The Medicare Star Rating system was instituted by CMS back in 2007 to focus on improving plans and enable Medicare beneficiaries to compare plans. CMS began publishing the Medicare Part C and D Star Ratings annually in 2009, where the stars measure the quality of health and drug services.
Medicare Star Ratings measure more than 30 different topics in five categories for MA plans and 14 topics in four categories for part D prescription drug plans. Plans that are both MA and Part D are measured across more than 45 topics in 9 categories, and results come from member surveys and information that plans and healthcare providers submit to Medicare.
When discussing Star Ratings with a Medicare beneficiary, it’s helpful to let them know how the plans are rated. The Star Rating categories include preventive services, management of chronic conditions, drug pricing and patient safety as well as customer services and member experience, including member complaints and performance.
Medicare uses the gathered data to rate the plans. A plan can get a rating between 1 and 5 stars. A 5-star rating is considered excellent. If a Medicare Advantage Plan, Medicare drug plan, or Medicare Cost Plans with a 5-star rating is available in the beneficiary’s area, they can use the 5-star Special Enrollment Period to switch from their current Medicare plan to a Medicare plan with a “5-star” quality rating. The special Enrollment Period can only be used once between December 8 and November 30.
MAPD TO PDP
If a beneficiary moves from a Medicare Advantage Plan that includes prescription drug coverage to a stand-alone Medicare Prescription Drug Plan, they will be disenrolled form the Medicare Advantage Plan, including the health benefit and will be returned to Original Medicare for coverage of their health services. Beneficiaries can only switch to a 5-star Medicare Prescription Drug Plan if one is available in their area.
MAPD TO MA
If a beneficiary moves from a Medicare Advantage Plan that has drug coverage to a 5-star Medicare Advantage Plan that doesn’t, they may lose their prescription drug coverage and must wait until their next enrollment opportunity go get drug coverage. They may also have to pay a Part D late enrollment penalty.
In addition to the Medicare 5-Star Special Enrollment Period, there are certain Medicare enrollment periods during which a Medicare eligible beneficiary may enroll in a 5-Star Medicare Advantage Plan.
Medicare Initial Enrollment Period
- Sign up for a 5-Star plan or any plan of any rating, when first eligible for MA
- Eligibility begins once enrolled in both Medicare Part A and Part B (and does not have End-Stage Renal Disease).
- Only eligible to enroll in plans offered in their area.
- 7-month Medicare Initial Enrollment Period begins 3 months before turning 65 years old, includes the birthday month, and continues for 3 months thereafter.
Medicare Annual Enrollment Period
- Medicare beneficiaries already enrolled in Part A and/or Part B may sign up for an MA plan during the fall Annual Enrollment Period, October 15 to December 7, each year.
- If already enrolled in an MA plan, may use this time to switch to a different MA plan.
Between April 1 and June 30
- For those who already had Part A of Medicare but waited to sign up for Part B during the Medicare general Enrollment Period (January 1 to March 31 each year), they can sign up for a Medicare Advantage plan between April 1 and June 30.
A Special Election Period
- Being enrolled in an MA plan with fewer than 5-Stars is not the only way to qualify for an SEP. Special Enrollment Periods may be granted to individuals for a variety of circumstances, such as living outside the U.S. at the time of their initial Medicare eligibility or residing in a long-term care facility.
5-Star Plan Marketing Limitations
You can let your Medicare eligible clients know that SEPs are available and that you can enroll them in a 5-Star plan if they’d like to switch. You cannot reach out to specific clients who are enrolled in lower-rated plans, and you cannot ask your clients to request an SEP. When in doubt, keep your communications brief and informative, then direct prospects and clients to call you for more information.