Trying to choose between Medicare Advantage (MA) and Medicare Part D drug plans can feel overwhelming. Private insurers offer these plans, which means that costs and coverage differ, sometimes dramatically, for each plan. It’s also difficult to know how well a plan performs based simply on what you see on the provider’s website. The Medicare 5 Star Rating System helps you compare your plan options.
What Is the Medicare 5 Star Rating System?
The Medicare Star Rating System measures the performance of both Medicare Advantage and Part D plans across a number of categories. Plans are awarded one to five stars, with five being the best.
Medicare implemented this rating system as a way to help consumers make more informed decisions regarding their healthcare. The program publishes its ratings in October for the upcoming year. Beneficiaries use that information to aid plan comparisons during Annual Enrollment (October 7 through December 15) and Medicare Advantage Open Enrollment (January 1 through March 31).
Plans receive an overall rating as well as star ratings in different categories.
How Does Medicare Rate Plans?
Medicare rates plans according to a wide range of metrics in either five (MA) or four (Part D) categories. The plan’s overall rating is based on how it performs in each of these categories. For MA plans that offer prescription drug coverage, plans are rated according to both their health services and their drug coverage.
Medicare Advantage Plan Star Ratings
Plans that cover health services, i.e. Medicare Advantage plans, receive ratings in five categories.
- Staying healthy: Do members get preventive screenings, check-ups, and vaccines to help them stay healthy?
- Managing chronic conditions: Do members receive appropriate treatments and diagnostics to help manage chronic conditions?
- Member experience: How do the plan’s members rate it?
- Member complaints and plan improvement: Includes how often members complain about the plan as well as whether the plan implemented improvements.
- Customer service: How well does the plan respond to member questions?
To assign scores, the Medicare Star Rating System uses feedback and information from a variety of sources. This includes member surveys, Medicare’s own monitoring activities, and information submitted by both the plan and clinicians.
Medicare Part D Plan Star Ratings
Medicare rates prescription drug plans in four categories, with an overall rating based on those scores. These categories include:
- Customer service: How well does the Part D plan respond to its members questions?
- Member complaints and plan improvement: Category includes how often members complain and whether plan performance improved over the year.
- Member experience: How do members rate the plan?
- Drug safety and pricing accuracy: Are members prescribed medications safely and in a way that best serves their condition? Is pricing information accurate?
Medicare bases these ratings on information taken from member surveys, the program’s own monitoring services, and information submitted by the plan.
How to Use the Medicare 5 Star Rating System
The most up-to-date information on each plan’s rating is available on the Medicare Plan Finder tool. Five-star plans are tagged with a special icon, a star with a 5 in the center and a yellow triangle surrounding it.
Do not rely on the star ratings listed in your Medicare & You handbook. If you prefer to not use the Plan Finder, you can call 800-MEDICARE. Or, call Medicare Solutions toll-free at 855-350-8101. One of our licensed agents is happy to answer all of your questions and assist you in finding the best plan to suit your needs.
Medicare publishes its ratings for the following year each October. That means that the 2019 plan ratings came out in October 2018. You likely recognize October as the month Medicare Annual Enrollment opens. That’s to allow beneficiaries to compare available plans across the categories listed above.
A plan’s rating should not be your only consideration (just as cost should not be the single deciding factor). For example, a drug plan rated 5 stars still isn’t the right one for you if it doesn’t cover your prescriptions. In addition to rating and costs, look at the plan’s coverage, provider network, drug formulary, and preferred pharmacies.
When are plans flagged as low-performing?
If a plan receives less than 3 stars for three or more years, Medicare deems that plan “low-performing.”
Plan Finder tags low-performing plans with a red triangle containing an exclamation point. If your plan has been flagged as low-performing, Medicare will notify you. That doesn’t mean you have to leave the plan. It’s simply a warning that it may be time to review your coverage options.
To enroll in a plan flagged as low-performing, you must either call the plan or Medicare directly. Enrolling in one of these plans via Plan Finder is not an option.
What Is the 5-Star Special Enrollment Period?
Medicare offers a variety of Special Enrollment Periods (SEP). These occur outside of the program’s standard enrollment periods, such as the Annual Enrollment Period that occurs every fall.
The 5-Star SEP allows you to enroll in a 5-star MA plan, Medicare Cost Plan, or Part D prescription drug plan. This SEP begins on December 8 and continues through November 30 of the following year. So, when plan ratings were released in October of 2018, the SEP began December 8, 2018 and will end on November 30, 2019.
Cautions when using the 5-Star SEP
Certain changes made during the 5-Star SEP may result in loss of coverage in other areas. Specifically, if you have an MA plan that includes prescription drug coverage, consider the following:
- If you enroll in a 5-star Part D plan during the SEP, you are disenrolled from your MA plan and returned to Original Medicare.
- Changing to a 5-star MA plan without drug coverage means you may lose prescription coverage and will have to wait for Annual Enrollment. You may also face the Part D late enrollment penalty.
As we’ve said before, deciphering all of this information can be incredibly confusing. The licensed agents at Medicare Solutions are happy to help. The best part? It’s free! Call us today to get started.