Medicare Advantage Star Ratings Changed in 2026. Here Is What That Means for Your Coverage.
Medicare Advantage Star Ratings Changed in 2026. Here Is What That Means for Your Coverage.
Medicare Advantage Star Ratings Changed in 2026. Here Is What That Means for Your Coverage.
6 minute read
If you are enrolled in a Medicare Advantage plan, you have probably seen the star rating system mentioned during open enrollment. A five-star plan is excellent. A four-star plan is above average. Plans rated below three stars for multiple years can be terminated. But what actually determines that rating, and why does it matter so much to you as a patient?
CMS updated the methodology for how Medicare Advantage star ratings are calculated for contract year 2026, and the results have been notable: fewer plans are achieving high ratings under the new approach, more plans are seeing their scores fall, and the financial consequences for plans ripple directly into the coverage experience you have as an enrollee.
How the Star Rating System Works
Medicare Advantage star ratings are published each fall by CMS and apply to the following contract year. Plans are scored on a scale of one to five stars across dozens of measures grouped into categories including preventive care and wellness, managing chronic conditions, member experience and complaints, and member access to care.
Plans that achieve four or more stars receive "quality bonus payments" from CMS, which amounts to additional federal dollars per enrollee. These bonus payments are significant. They help plans fund richer benefits, lower premiums, and extras like dental, vision, and transportation. Plans that score below three stars for three consecutive years can be terminated, meaning they lose their ability to continue enrolling Medicare beneficiaries.¹
The star rating a plan earns in a given fall applies to the payments CMS makes to that plan for the following contract year. So the 2026 star ratings, published in fall 2025, affect how much CMS pays plans throughout 2026.
What Changed in the 2026 Methodology
CMS updated several aspects of how star ratings are calculated for contract year 2026. The most significant change involves how the agency handles the statistical guardrails designed to prevent plans from gaming the rating system.
CMS implemented updates to the "improvement measures," which reward plans that show meaningful gains in quality even if their absolute scores are not at the top. The agency also adjusted the way certain patient experience and access measures are weighted, and made changes to how plans serving high proportions of low-income or dual-eligible beneficiaries are evaluated.
The practical result has been that fewer plans are landing in the four-star-and-above tier. According to CMS data published in fall 2025, the share of Medicare Advantage enrollees in plans rated four stars or above declined compared to prior years.² This shift means a larger portion of Medicare Advantage enrollees are now in plans that do not qualify for bonus payments.
Why This Matters for Your Coverage
The connection between star ratings and your day-to-day coverage experience is not always obvious, but it runs through the plan's finances.
Plans earning bonus payments have more revenue to work with. They can afford richer formularies, lower cost-sharing, fewer restrictions on specialty drugs, and more generous prior authorization policies. When a plan loses its quality bonus payment because its rating dropped, it faces pressure to cut somewhere. The most common places those cuts appear are in formulary design, benefit structures, and utilization management.
In practice, a plan that drops from four stars to three stars may respond by tightening prior authorization requirements for certain drug classes or procedures, moving high-cost drugs to more restrictive tiers, or shrinking its benefit extras like over-the-counter allowances or dental coverage.
None of these changes may be announced with fanfare. You may simply notice, when you fill a prescription in January or seek a specialist referral, that something that was covered last year now requires an additional step or costs more.
Prior authorization is the area most directly affected. Research has consistently found that Medicare Advantage plans use prior authorization far more extensively than traditional Medicare. A 2022 report from the HHS Office of Inspector General found that Medicare Advantage plans denied 13 percent of prior authorization requests for services that met Medicare coverage rules, a finding that raised questions about whether utilization management was being used appropriately.³
When a plan is under financial pressure from a lower star rating, the pressure to tighten utilization management increases.
How to Know If Your Plan's Rating Dropped
CMS publishes star ratings for every Medicare Advantage plan on Medicare.gov, and this information is available in the "Find a Medicare plan" tool. You can look up your current plan by name and see its current star rating.
Your plan's Annual Notice of Change, mailed to you each fall before open enrollment, should also reflect any major benefit changes for the coming year. Reading this document is one of the most important things you can do as a Medicare Advantage enrollee. It spells out changes to your premium, cost-sharing, drug coverage, and prior authorization requirements.
If your plan's rating dropped from four or five stars to three stars, pay particular attention to the changes in your drug formulary and the prior authorization requirements for any specialty medications you take.
What to Do If Your Plan's Rating Dropped
If you are enrolled in a plan that dropped in its star rating, your first step is to compare alternatives during the annual enrollment period, which runs each fall from October 15 to December 7.
Use Medicare.gov's Plan Finder to compare plans available in your area. Enter your specific medications to see how different plans cover them and at what tier. A plan with a better star rating that covers your medications well may cost you less overall even if the premium is slightly higher.
If you are outside the enrollment window, you still have options. If your plan dropped to three stars or below for the current year, CMS may allow a Special Enrollment Period. Ask your plan directly about your enrollment rights if you are concerned about coverage quality.
If your plan denies a drug or procedure under its current formulary or prior authorization policies, you have the right to appeal. A denial is not final until you have exercised your internal appeal rights and, if necessary, requested an independent external review.
What This Means for You
A star rating is not just a quality score on paper. It is a signal about your plan's financial health and, indirectly, the generosity of your coverage. As CMS continues to refine the rating methodology, the plans at the margin of the four-star threshold face real financial pressure, and that pressure shows up in the formulary decisions and utilization management policies that affect you directly.
If your coverage feels more restrictive than it used to be, a change in your plan's star rating may be part of the explanation.
Ellen can help you understand a denial and build your appeal. Start here
Frequently Asked Questions
Where can I find my Medicare Advantage plan's current star rating?
CMS publishes star ratings for every Medicare Advantage plan at Medicare.gov. Use the "Find a Medicare plan" tool, search for your plan by name, and the current star rating is displayed on the plan's detail page. You can also call 1-800-MEDICARE (1-800-633-4227) to ask about your plan's current rating.
Can I leave my plan mid-year if its star rating dropped?
In most cases, you cannot leave a Medicare Advantage plan mid-year unless you qualify for a Special Enrollment Period. However, CMS provides a specific enrollment right for beneficiaries in plans rated below a certain threshold. Contact your State Health Insurance Assistance Program (SHIP) for free personalized counseling about your enrollment options.
If my plan denies a drug, does the star rating affect my appeal rights?
No. Your right to appeal a coverage denial is independent of your plan's star rating. You can request an internal appeal from your plan and, if that is denied, an independent external review through a CMS-contracted Independent Review Entity. These rights apply regardless of how your plan is rated.
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