Medicare Advantage Ratings 2026 in Newport Beach, CA

What 2026 Medicare Advantage star ratings actually are

Every year the Centers for Medicare & Medicaid Services scores Medicare Advantage and Part D drug plans on a scale of one to five stars, in half-star steps. The results appear on Medicare.gov’s plan comparison tool next to each plan’s premium and estimated costs, and CMS posts the full technical files on its Part C and D performance data page. Plans are allowed to advertise their overall score, which is why the number turns up on mailers in Newport Beach every autumn.

The year in the label is the plan year the ratings are shown for, not the year they were calculated. The 2026 Medicare Advantage star ratings were released in the fall of 2025 so people could compare plans for coverage starting in January 2026. The set CMS released this October carries next year’s label and is the one you see while shopping during the current annual enrolment period. If a flyer quotes a rating without a year, ask which one it is.

There are three kinds of score. A Medicare Advantage plan that includes drug coverage gets an overall rating plus separate summary ratings for its health services and its drug services. A plan without drug coverage gets a health rating only. A standalone Part D plan, the kind someone in Original Medicare buys alongside a Medicare Supplement, gets a drug rating only. Medicare Supplement policies themselves are not star rated at all; they are standardized by law, and the meaningful differences between them are price, the insurer’s pricing history and service.

Two labels are worth recognizing. A plan marked as too new or too small to be rated simply has not built up enough data yet, which says nothing about quality in either direction. A plan carrying the low performing icon has scored below three stars for several years in a row, and Medicare treats that as a warning to members rather than a routine score.

The rest of this guide covers what goes into the number, where it falls short, and how to put it to work for a Newport Beach household without letting it make the decision for you.

What the measures cover, category by category

The overall score is built from dozens of individual measures, grouped into categories. CMS adds, retires and reweights measures from year to year, so the mix shifts, but the broad shape has been steady for some time.

On the health side the categories are:

• Staying healthy. Whether members get screenings, vaccines and checkups at the expected rate: cancer screenings, annual flu shots, the kind of routine care that catches problems early.
• Managing chronic conditions. How well the plan’s members with diabetes, heart disease, high blood pressure or osteoporosis are followed, including follow-up after a hospital stay and whether medication reviews happen.
• Member experience. Survey answers from members about getting appointments quickly, getting needed care and rating the plan overall.
• Complaints and changes in performance. How often members complain to Medicare, how many leave the plan, and whether the plan is getting better or worse over time.
• Customer service. Whether appeals are decided on time and fairly, and whether the call centre answers and can help callers who need an interpreter.

On the drug side the measures look at customer service, complaints and members leaving, member experience with getting prescriptions filled, and drug safety and pricing accuracy: whether the plan flags risky combinations, whether members with certain conditions stay on their medication, and whether the prices posted on Medicare.gov match what the plan actually charges.

Not every measure counts equally. CMS gives heavier weight to some, particularly outcome measures, member experience and access, and lighter weight to process measures that simply count whether a step was taken. CMS has also been adjusting how it rewards plans that do well for members with lower incomes or disabilities, a change that moves some contracts up and others down independent of anything a given member would notice.

The practical point is that a single overall number blends very different things. A plan can be excellent at screenings and mediocre at answering the phone. The individual measure scores, visible by clicking into a plan on Medicare.gov, are often more useful than the headline score, because you can look at the parts that match your own situation.

Where the data comes from and why it runs behind

The measures draw on several sources, and each brings its own delay.

Clinical quality data comes from records plans submit about the care their members received during a measurement year. Collecting, auditing and scoring that data takes many months, so a rating shown this autumn largely reflects care delivered well before last January.

Member surveys are mailed and phoned to a sample of members, who rate their experience with the plan, their doctors and their drug coverage. The answers reflect how the plan felt to the people who happened to be sampled, at the time they were asked.

Administrative data from CMS itself covers complaints, members leaving, appeal timeliness and call centre tests in which CMS staff phone the plan posing as callers.

Prescription claims feed the drug safety and medication adherence measures.

The result is a picture with a built-in lag. If a plan changed its medical groups, tightened its prior authorization rules, or merged with another contract in the last year, the score you see may not reflect it yet. The reverse also happens: a plan that fixed a weak call centre may carry a lower score for a cycle after the problem is gone.

None of this makes the ratings unreliable. It makes them a record of past performance, which is a reasonable guide to future performance but not a guarantee of it. When you read a score, the honest question is: what was this plan like for its members a year or two ago, and has anything I care about changed since? The plan’s current Annual Notice of Change and Evidence of Coverage answer the second half of that question; the rating cannot.

The limits a single number cannot overcome

Ratings are most useful once you know what they are blind to. Five limits matter most for someone shopping in Newport Beach.

The score belongs to the contract, not your plan. An insurer may run many plans under one Medicare contract, sometimes spread across several states. All of them share one rating. The HMO you are considering, with its particular Orange County medical groups, may perform better or worse than the contract average that is printed next to it.

It is an average of other people’s experience. A plan that does well for members who mostly need screenings can still be a poor fit for someone managing a complex cancer or a rare condition. The members whose results build the score may look little like you.

It does not see your doctors. No measure tells you whether your cardiologist, your orthopaedic surgeon or the physician group you have used for a decade is in the network. A five-star plan that excludes your doctors is a worse plan for you than a lower rated one that includes them.

It does not see your drugs or your costs. The drug measures check pricing accuracy and safety across the membership. They do not tell you whether your medication is on the formulary, which tier it sits on, or what you would pay over a year. Two plans with the same score can produce very different bills for the same prescription list.

It only partly sees friction. Prior authorization requirements, referral rules and the time it takes to get a specialist approved affect daily life more than most measures. Appeals and access survey questions capture some of that, but only indirectly, and only for the members sampled.

There is also the question of who is selling. A rating is easy to repeat, and it is sometimes used to close a conversation rather than start one. If anyone, including us, leads with a plan’s score and never asks about your doctors and prescriptions, the comparison has not really started.

The Medicare Advantage star ratings decline, explained

Over the last several rating cycles, fewer Medicare Advantage contracts have reached the top of the scale than in the years just before. People who stayed in the same plan have noticed their score slip, and some insurers have mentioned it when explaining benefit changes. Three forces sit behind the Medicare Advantage star ratings decline.

The pandemic adjustments ended. During the public health emergency, CMS used special rules that protected plans from sharp drops in measures disrupted by closed offices and postponed care. When those rules expired, scores returned to being calculated on actual performance, and some fell.

The scoring method changed. CMS altered how it sets the cut points that divide one star level from the next, including removing extreme outliers before setting them, and shifted weight toward member experience and access. Those changes raised the bar on some measures. Several insurers challenged their results in court, and in a number of cases CMS recalculated and published corrected scores.

Some performance did slip. Call centre tests, appeal timeliness and member experience surveys moved for real at some plans, and those are areas a member feels directly.

Why it matters to you: plans rated at four stars or above qualify for quality bonus payments from Medicare, and plans use that money, along with other payments, to fund lower premiums and supplemental benefits such as dental, vision, hearing or fitness. When a contract drops below that line, the bonus shrinks and the extras can follow the next year. That is one reason a plan’s Annual Notice of Change deserves a careful read this autumn.

What a drop does not mean: it does not mean your doctors left, that your claims will be denied, or that the plan has become unsafe. A half-star change may reflect a methodology shift more than anything a member experiences. Treat a decline as a prompt to recheck the network, the formulary and the benefit changes, and to compare the alternatives. If they still fit better where you stand, the score alone is not a reason to move.

What a rating answers, and what to check instead

The quickest way to put ratings in their place is to list the questions people bring to a plan comparison and ask which ones the score can answer.

Six of the nine questions get no answer from the score at all. That is not a flaw in the ratings; they were built to compare quality across contracts, not to tell one person which plan fits. Medicare’s own guide to health plan options makes the same point by putting network type, costs and coverage rules ahead of the comparison of scores.

The network check for Newport Beach

In Newport Beach the network question usually starts with Hoag. Many residents have used Hoag Hospital Newport Beach and the physicians around it for years, others see specialists at UCI Health in Irvine or Orange, and some keep doctors in Los Angeles. Which of those a Medicare Advantage plan reaches depends on its contracts with medical groups and hospitals, and those contracts change. Do not rely on what a neighbour’s plan covered last year.

Most Orange County HMOs work through medical groups or independent physician associations. When you join, you choose a primary doctor, and that choice usually ties you to the group’s specialists and hospitals. A plan can be in network with a hospital overall while the particular group you pick sends patients somewhere else. The step people skip is confirming the group, not just the doctor.

A careful network check looks like this:

1. List every doctor you have seen in the last two years and the group or practice each one bills through.
2. Search each name in the plan’s current provider directory for the coming year, not the current one.
3. Call each office and ask whether it will accept that specific plan next year, by plan name. Directories lag behind contracts.
4. Confirm which hospital the medical group admits to, and whether emergency and urgent care rules are clear to you.
5. If you split the year between Newport Beach and somewhere else, a desert home, family out of state, long trips on the water, check how the plan handles routine care away from home.

That last step matters more here than in many cities. An HMO covers emergencies and urgent care anywhere in the country but generally covers routine care only in its service area. A PPO often covers out-of-network care at higher cost. For someone who spends months away, plan type can outweigh a whole star of difference.

If you are still working, or covered through a spouse’s employer, the comparison changes again. The Newport Beach health insurance guide covers how employer and individual coverage interact with Medicare timing, and Medicare’s getting started page sets out the enrolment windows.

The drug check, and the separate Part D score

A Medicare Advantage plan with drug coverage carries a drug summary rating as well as a health rating. It is worth looking at separately, because a plan can score well on health and poorly on drugs, or the reverse. Still, the drug score is about how the plan treats its members overall. Whether it suits you depends on your own list.

Start with every medication, dose and frequency, including anything injected or infused and anything you take only part of the year. Then, for each plan on the shortlist:

• Confirm each drug is on the formulary for next year, not this year. Formularies change on January first.
• Note the tier. The same drug can sit on a different tier at a different plan, and tiers drive what you pay.
• Look for restrictions: prior authorization, step therapy (trying a cheaper drug first) and quantity limits.
• Check which pharmacies are preferred. A plan’s lowest prices may apply only at certain chains or through mail order.
• Run the list through the Medicare.gov drug price tool to see an estimated annual cost.

Federal changes to Part D have also reshaped drug costs, including a yearly cap on what members pay out of pocket for covered drugs. Medicare’s Part D overview carries the current rules and the current figure, which is updated annually. Plans responded to those changes by adjusting formularies and premiums, so last year’s comparison is a poor guide to this one.

Someone in Original Medicare with a Medicare Supplement policy buys a standalone Part D plan, and its drug rating is the only score that applies to them. The same checklist works there. The Medicare Supplement side has no rating, so the comparison there is premium, the insurer’s history of price increases, and service. Medicare’s page on what Medicare costs covers the premiums every enrollee pays regardless of plan choice.

A ratings-aware decision order, with three Newport Beach households

Put the checks in order and the rating finds its natural place:

1. Original Medicare or Medicare Advantage? Decide the structure first, because it determines which ratings apply.
2. Network. Remove every plan that does not reach your doctors, your medical group and your hospital.
3. Drugs. Remove every plan that leaves a medication uncovered or restricted in a way you cannot live with.
4. Cost. Compare premium, copays and the maximum out-of-pocket for a normal year and a hard one.
5. Rating. Among plans still standing, prefer the stronger score, and read the individual measures that match your needs.

Two rating rules can change timing. A plan with a five-star overall rating can be joined through a special enrolment period once a year, outside the usual window, which is handy if a top rated plan fits and you missed open enrolment. And members of a plan flagged as a consistent low performer may be able to switch through a special enrolment period of their own. Neither rule reopens a Medicare Supplement guarantee, so moving out of Medicare Advantage later still depends on the trial right described below.

A Corona del Mar couple, both new to Medicare. Their doctors belong to one large medical group and they want Hoag for anything serious. The top rated plan on their screen does not include that group. The second plan does, carries a solid but lower score, and covers both of their prescriptions on low tiers. They take the second plan and keep the comparison sheet for next autumn.

A widower on the Balboa Peninsula who winters out of state. His current HMO is highly rated, but he has paid for routine care away from home twice. Plan type matters more to him than score. He weighs a PPO against returning to Original Medicare with a Supplement, knowing that outside the trial right he would face health questions for Medigap.

A Newport Coast retiree on a specialty medication. Her plan’s score dropped this year after the methodology changes, and a neighbour told her to leave. Her drug sits on the same tier, her specialist stays in network, and the Annual Notice of Change shows only a minor benefit change. She stays, and sets a reminder to check again next September.

If you would like the same worksheet filled in for your own doctors and prescriptions, reach Joseph Antonucci through the contact page. Readers who are also veterans should see how Medicare Advantage works alongside VA care, and the general Medicare Advantage explainer from our Yorba Linda series covers HMO and PPO structure in more depth. To see how health costs fit retirement income, try the retirement income calculator. If a sales experience felt wrong, the California Department of Insurance consumer help line takes complaints.

Rules That Protect a Newport Beach Shopper Comparing Rated Plans

A plan’s quality score sits inside a set of federal and California rules. Knowing them keeps a good number from becoming the only thing you look at.

A rating may be advertised, but not bent. Federal marketing rules let a plan mention its overall rating only alongside the rating year, and only the rating Medicare actually published for that contract. A flyer that rounds a score up, quotes an old year as current, or implies Medicare endorses one plan over another is a reason to stop and check the score yourself on Medicare.gov.

Nobody may press you with a deadline that is not real. Agents cannot cold call, show up uninvited, or claim a rating is about to change to rush a signature. The annual enrolment period and any special enrolment period you qualify for are published by Medicare, not by a salesperson.

A first move into Medicare Advantage can be reversed. If you join a Medicare Advantage plan for the first time, a federal trial right lets you return to Original Medicare within the first year and buy certain Medicare Supplement policies without health questions. Once that year passes, California’s birthday rule helps people who already hold a Medigap policy switch, but it does not reopen Medigap to someone leaving Medicare Advantage.

Counsellors who are paid to explain, not to enrol. The California Department of Aging funds HICAP, the free state Medicare counselling service. A counsellor can walk through a plan’s rating, its Evidence of Coverage and its drug list with you and has no commission riding on the outcome.

Every seller needs a California licence. The California Department of Insurance keeps a public licence lookup that shows a producer’s status, lines of authority and any public discipline. Run it before you hand anyone your Medicare number, including this practice.

How an Independent Producer Uses Ratings in a Plan Review

Joseph Antonucci is a licensed independent insurance producer, California licence #4360370, with authority for Life and Accident & Health. He is not tied to one insurer, so Medicare Advantage, Medicare Supplement and Part D plans from multiple carriers can be compared for a Newport Beach household on the same page.

In a review, the published rating is one column, not the verdict. The other columns come from you: the doctors you see and the medical groups they bill through, the hospital you would want after a fall, every prescription with its dose, and the months you spend away from Orange County. Each shortlisted plan is checked against that list, and the rating then helps break ties between plans that already fit.

Some things fall outside the role:

• No medical advice. Choosing a doctor, a treatment or a drug is for you and your clinicians.
• No tax or legal advice. Joseph Antonucci is not a CPA or an attorney. Income-related premium adjustments, Medi-Cal planning, trusts and estate questions belong with one or both.
• No securities. Variable annuities and variable universal life require FINRA registration on top of an insurance licence and are discussed for comparison only, not placed.
• No property and casualty. Auto, home, renters, umbrella and boat coverage sit outside the licence; we can refer you to a licensed property & casualty agent.

The review is free and carries no obligation to enrol in anything.

Frequently Asked Questions

What are Medicare Advantage ratings for 2026?

They are the one to five star scores CMS assigned to Medicare Advantage and Part D contracts for the 2026 plan year, released in the fall of 2025. They summarize preventive care, chronic condition management, member experience, complaints and customer service. The ratings released this October carry next year’s label.

Where can I see 2026 Medicare Advantage star ratings for plans in Newport Beach?

Medicare.gov’s plan comparison tool shows each plan’s overall score next to its costs once you enter your ZIP code. Click into a plan to see the summary and individual measure scores. CMS also publishes the full data files for anyone who wants the detail.

Is a five-star plan always the best choice?

No. A five-star rating describes how a contract performed for its members on average. If that plan leaves out your doctors, your medical group or one of your prescriptions, a lower rated plan that covers them will usually serve you better.

Why have Medicare Advantage star ratings declined?

Pandemic-era protections ended, CMS changed how it sets the thresholds between star levels and reweighted some measures, and some plans’ service and member experience slipped. Several insurers disputed their results and some scores were recalculated. A decline is a reason to recheck your plan, not automatically to leave it.

Does a lower rating mean my benefits will change?

It can. Plans rated four stars or higher receive quality bonus payments that often fund supplemental benefits and lower premiums, so a drop below that level can affect next year’s extras. The Annual Notice of Change your plan sends each September shows what is actually changing.

Can I switch plans because of a Star Rating?

During the annual enrolment period anyone can switch for any reason. Outside it, a five-star special enrolment period lets you join a plan rated five stars once a year, and members of plans flagged as consistent low performers may qualify for their own special enrolment period.

Are Medicare Supplement plans star rated?

No. Medicare Supplement policies are standardized, so the benefits of a given plan letter are the same from every insurer. Compare them on premium, the insurer’s history of increases and service. A standalone Part D plan bought alongside a Supplement does carry a drug rating.

Why does my plan share a rating with plans in other states?

Ratings are assigned to the Medicare contract, and one contract can hold many plans across several regions. Your local plan inherits the contract score even if its own medical groups perform differently.

What does it mean if a plan is too new to be rated?

It has not enrolled members long enough, or in enough numbers, to produce reliable scores. That says nothing good or bad about quality. Judge it on network, drugs and cost, and on the insurer’s ratings for its other contracts if those help.

Do Star Ratings measure prior authorization or denials?

Only partly. Appeals measures and member survey questions about getting needed care reflect some of that experience. The plan’s Evidence of Coverage tells you which services need approval in advance, and that is the better source for your own situation.

Should a Newport Beach resident check Hoag access separately?

Yes. Ratings do not reflect which hospitals or medical groups a plan contracts with. Confirm the medical group you would join, which hospital it uses, and call the doctors’ offices to ask about next year by plan name.

Does it cost anything to have someone review ratings and plans with me?

No. HICAP counselling is free and state funded, and a plan review with Joseph Antonucci carries no fee or obligation. Questions about taxes, trusts or Medi-Cal planning should go to a CPA or an attorney.

A Star Rating is worth reading, as long as it comes after the questions only your own doctors and prescriptions can answer. To keep reading, the Newport Beach resource hub collects local coverage guides, the Newport Beach Medicare overview explains Parts A through D and when to enrol, and the Medicare library holds every article in this series. If retirement income is on the table too, start with our planning tools. We work with Newport Beach residents and the rest of Orange County from Irvine at (949) 656-5301.

This article is general education, not individualized medical, financial, tax or legal advice. It is not connected with or endorsed by the United States government or the federal Medicare program. Star Ratings are published by the Centers for Medicare & Medicaid Services, are assigned to contracts rather than individual plans, and are recalculated every year. Premiums, networks, drug coverage, supplemental benefits and availability are set by each plan, differ by county and ZIP code, and can change every plan year. Nothing here is an offer, a quote or a promise of what any plan will pay. Medicare Supplement guarantees depend on the claims-paying ability of the issuing insurance company and are not insured by the FDIC or backed by any government agency. Confirm a plan’s terms in its Evidence of Coverage before enrolling, and consult a qualified tax advisor or attorney on anything involving taxes, trusts or Medi-Cal eligibility.

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