Medicare enrollment and evolving CMS quality standards

Medicare eligibility is generally available to individuals aged 65 and older, as well as those under 65 with specific disabilities, end-stage renal disease, or ALS. The program consists of four parts: Part A (hospital insurance), Part B (medical services), Part C (Medicare Advantage), and Part D (prescription drug coverage).

For many beneficiaries, enrollment is automatic if they have been receiving Social Security or Railroad Retirement Board benefits for at least four months prior to turning 65. While Part A coverage is often provided without a premium, certain individuals may be required to pay if they have not paid Medicare taxes for at least 10 years.

To improve health outcomes, the Centers for Medicare and Medicaid Services (CMS) is shifting its Star Ratings system. The new approach rewards Medicare Advantage plans that demonstrate actual health improvements—such as medication adherence and closing care gaps—rather than just documenting existing health issues. This shift aligns with the work of Community Health Workers, who assist members in navigating social barriers like transportation and language to ensure effective care follow-through.