Georgia Medicare Star Ratings: 5-Star Quality Guide

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Georgia Medicare Star Ratings: How the 5-Star Quality Rating System Works, Why It Drives Billions in Plan Funding, and How Georgia Beneficiaries Can Use It to Choose Better Plans

By Brevy Care Team · Last verified May 13, 2026

Medicare Star Ratings are the federal government's report card on Medicare Advantage and Part D prescription drug plans. Under Section 1853(o) of the Social Security Act (42 USC 1395w-23(o)) and the implementing regulations at 42 CFR 422.160 through 42 CFR 422.166 (for Medicare Advantage) and 42 CFR 423.180 through 42 CFR 423.186 (for Part D), the Centers for Medicare and Medicaid Services scores each plan contract on a scale of 1 star (poor) to 5 stars (excellent) across roughly 40 quality measures every year. The ratings serve four critical roles: they give beneficiaries an apples-to-apples comparison tool, they unlock Quality Bonus Payments worth billions of dollars to high-rated plans (which fund the richer dental, vision, hearing, and OTC supplemental benefits beneficiaries see in 4-star and 5-star plans), they expose chronically low-rated plans to CMS termination, and they unlock the 5-Star Special Enrollment Period, which lets any Medicare beneficiary switch into a 5-star plan one time per year outside the standard enrollment windows. For Georgia, where Medicare Advantage penetration exceeded 55 percent in 2026 and approximately 950,000 Georgians are enrolled in MA plans across roughly 75 different contracts, Star Ratings have major practical and financial consequences. This guide explains the statutory framework, the measures and methodology, how Quality Bonus Payments work, the 5-Star SEP, recent rule changes including the 2024 Tukey Outlier Deletion methodology and the new Health Equity Index, and walks through worked examples for typical Georgia plan-shopping scenarios. :::

Federal authority: Section 1853(o), Section 1860D-3, and the Medicare Star Ratings regulations

The Medicare Star Ratings system rests on a combination of statute and regulation. The statutory anchor for Medicare Advantage Star Ratings is Section 1853(o) of the Social Security Act, codified at 42 USC 1395w-23(o). Section 1853(o) was added to the Social Security Act by Section 3201 of the Patient Protection and Affordable Care Act of 2010 (Public Law 111-148, March 23, 2010). Before the ACA, Medicare Advantage plans had been subject to quality reporting requirements created by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108-173), but those reports were primarily informational and did not directly drive plan payment. The ACA changed that. Section 1853(o) requires CMS to apply a quality-based payment adjustment to each MA plan's county benchmark: plans rated 4 stars or higher receive a 5 percent bonus on the benchmark payment used to calculate their federal capitation revenue, and plans operating in "qualifying counties" (counties with at least 25 percent MA penetration where fee-for-service Medicare costs are below the national average) receive a 10 percent "double bonus." This Quality Bonus Payment, or QBP, generates roughly 12 to 15 billion dollars per year in additional federal payments to high-rated MA contracts nationwide.

Part D prescription drug plans are subject to a parallel Star Ratings framework under Section 1860D-3 of the Social Security Act, which authorizes CMS to evaluate Part D plan performance and apply quality-based oversight. Part D plans are scored on measures specific to prescription drug coverage, including medication adherence, completion of Comprehensive Medication Reviews under Medication Therapy Management, customer service, complaints, and appeals timeliness.

The implementing regulations sit in two parallel parts of Title 42 of the Code of Federal Regulations. 42 CFR 422.160 through 422.166 governs Medicare Advantage Star Ratings: 42 CFR 422.162 specifies the data sources (HEDIS, CAHPS, HOS, administrative data, plan-reported data); 42 CFR 422.164 sets the cut points (the statistical thresholds that determine whether a contract earns 1, 2, 3, 4, or 5 stars on each measure); and 42 CFR 422.166 sets the weighting (member experience and complaints receive 4x weight, intermediate clinical outcomes receive 3x weight, process measures receive 1x weight, and improvement measures receive 5x weight). 42 CFR 423.180 through 423.186 governs Part D Star Ratings using the same general methodology.

Two additional regulations are critical for Georgia beneficiaries. First, 42 CFR 422.62(b)(15) creates the 5-Star Special Enrollment Period, which allows any Medicare beneficiary to enroll in a 5-star MA contract or Part D contract one time during the period December 8 of the year ratings are released through November 30 of the following year. Second, 42 CFR 422.510 authorizes CMS to terminate Medicare Advantage and Part D contracts that maintain a Star Rating below 3 stars (that is, 2.5 stars or lower) for three consecutive years. Roughly 5 to 10 contracts nationwide face contract termination each year under this rule.

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Key takeaways

• Statutory anchor: Star Ratings are required by Section 1853(o) SSA (42 USC 1395w-23(o)) for Medicare Advantage and Section 1860D-3 SSA for Part D, implemented at 42 CFR 422.160-422.166 and 42 CFR 423.180-423.186.
• The scale: Plans are scored from 1 star (poor) to 5 stars (excellent) in 0.5-star increments across roughly 40 quality measures grouped into approximately 9 categories.
• Quality Bonus Payments: Plans rated 4 stars or higher receive a 5 percent QBP on their county benchmark; plans in qualifying counties receive 10 percent. QBP funds richer supplemental benefits like dental, vision, hearing, and OTC allowances.
• 5-Star Special Enrollment Period: Any Medicare beneficiary may use 42 CFR 422.62(b)(15) to switch into a 5-star plan one time between December 8 and November 30. The 5-Star SEP cannot be used to switch out of a plan and cannot be used more than once per year.
• Low-rated plan termination: Plans rated 2.5 stars or below for three consecutive years can be terminated by CMS under 42 CFR 422.510, with affected enrollees receiving a special enrollment period to switch.
• Recent methodology: The 2024 Star Ratings cycle introduced Tukey Outlier Deletion (88 Fed Reg 22120), which dropped industry-wide ratings modestly. The 2025 cycle (89 Fed Reg 30448) phases in the Health Equity Index reward starting with 2027 Star Ratings, replacing the legacy Reward Factor.
• Georgia scale: Roughly 950,000 Georgians are enrolled in MA plans across approximately 75 contracts. MA penetration exceeded 55 percent in 2026, above the national average.
• Where to look: Medicare Plan Finder at medicare.gov/plan-compare is the official tool. The annual Medicare and You handbook also lists ratings.
• Brevy at brevy.com helps Georgia families understand how Star Ratings translate into real plan differences before choosing a Medicare Advantage or Part D plan. :::

The 5-star scale: what each level means

Star Ratings are calculated on a 1-to-5 scale in 0.5-star increments. The qualitative interpretation:

• 5 stars: Excellent. Top of the industry. Roughly 5 to 15 MA contracts and 3 to 5 Part D contracts nationwide hold 5-star overall ratings in any given year. The number fluctuates significantly based on annual methodology updates.
• 4.5 stars: Above average. High-performing contracts that fall just short of 5 stars.
• 4 stars: Above average. The Quality Bonus Payment threshold. Plans below 4 stars do not receive QBP funding.
• 3.5 stars: Average to above average.
• 3 stars: Average.
• 2.5 stars: Below average. Triggers the termination clock under 42 CFR 422.510 if maintained for three consecutive years.
• 2 stars: Below average.
• 1.5 stars and 1 star: Poor. Rare; most plans below this level have been terminated or restructured.

The overall Star Rating is a weighted average of all measure-level ratings, with weighting determined by 42 CFR 422.166. Member experience and complaints measures, which are weighted 4x, drive a disproportionate share of the overall rating. This is intentional: CMS has concluded that beneficiary experience and complaint rates are the most direct signal of plan quality from the consumer's perspective.

The 40+ quality measures

Star Ratings draw on data from five sources:

1. HEDIS (Healthcare Effectiveness Data and Information Set): Plan-reported clinical performance data audited by external entities, covering measures like cancer screenings, diabetes care, and statin therapy.
2. CAHPS (Consumer Assessment of Healthcare Providers and Systems): Annual member surveys covering experience with care, customer service, and overall satisfaction.
3. HOS (Health Outcomes Survey): Functional health assessments completed by a sample of plan members.
4. Administrative data: Claims, encounter data, complaints, appeals, disenrollment data collected by CMS.
5. PQA (Pharmacy Quality Alliance) measures: Part D-specific measures for medication adherence and MTM completion.

For the 2026 plan year (Star Ratings released October 2025), Medicare Advantage and Part D plans were scored on approximately 40 measures grouped into 9 categories.

Staying Healthy: Screenings, Tests, and Vaccines

Process measures focused on preventive care:

• Breast Cancer Screening: HEDIS measure tracking mammogram completion for women aged 50 to 74.
• Colorectal Cancer Screening: HEDIS measure tracking colonoscopy, FIT, or sigmoidoscopy completion for adults aged 50 to 75.
• Annual Flu Vaccine: CAHPS-reported flu vaccination rate.
• Improving or Maintaining Physical Health: HOS measure tracking self-reported functional health.
• Improving or Maintaining Mental Health: HOS measure tracking self-reported mental health.
• Monitoring Physical Activity: HOS measure tracking whether providers discussed physical activity with seniors.
• Adult BMI Assessment: HEDIS measure tracking documentation of BMI in adults.
• Special Needs Plan Care for Older Adults: HEDIS measure specific to SNP plans (D-SNP, C-SNP, I-SNP).

Managing Chronic (Long Term) Conditions

Intermediate outcome and process measures:

• Osteoporosis Management in Women who had a Fracture: HEDIS measure tracking bone density testing and prescription after fracture.
• Diabetes Care: Eye Exam: HEDIS measure tracking annual retinal exam completion.
• Diabetes Care: Kidney Disease Monitoring: HEDIS measure tracking annual nephropathy screening.
• Diabetes Care: Blood Sugar Controlled: HEDIS measure tracking HbA1c control (typically below 9 percent).
• Controlling Blood Pressure: HEDIS measure tracking hypertension control under 140/90 mmHg.
• Rheumatoid Arthritis Management: HEDIS measure tracking DMARD prescription.
• Reducing the Risk of Falling: HOS measure tracking provider conversations about fall prevention.
• Plan All-Cause Readmissions: HEDIS measure tracking 30-day readmission rate.
• Statin Therapy for Patients with Cardiovascular Disease: HEDIS measure tracking statin prescription for ASCVD.

Member Experience with the Health Plan

CAHPS member survey results (4x weight):

• Getting Needed Care: Member-reported difficulty obtaining care.
• Getting Appointments and Care Quickly: Member-reported wait times.
• Customer Service: Member-reported experience with plan customer service.
• Rating of Health Care Quality: Member-reported overall care rating.
• Rating of Health Plan: Member-reported overall plan rating.
• Care Coordination: Member-reported experience with care coordination across providers.

Member Complaints and Changes in the Health Plan's Performance

Administrative data (4x weight):

• Complaints about the Health Plan: CMS-tracked complaint rate per 1,000 enrollees.
• Members Choosing to Leave the Plan: Voluntary disenrollment rate.
• Health Plan Quality Improvement: Composite measure tracking year-over-year improvement.

Health Plan Customer Service

Administrative measures for plan operations:

• Plan Makes Timely Decisions about Appeals: Tracking compliance with Section 1852(g) appeal timeframes.
• Reviewing Appeals Decisions: Independent Review Entity (IRE) affirmance rate when plan denials are appealed.
• Call Center Foreign Language Interpreter and TTY Availability: CMS-audited measure.

Part D measures

For Part D contracts and the Part D component of MA-PD contracts:

• Call Center Foreign Language Interpreter and TTY
• Appeals Auto-Forward (plan failure to make a timely decision)
• Appeals Upheld Rate
• Complaints about the Drug Plan
• Members Choosing to Leave the Drug Plan
• Drug Plan Quality Improvement
• Rating of Drug Plan (CAHPS)
• Getting Needed Prescription Drugs (CAHPS)
• MPF Price Accuracy (Medicare Plan Finder price accuracy)
• Medication Adherence for Diabetes Medications (PQA)
• Medication Adherence for Hypertension RAS Antagonists (PQA)
• Medication Adherence for Cholesterol Statins (PQA)
• MTM Program Completion Rate for CMR (PQA)
• Statin Use in Persons with Diabetes (PQA)

How the overall Star Rating is calculated

CMS calculates the overall Star Rating in three steps.

Step 1: Measure-level rating

For each individual measure (for example, Breast Cancer Screening), CMS analyzes the performance of all eligible contracts nationwide. The Tukey Outlier Deletion method, adopted in 88 Fed Reg 22120 (April 2023) and applied beginning with the 2024 Star Ratings cycle, removes statistical outliers (contracts whose performance is far above or below the mean) before calculating cut points. CMS then sets four cut points dividing the remaining performance into five bands (1, 2, 3, 4, and 5 stars). Each contract receives a measure-level rating from 1 to 5 based on which band its performance falls into.

Step 2: Category-level rating

Measures are grouped into approximately 9 categories. CMS calculates a category-level rating by taking a weighted average of the measure-level ratings within each category, using the weighting rules in 42 CFR 422.166.

Step 3: Overall rating

The overall Star Rating is a weighted average across all measures, rounded to the nearest 0.5. The Reward Factor (historical) added a small bonus for contracts with high and stable performance. Beginning with 2027 Star Ratings (measurement year 2025), the Reward Factor is replaced by the Health Equity Index, which rewards contracts that perform well on quality measures specifically for enrollees with social risk factors (low-income subsidy recipients, dually eligible individuals, and people with disabilities).

Quality Bonus Payments: how Star Ratings translate into plan revenue

The Quality Bonus Payment structure under Section 1853(o) and 42 CFR 422.258 is the single biggest financial consequence of Star Ratings.

The bonus tiers

• 4 stars or higher: 5 percent bonus to the county benchmark.
• 4 stars or higher in qualifying county: 10 percent bonus ("double bonus").
• Below 4 stars: 0 percent bonus.

What counts as a "qualifying county"

Under Section 1853(o)(3)(B), a qualifying county is one that satisfies three criteria: (1) the county had Medicare Advantage penetration of at least 25 percent as of a specified baseline year, (2) county fee-for-service Medicare costs are below the national average, and (3) the county was previously designated a "double bonus" county. Approximately 200 counties nationwide qualify for the double bonus. Atlanta-area counties (Fulton, DeKalb, Cobb, Gwinnett) are not typically qualifying counties because MA penetration was high pre-baseline.

Why QBP funds matter

When a plan receives a QBP, the additional federal capitation revenue does not flow to the plan as pure profit. Under the MA bidding rules, plans must devote QBP-funded dollars to:

1. Reduced Part C premium (lower or zero monthly plan premium)
2. Reduced Part B premium giveback (paying back a portion of the enrollee's Part B premium)
3. Reduced cost-sharing on Medicare-covered services (lower copays, lower deductibles)
4. Supplemental benefits not covered by Original Medicare (dental, vision, hearing, OTC allowances, fitness memberships, transportation, meals after hospitalization)

This is why 4-star and 5-star plans typically offer richer supplemental benefit packages than lower-rated plans. A 4-star plan with 100,000 enrollees and a $1,000-per-member-per-month county benchmark receives an extra $50 PMPM in federal revenue ($60 million per year for the contract), much of which must be deployed back to members as benefits or premium reductions.

What this means for Georgia consumers

When a Georgia beneficiary compares two plans during AEP and notices that the 4-star plan offers $200 per quarter in OTC allowance and $3,000 per year in dental coverage while the 3-star plan offers $50 per quarter OTC and $1,000 dental, the difference is largely explained by QBP. The higher-rated plan is funding richer benefits from its QBP revenue stream.

The 5-Star Special Enrollment Period (42 CFR 422.62(b)(15))

The 5-Star SEP is one of the most powerful and least-used enrollment tools in Medicare.

How it works

Under 42 CFR 422.62(b)(15), any Medicare beneficiary (regardless of current plan or current enrollment status) may use the 5-Star SEP to enroll in a 5-star MA contract or 5-star Part D contract during the SEP window. The SEP runs from December 8 of the year Star Ratings are released through November 30 of the following calendar year. The SEP may be used only one time during this window.

The mechanics

Star Ratings for the upcoming plan year are typically released by CMS in early October. The 5-Star SEP opens December 8 of that release year. For example, the October 2025 Star Ratings release for plan year 2026 opened the 5-Star SEP on December 8, 2025, and the SEP runs through November 30, 2026.

The effective date of enrollment under the 5-Star SEP is the first day of the month following the request. A Georgia beneficiary who calls 1-800-MEDICARE on March 15 to use the 5-Star SEP will have an April 1 effective date.

What the 5-Star SEP can and cannot do

Can do:

• Switch from any plan (including a current 5-star plan) INTO a different 5-star plan (although this is rare)
• Switch from Original Medicare into a 5-star MA plan
• Switch from a non-5-star MA plan into a 5-star MA plan
• Switch from a non-5-star Part D plan into a 5-star Part D plan
• Add Part D coverage by enrolling in a 5-star standalone PDP

Cannot do:

• Switch OUT of a 5-star plan to a lower-rated plan (must wait for AEP or another SEP)
• Be used more than once per SEP window
• Be used to switch to a plan that is not currently 5 stars (measure-level 5 stars do not count)

Practical impact in Georgia

In 2026, the most consistent 5-star MA option in Georgia is Kaiser Foundation Health Plan of Georgia's Senior Advantage plan, which serves metro Atlanta counties. Outside metro Atlanta, 5-star MA contracts are sparse. For Part D, several 5-star standalone PDPs are available statewide.

Low-rated plan termination under 42 CFR 422.510

CMS does not just reward high-rated plans; it also penalizes chronically low-rated plans. Under 42 CFR 422.510, CMS may terminate the contract of any Medicare Advantage or Part D plan that maintains an overall Star Rating below 3 stars (that is, 2.5 stars or lower) for three consecutive years. The termination process:

1. Year 1 low rating: CMS issues a notice of unsatisfactory performance.
2. Year 2 low rating: CMS issues an escalated notice and may require a corrective action plan.
3. Year 3 low rating: CMS issues a contract termination notice. The contract is terminated effective the end of the plan year following the termination notice.
4. Affected enrollees: Receive a Special Election Period under 42 CFR 422.62(b)(4) running from the termination notice date through the end of the second month after the contract termination effective date.

Roughly 5 to 10 contracts nationwide face termination each year under this rule. Affected Georgia enrollees should immediately use their SEP to enroll in a higher-rated plan rather than defaulting to Original Medicare with no Part D coverage (which would create a Part D Late Enrollment Penalty exposure).

Recent methodology updates

The Star Ratings methodology has evolved significantly in recent years. Three major updates are relevant for the 2026 plan year and forward.

Tukey Outlier Deletion (88 Fed Reg 22120, April 2023)

Pre-2024, CMS calculated cut points using simple percentile-based statistics: for example, the 90th percentile became the 5-star threshold for a given measure. This method was vulnerable to manipulation: a small number of contracts with extreme outlier performance could distort cut points industry-wide. Starting with the 2024 Star Ratings cycle (released October 2023, applying to plan year 2024), CMS adopted the Tukey Outlier Deletion methodology. Under Tukey, CMS removes contracts whose performance is more than 1.5 times the interquartile range above the 75th percentile or below the 25th percentile before calculating cut points. The remaining contracts' performance determines the cut points.

The practical effect: cut points became more stable year over year and harder to inflate. The industry-wide impact was a modest decline in average Star Ratings. Pre-Tukey, the industry average overall Star Rating was approximately 4.15. Post-Tukey, the average fell to approximately 4.04. Fewer contracts achieved 4+ stars, and the QBP-eligible contract count declined modestly.

Health Equity Index (87 Fed Reg 27704, May 2022 and 89 Fed Reg 30448, April 2024)

The Health Equity Index, introduced in 87 Fed Reg 27704 and refined in 89 Fed Reg 30448, replaces the legacy Reward Factor starting with 2027 Star Ratings (measurement year 2025). The HEI rewards contracts that perform well on quality measures specifically for enrollees with social risk factors:

• Low-income subsidy (LIS) recipients: Beneficiaries who receive Extra Help (Part D LIS), who tend to have lower incomes and worse social determinants of health.
• Dually eligible beneficiaries: Those enrolled in both Medicare and Medicaid.
• People with disabilities: Beneficiaries under 65 enrolled in Medicare due to disability.

The HEI can add up to 0.4 to a contract's overall Star Rating. Contracts that demonstrate strong performance on quality measures for social-risk subpopulations receive a positive HEI adjustment; contracts with disparities between high-resource and low-resource enrollees receive no adjustment or a negative adjustment.

The HEI is a major financial incentive for plans to invest in care delivery for traditionally underserved populations.

2025 Star Ratings methodology updates (89 Fed Reg 30448)

The April 2024 final rule made several refinements applicable to 2025 Star Ratings and beyond:

• Refined statistical methodology for low-enrollment contracts (small contracts with fewer than 500 enrollees on a given measure are treated differently)
• New measures added in the Drug Safety category
• Some measures retired (e.g., HOS-based measures with low response rates)
• Continued use of Tukey Outlier Deletion
• Phased introduction of HEI

Georgia Medicare Advantage Star Ratings landscape

Georgia's Medicare Advantage market is one of the largest in the South.

Market scale

• Approximately 950,000 Medicare beneficiaries enrolled in MA plans in Georgia (2026)
• Approximately 55 percent MA penetration (above the national average of approximately 50 percent)
• Approximately 75 active MA contracts available across the state
• Major issuers: Humana, UnitedHealthcare, Aetna (CVS Health), Anthem Blue Cross Blue Shield of Georgia, Wellcare (Centene), Kaiser Permanente, Cigna, Centene

Star Ratings distribution in Georgia for the 2026 plan year

Based on the October 2025 Star Ratings release:

• 5-star MA contracts: Limited. Kaiser Foundation Health Plan of Georgia Senior Advantage has historically rated between 4.5 and 5 stars and has at times achieved the 5-star threshold. Availability is concentrated in metro Atlanta.
• 4.5-star contracts: Roughly 5 to 8 contracts across major issuers.
• 4-star contracts: Roughly 25 to 30 contracts.
• 3.5-star contracts: Roughly 20 to 25 contracts.
• 3 stars or below: Roughly 10 to 15 contracts.

The exact distribution shifts annually; Georgia beneficiaries should always check the current Star Rating on Medicare.gov Plan Finder before enrolling.

County-level variation

Star Ratings apply at the contract level, not the county level. A single Humana contract (for example, H1019) covers a defined service area within Georgia, and the contract's overall rating applies to every county the contract serves. However, plan benefits and premiums vary by county within a contract. A Humana Gold Plus HMO Atlanta plan and a Humana Gold Plus HMO Savannah plan may be under the same contract H1019 (and therefore share the same Star Rating) but offer different premiums, copays, and supplemental benefits depending on county.

Where to look up Star Ratings

Medicare Plan Finder (medicare.gov/plan-compare)

The official consumer-facing tool. Enter ZIP code and view all MA and Part D plans available in the area, with overall Star Rating displayed prominently. Filter and sort options allow shoppers to prioritize by Star Rating, premium, drug coverage, or supplemental benefits. Each plan's detail page shows individual category ratings (e.g., the diabetes care subscore).

Medicare and You handbook

Mailed by CMS to all Medicare beneficiaries each fall. Lists Star Ratings for MA and Part D contracts available in the beneficiary's state.

Plan marketing materials

Under the CMS Medicare Marketing Guidelines, plans rated 4 stars or higher may prominently display the Star Rating in advertising. Plans rated below 4 stars must include the rating only in the required disclaimer, not as a marketing highlight. A plan that prominently advertises "5 stars" or "4.5 stars" in mailers and TV ads is communicating the most recent CMS rating.

CMS Star Ratings Technical Notes

The annual technical document published by CMS describing measure-by-measure methodology, cut points, and weights. Useful for advanced users and advocates.

Worked examples for Georgia

Example 1: Margaret 67 Atlanta plan shopping during AEP

Margaret turned 65 in 2024 and joined a Medicare Advantage plan at that time. She lives in Atlanta (Fulton County). It is October 2025 and the Annual Enrollment Period for plan year 2026 has just opened. She logs on to medicare.gov/plan-compare and enters her ZIP code. Two HMO options stand out:

• Humana Gold Plus HMO Atlanta: Overall rating 4 stars; $0 premium; $200 per quarter OTC allowance; $2,500 per year dental benefit; $200 per year vision benefit; includes prescription drug coverage; receives a 5 percent QBP under Section 1853(o).
• Aetna Medicare Choice HMO Atlanta: Overall rating 3 stars; $0 premium; $100 per quarter OTC allowance; $1,500 per year dental benefit; $100 per year vision benefit; includes prescription drug coverage; receives no QBP.

Margaret reviews the category subscores. The Humana plan rates 4 stars on Member Experience (4x weight), 4 stars on Diabetes Care (3x weight), and 4 stars on Customer Service. The Aetna plan rates 3 stars across most categories with a 2-star Customer Service score. She chooses Humana Gold Plus HMO based on the higher overall rating, the richer supplemental benefits funded by QBP, and the stronger customer service score. Effective January 1, 2026.

Example 2: Robert 70 Savannah uses 5-Star SEP

Robert lives in Savannah (Chatham County) and is enrolled in a 3.5-star Humana MA plan that he joined at age 65. In April 2026, he is reviewing his coverage and discovers that a Kaiser MA plan available in his area received a 5-star overall rating in the October 2025 release (assume Kaiser expanded its service area to Savannah for the 2026 plan year).

Robert calls 1-800-MEDICARE on April 10, 2026, identifies the 5-star Kaiser plan, and requests enrollment under the 5-Star SEP (42 CFR 422.62(b)(15)). The CMS representative confirms the SEP eligibility and processes the enrollment. Effective date: May 1, 2026.

Robert is now enrolled in Kaiser Senior Advantage. He cannot use the 5-Star SEP again until December 8, 2026, when the SEP window for plan year 2027 ratings opens. He can switch back to Original Medicare or to a different MA plan during the MA Open Enrollment Period (January 1 through March 31, 2027) or the AEP (October 15 through December 7, 2026), but he cannot use the 5-Star SEP again in this window.

Example 3: Linda 68 Macon faces low-rated plan termination

Linda lives in Macon (Bibb County) and has been enrolled in a small regional MA plan since 2022. The plan's overall Star Rating history:

• 2024 plan year: 2.5 stars
• 2025 plan year: 2.5 stars
• 2026 plan year: 2 stars

This is three consecutive years below 3 stars. Under 42 CFR 422.510, CMS issues a contract termination notice in February 2026, effective December 31, 2026. Linda receives a written notice from the plan in March 2026 explaining the termination and her Special Election Period.

Linda has a SEP under 42 CFR 422.62(b)(4) running from the termination notice through the end of the second month after termination (February 28, 2027). She uses the SEP to enroll in a 4-star Humana HMO Macon plan effective July 1, 2026, four months before her current plan terminates. She does not wait until the plan actually terminates because she wants to avoid any coverage gap or last-minute scramble.

Example 4: Charles 72 Augusta sees QBP impact in plan benefits

Charles is comparing two MA plans in Augusta (Richmond County) for plan year 2026:

• Anthem Blue Cross Blue Shield Medicare Advantage HMO Augusta: 4.5 stars; $0 premium; $200 per month OTC allowance; $3,500 per year dental; $200 per year hearing aids; receives a 5 percent QBP.
• A 3-star competitor plan: $0 premium; $50 per month OTC; $1,000 per year dental; no hearing aid benefit; receives no QBP.

The 4.5-star plan offers approximately $2,500 more in annual supplemental benefits than the 3-star competitor. The difference is largely attributable to the QBP revenue, which the higher-rated plan is required to deploy into benefits under the MA bidding rules. Charles enrolls in Anthem BCBS Medicare Advantage HMO Augusta. Effective January 1, 2026.

Example 5: Patricia 65 Columbus reviews diabetes-specific category ratings

Patricia turning 65 in March 2026 has Type 2 diabetes managed with metformin and a GLP-1 agonist. She wants a plan that excels on diabetes care, not just overall.

She uses Medicare Plan Finder for her Columbus ZIP code and reviews not just the overall Star Rating but the individual category scores. She finds:

• Wellcare Medicare HMO Columbus: Overall 4 stars; Diabetes Care: Blood Sugar Controlled rated 5 stars; Diabetes Care: Eye Exam rated 5 stars; Diabetes Care: Kidney Disease Monitoring rated 5 stars.
• A competing 4.5-star plan: Overall 4.5 stars but Diabetes Care: Blood Sugar Controlled rated only 3 stars.

Patricia chooses the Wellcare plan despite its lower overall rating because the diabetes-specific subscores are stronger. For a beneficiary managing a specific chronic condition, category-level ratings can matter more than the overall rating. Effective April 1, 2026 (her first month of Medicare entitlement).

Example 6: Henry 73 Athens disenrolls from low-rated plan

Henry is enrolled in a 2-star Medicare Advantage plan in Athens (Clarke County). He is frustrated by long appointment wait times, difficulty getting prior authorizations, and poor customer service. In June 2026, he wants to switch.

He considers his options:

1. 5-Star SEP: Could be used to switch INTO a 5-star plan. He checks Medicare Plan Finder and discovers that no 5-star MA plans are available in his county. He cannot use the 5-Star SEP.
2. MA Open Enrollment Period (MA OEP): 42 CFR 422.62(a)(3) allows MA enrollees to make a one-time change during January 1 through March 31 each year. Henry missed his 2026 MA OEP and cannot use it.
3. Annual Enrollment Period (AEP): October 15 through December 7, 2026, for plan year 2027. Henry will need to wait.
4. Special Enrollment Period: Other SEPs may apply if Henry has a qualifying event (move, loss of employer coverage, Medicaid eligibility change, etc.). He has no qualifying event.

Henry must wait until AEP 2026 to switch. He uses the intervening months to research alternative plans through GeorgiaCares SHIP and compares their Star Ratings carefully. During AEP in October 2026, he enrolls in a 4-star Humana HMO Athens plan effective January 1, 2027.

Common mistakes to avoid

1. Choosing a plan based on premium alone. A $0 premium 2-star plan may cost more in unmet care needs than a $0 premium 4-star plan. The Star Rating reflects actual member experience and clinical outcomes.

2. Confusing overall Star Rating with category ratings. A 4-star plan can have a 2-star diabetes measure or a 2-star customer service score. Always drill into the category breakdown if you have specific health concerns.

3. Believing the 5-Star SEP can be used to switch FROM a 5-star plan. The SEP only allows switching INTO a 5-star contract. Once enrolled in a 5-star plan, you must wait for AEP or another SEP to switch.

4. Believing the 5-Star SEP can be used multiple times per year. The SEP is limited to one use per window (December 8 through November 30).

5. Assuming the current plan's Star Rating will not change year over year. Ratings are released annually in October. A 4-star plan one year may drop to 3.5 stars or rise to 4.5 stars the next year. Re-check before AEP each fall.

6. Not realizing that 4+ star plans offer richer supplemental benefits because of QBP. The dental, vision, hearing, and OTC differences between 4-star and 3-star plans are largely funded by the Quality Bonus Payment under Section 1853(o).

7. Overlooking Part D-specific Star Ratings when comparing MA-PD plans. An MA-PD contract has both an overall MA Star Rating and a separate Part D Star Rating. Both matter if you take prescription drugs.

8. Believing low-rated plans cannot be terminated by CMS. They can be, under 42 CFR 422.510, after three consecutive years below 3 stars. Affected enrollees get a Special Election Period.

9. Confusing Medicare Plan Star Ratings with Star Ratings for hospitals or nursing homes. CMS operates several separate Star Ratings systems (hospital, nursing home, home health, dialysis, MA, Part D). The methodology and measures differ.

10. Not using Medicare Plan Finder to compare ratings side by side. The Plan Finder at medicare.gov/plan-compare is the authoritative tool. Plan brochures and salespeople may not present an unbiased comparison.

Frequently asked questions

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What is the legal authority for Medicare Star Ratings?

The Medicare Advantage Star Ratings system is governed by Section 1853(o) of the Social Security Act (42 USC 1395w-23(o)) and implemented at 42 CFR 422.160 through 422.166. The Part D Star Ratings system is governed by Section 1860D-3 of the Social Security Act and implemented at 42 CFR 423.180 through 423.186. The framework was substantially expanded by the Affordable Care Act of 2010 (Public Law 111-148, Section 3201).

How is the overall Star Rating calculated?

The overall Star Rating is a weighted average of approximately 40 quality measures grouped into roughly 9 categories. Member experience and complaints measures are weighted 4x, intermediate clinical outcomes are weighted 3x, process measures are weighted 1x, and improvement measures are weighted 5x. The final rating is rounded to the nearest 0.5 star.

When are Star Ratings released?

CMS typically releases Star Ratings in early October each year. The October release applies to the upcoming plan year. For example, ratings released in October 2025 apply to plan year 2026.

What is a Quality Bonus Payment?

Under Section 1853(o), Medicare Advantage contracts rated 4 stars or higher receive a 5 percent bonus on their county benchmark payment. Plans in qualifying counties (low MA penetration and below-average FFS Medicare costs) receive a 10 percent double bonus. QBPs generate roughly $12 to $15 billion per year in additional federal payments to high-rated contracts.

What is the 5-Star Special Enrollment Period?

The 5-Star SEP, codified at 42 CFR 422.62(b)(15), allows any Medicare beneficiary to enroll in a 5-star MA or Part D contract one time during the period December 8 through November 30. The SEP only allows switching INTO a 5-star plan, not switching out of one. The effective date is the first of the month following the request.

Can I use the 5-Star SEP more than once per year?

No. The SEP allows only one use per window (December 8 through November 30). If you use it in March, you cannot use it again in October of the same year.

Can the 5-Star SEP be used to switch from one 5-star plan to a different 5-star plan?

Yes, technically. The SEP allows enrollment in any 5-star plan regardless of current enrollment status. In practice, this is rare because beneficiaries who are already in a 5-star plan typically have no reason to switch.

What happens if a Medicare Advantage plan gets 2.5 stars or below?

Under 42 CFR 422.510, CMS may terminate the contract of any plan that maintains a Star Rating below 3 stars for three consecutive years. Affected enrollees receive a Special Election Period running from the termination notice through the end of the second month after the contract termination effective date.

Can I switch out of a low-rated plan immediately?

Generally no, unless you have another applicable SEP. You can switch during the Annual Enrollment Period (October 15 through December 7) or the Medicare Advantage Open Enrollment Period (January 1 through March 31). If your plan is being terminated by CMS under 42 CFR 422.510, you receive a Special Election Period to switch immediately.

Do Star Ratings apply to Special Needs Plans?

Yes. Dual-Eligible Special Needs Plans (D-SNP), Chronic Condition SNPs (C-SNP), and Institutional SNPs (I-SNP) all receive Star Ratings under the same general methodology, plus an additional SNP-specific Care for Older Adults measure.

What is the Tukey Outlier Deletion methodology?

Adopted in 88 Fed Reg 22120 (April 2023) and applied beginning with the 2024 Star Ratings cycle, Tukey Outlier Deletion is a statistical method that removes contracts with extreme outlier performance before calculating cut points. This makes cut points more stable year over year and harder to manipulate. The 2024 cycle saw industry-wide average ratings decline modestly as a result.

What is the Health Equity Index?

The Health Equity Index, introduced in 87 Fed Reg 27704 (May 2022) and refined in 89 Fed Reg 30448 (April 2024), replaces the legacy Reward Factor starting with 2027 Star Ratings (measurement year 2025). The HEI rewards contracts that perform well on quality measures specifically for enrollees with social risk factors: low-income subsidy recipients, dually eligible individuals, and people with disabilities. The HEI can add up to 0.4 to a contract's overall Star Rating.

Where do Star Ratings data come from?

Five sources: HEDIS (clinical performance data audited by external entities), CAHPS (annual member surveys), HOS (Health Outcomes Survey), administrative data (claims, complaints, appeals), and PQA (Pharmacy Quality Alliance measures for Part D).

How can I see Star Ratings for plans available in Georgia?

Use Medicare Plan Finder at medicare.gov/plan-compare. Enter your ZIP code and view all plans available, sorted or filtered by Star Rating. Detailed category scores are available on each plan's detail page. The annual Medicare and You handbook also lists ratings.

Are Star Ratings the same across all counties a plan serves?

Yes. Star Ratings apply at the contract level, not the county level. A single contract (e.g., H1019 for Humana Gold Plus) covers a defined service area, and the contract's rating applies to every county within that service area. However, the plan's benefits and premiums vary by county within the contract.

Why does my MA plan offer dental and vision benefits while Original Medicare does not?

Because MA plans receive QBP revenue under Section 1853(o) if they are rated 4 stars or higher, which must be deployed back to members as reduced premiums, reduced cost-sharing, or supplemental benefits. Original Medicare has no QBP and no supplemental benefit funding mechanism.

How weighty are member experience scores compared to clinical scores?

Member experience and complaints measures are weighted 4x. Intermediate clinical outcomes (e.g., blood pressure controlled, statin therapy) are weighted 3x. Process measures (e.g., screenings) are weighted 1x. This means a plan's customer service and complaint rate drive a disproportionate share of the overall rating.

Can a plan dispute its Star Rating?

Plans may request CMS reconsideration of measure-level ratings under specific circumstances. Plans cannot dispute the overall rating directly but may challenge measure-level calculations through CMS administrative processes.

What is a "double bonus" county?

Under Section 1853(o)(3)(B), a qualifying county receives a 10 percent QBP instead of 5 percent. Qualifying counties have at least 25 percent MA penetration as of a baseline year, fee-for-service Medicare costs below the national average, and were previously designated double-bonus counties. Approximately 200 counties nationwide qualify.

Does Original Medicare have Star Ratings?

No. Star Ratings apply only to Medicare Advantage and Part D plans. Original Medicare (Parts A and B fee-for-service) is not rated. However, individual hospitals, nursing homes, home health agencies, and dialysis facilities have their own separate Star Ratings systems.

How do Star Ratings differ from CMS Care Compare?

Care Compare is a CMS website (medicare.gov/care-compare) that displays Star Ratings for hospitals, nursing homes, home health agencies, hospice, dialysis, and physicians. These are different rating systems from the MA and Part D plan Star Ratings, though all are operated by CMS.

Can I see Star Ratings before I turn 65?

Yes. Medicare Plan Finder is publicly accessible at medicare.gov/plan-compare and allows anyone to look up plans in any ZIP code. You can review ratings months before your Initial Enrollment Period to plan your enrollment choice.

How do Star Ratings interact with prior authorization rules?

Plans must meet timeliness requirements for prior authorization decisions under 42 CFR 422.138 (effective January 2026 under 89 Fed Reg 8758). Plans that fail to meet PA timeframes are penalized in the Appeals Auto-Forward measure and the Plan Makes Timely Decisions about Appeals measure, both of which feed into the Star Rating.

What is the Medicare Advantage Open Enrollment Period?

The MA OEP, codified at 42 CFR 422.62(a)(3), runs from January 1 through March 31 each year. Any MA enrollee may use the MA OEP one time to switch to a different MA plan or to Original Medicare with a standalone Part D plan. The MA OEP is separate from the 5-Star SEP.

How does GeorgiaCares help with Star Ratings?

GeorgiaCares is Georgia's State Health Insurance Assistance Program (SHIP), funded by CMS and the Georgia Division of Aging Services. GeorgiaCares counselors provide free, unbiased Medicare counseling and can walk Georgia beneficiaries through Star Ratings, plan comparisons, and enrollment strategies. Call 1-866-552-4464 for free counseling. :::

Get help comparing plans by Star Rating

Choosing a Medicare Advantage or Part D plan based on Star Ratings can save thousands of dollars and meaningfully improve quality of care. Free counseling and dispute help are available from federal, state, and nonprofit resources serving Georgia.

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Georgia Medicare and plan-comparison resources

Medicare and federal resources

• Medicare: 1-800-MEDICARE (1-800-633-4227); 24/7 plan enrollment, Star Ratings questions, and 5-Star SEP processing
• Medicare Plan Finder: medicare.gov/plan-compare; the official tool for comparing plans by Star Rating
• Social Security Administration: 1-800-772-1213; Medicare enrollment questions
• Medicare Rights Center: 1-800-333-4114; free national Medicare counseling
• Center for Medicare Advocacy: 1-860-456-7790; appeals and advocacy
• Justice in Aging: 202-289-6976; policy and beneficiary protection advocacy

Georgia counseling and oversight

• GeorgiaCares (Georgia SHIP): 1-866-552-4464; free Medicare counseling and Star Ratings comparison statewide
• Georgia Department of Insurance: 1-800-656-2298; plan oversight and consumer complaints
• Georgia Department of Community Health Medicaid Member Services: 1-866-211-0950; for dually eligible beneficiaries
• Georgia Aging and Disability Resource Connection: 1-866-552-4464; aging services and Medicare counseling
• Eldercare Locator: 1-800-677-1116; refers to local Georgia Area Agencies on Aging

Legal assistance for Georgia seniors

• Atlanta Legal Aid Senior Citizens Law Project: 404-377-0701; free legal help for low-income seniors in metro Atlanta
• Georgia Legal Services Program: 1-800-498-9469; free legal help for low-income Georgians outside metro Atlanta
• AARP Georgia: 1-866-295-7277; advocacy and member resources
• Senior Citizens Law Office: free Medicare counseling for low-income seniors

Information resources

• Brevy: brevy.com; eldercare guides and Medicare plan comparison context for Georgia families
• 211 Georgia: dial 211; community resource referrals
• National Council on Aging BenefitsCheckUp: benefitscheckup.org; comprehensive benefit screening

Brevy is committed to helping Georgia families navigate Medicare Advantage and Part D Star Ratings, the 5-Star Special Enrollment Period, Quality Bonus Payments, and the plan-comparison process. Visit brevy.com for more guides on Medicare in Georgia, or call 1-866-552-4464 for free counseling from GeorgiaCares.

Disclaimer: This guide explains federal Medicare Advantage and Part D Star Ratings under Section 1853(o) and Section 1860D-3 of the Social Security Act and the implementing regulations at 42 CFR 422.160-422.166 and 42 CFR 423.180-423.186 as of May 2026. Star Ratings are released annually each October by CMS and change every year. Quality Bonus Payment levels, qualifying county designations, and methodology updates change frequently. This is general educational information, not Medicare enrollment advice. Always verify current Star Ratings and plan availability on Medicare Plan Finder at medicare.gov/plan-compare before enrolling. :::