

Those measures roll up through several layers:

• Individual measures — a score for each applicable quality or performance measure
• Domains — related measures grouped into categories like preventive care, chronic-condition management, member experience, complaints, and drug safety
• Part C and Part D summary ratings — health-plan measures produce a Part C rating; drug measures produce a Part D rating
• Overall rating — an MA-PD plan combines its applicable Part C and Part D scores

Not every measure counts equally. CMS assigns weights based on how important a given measure is considered — and for 2026, that weighting shifted meaningfully. CMS cut the weight given to patient-experience, complaint, and access-related measures from 4x down to 2x, while outcome and improvement measures kept more influence. CMS also added a new kidney health evaluation measure for members with diabetes, and reintroduced measures tracking physical and mental health.

The practical effect: a plan’s overall rating is not a simple average of every score. It’s a weighted calculation that, for 2026, leans more heavily on clinical outcomes than on member-reported experience.

Where Does Medicare Get the Information?

CMS doesn’t rely on one survey. Ratings are built from multiple data sources, including:

• Healthcare claims and medical records
• Prescription drug claims
• Plan-reported information
• Member complaints submitted to Medicare
• Appeals and coverage decisions
• Member disenrollment data
• Call-center testing
• HEDIS clinical performance data
• CAHPS member experience surveys

Together, these sources let CMS look at both clinical performance (did eligible members get cancer screenings or appropriate diabetes care?) and member experience (could they get appointments quickly, did they feel satisfied with their plan?).

Ratings Are Based Largely on Past Performance

One detail consumers often miss: the year on a Star Rating isn’t the year the underlying care happened. CMS needs time to collect and validate data, so the 2026 ratings largely reflect earlier measurement periods — think of them as a report card on recent history, not a live guarantee of what you’ll experience in 2026.

Ratings shift year to year for a mix of reasons: performance genuinely changed, CMS adjusted its measures or scoring thresholds, or competing contracts simply performed differently on a curve. A plan can lose half a star without any real decline in day-to-day service. The 2026 ratings appear on Medicare Plan Finder now and also factor into Medicare Advantage quality bonus payments for 2027.

Medical Care Measures for Medicare Advantage Plans

Plans are scored partly on how well they help members get preventive care and manage ongoing conditions. Applicable 2026 measures may include:

• Breast and colorectal cancer screening
• Annual flu vaccination
• Osteoporosis management after a fracture
• Diabetes care and kidney health evaluations
• Controlling high blood pressure
• Follow-up after an emergency department visit
• Transitions of care after hospitalization
• Fall risk reduction
• Improving or maintaining physical and mental health
• Medication reconciliation after discharge

Plans don’t deliver this care directly — they coordinate with your doctors, hospitals, and pharmacies to close gaps: screening reminders, transportation help, post-discharge outreach. A plan’s score rises when more eligible members actually receive recommended care, and it’s worth noting that member choices (a missed screening, a delayed refill) can pull the score down even when the plan made the outreach attempt.

Prescription Drug Measures

For MA-PD and standalone Part D plans, CMS also evaluates how safely and effectively the drug benefit is run:

• Medication adherence for diabetes, blood pressure, and cholesterol drugs
• Appropriate statin therapy for certain members with diabetes
• Avoidance of potentially harmful medications and safe opioid use
• Accuracy of prices displayed on Medicare Plan Finder
• Members’ ability to get needed prescriptions
• Drug-plan complaints, disenrollment, and quality improvement

Adherence measures rely on pharmacy claims — they can confirm a prescription was filled on time, though not whether every dose was taken. Plans respond with tools like 90-day supplies, refill reminders, mail order, and lower copays at preferred pharmacies.

Member Experience and Customer Service

CMS also considers what members report: getting appointments quickly, care coordination, prescription access, and interactions with customer service — including call-center testing for interpreter and TTY access. As noted above, this category’s weight was cut from 4x to 2x starting with the 2026 ratings, so it still matters, but it has less pull on the overall score than it did under the prior methodology.

Complaints, Appeals, and Members Leaving the Plan

A plan’s rating can suffer from an unusually high complaint volume or higher-than-expected member turnover. Common complaint drivers include authorization delays, prescription access issues, billing problems, provider-directory inaccuracies, and disenrollment friction. CMS also tracks whether plans handle appeals on time — repeated missed deadlines can drag a rating down, and high voluntary disenrollment is itself treated as a warning sign.

Improvement, Cut Points, and Adjustments

CMS weighs improvement heavily, not just a snapshot of current performance — a plan trending upward can benefit, while a declining plan can be penalized even at the same absolute performance level. For each measure, CMS sets thresholds called cut points, and a contract’s raw score is measured against those thresholds to determine its star rating for that item. Technical adjustments for missing data, statistical outliers, disaster impacts, and differing plan populations also come into play — which is how a plan can lose half a star without any dramatic change in day-to-day operations.

What Is the Five-Star Special Enrollment Period?

If a five-star Medicare Advantage, Medicare Cost, or Part D plan is available in your area, you may be able to switch into it through the Five-Star Special Enrollment Period, which runs December 8 through November 30 of the following year and generally can be used only once during that window.

Availability depends entirely on whether a five-star plan exists in your service area — and switching requires care. Moving from an MA-PD plan into a five-star Medicare Advantage plan without drug coverage could leave you without Part D. Enrolling in a standalone Part D plan can also trigger disenrollment from certain Medicare Advantage coverage and drop you back to Original Medicare.

How Much Should the Star Rating Influence Your Decision?

Treat the Star Rating as one input among several, not the whole decision:

• Doctors and hospitals — confirm your physicians, specialists, and preferred hospitals are in-network
• Prescriptions — check every medication against the formulary, tier, pharmacy, and any restrictions
• Total costs — compare premiums, deductibles, copays, coinsurance, and the out-of-pocket maximum
• Travel needs — understand how routine, urgent, and emergency care work outside Northwest Florida
• Plan rules — review referral requirements, prior authorization, and step therapy
• Additional benefits — check limits and eligibility for dental, vision, hearing, transportation, and OTC allowances
• Star Rating — useful as evidence of documented quality, especially when comparing otherwise-similar plans

A four-star plan that covers your doctors and prescriptions is often a far better fit than a five-star plan that doesn’t. On the other hand, a consistently low rating — especially below three stars — is worth digging into further before you enroll.

The Bottom Line for Northwest Florida Medicare Beneficiaries

For beneficiaries across Pace, Milton, Pensacola, Jay, Gulf Breeze, and the surrounding area, the goal isn’t finding the plan with the most stars — it’s finding coverage that combines dependable quality with the doctors, prescriptions, benefits, and costs that actually fit your life. Star Ratings are a useful data point, but they can’t replace a personalized comparison.

Internal Links

• Five Medicare Mistakes That Can Quietly Drain Your Retirement Savings
• How to read your Medicare Summary Notice
• Annual Enrollment Period checklist for 2026

Official Sources

• CMS: 2026 Star Ratings Fact Sheet
• CMS: 2026 Star Ratings Technical Notes
• CMS: 2026 Star Ratings Measures and Weights
• CMS: Part C and Part D Performance Data
• Medicare: Special Enrollment Periods
• Medicare Plan Finder

Medicare Disclaimer

Mark Garrett  •  AJ Health and Wealth  •  Northwest Florida