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Top Performing Medicare Plans for 2016

The Centers for Medicare & Medicaid Services (CMS) strives to improve the quality of care for Medicare beneficiaries. One of the ways CMS does so is through the Overall Star Rating service, which rates the various aspects of a Medicare plan. The system gives consumers an easy overview of any given Medicare plan by simply ranking the plan on a scale of 1 (lowest) to 5 (highest). In this article, we’ll look at the highest-rated plans for 2016.


Ratings Calculation

The ratings range from 1 to 5 stars with 1 star being the lowest performing plan and 5-star plans deemed the best available. Besides providing an overall rating, Medicare also assigns ratings to individual categories. This is a convenient method of quickly learning the difference between plans.

Medicare reviews the performance of every plan, every year, and it announces the updated ratings each fall. After ensuring a plan covers your needs and is priced affordably, high Star Ratings should be the next attribute you look for. Here are the ways each plan is evaluated.[1]

Overall Ratings

  • Staying Healthy: Evaluates whether members received the requisite screenings, vaccines, and tests in order to stay healthy
  • Managing Chronic (Long-term) Conditions: Evaluates each plan’s performance ensuring individuals with chronic conditions get the right tests and treatments to help manage their condition
  • Member Experience: Analyzes member satisfaction ratings for each plan
  • Member Complaints: Looks at how often members and Medicare found problems with the plan; determines if the plan has improved over time
  • Customer Service: Measures how well plans handle member appeals

Part D Ratings

  • Customer Service: Measures how well plans handle member appeals
  • Member Complaints: Gauges how often Medicare and members found problems with the plan, as well as whether its performance changed over time
  • Member Experience: How members rate the plan
  • Drug Safety and Accuracy of Pricing: Analyzes whether members with certain medical conditions are prescribed drugs in a clinically recommended manner for their condition; pricing information of each plan is also a consideration

Information on Part D plans comes from a number of sources, and it can be based on Medicare’s own monitoring activities, reviews of billing, and member surveys.[2]

There is a host of other data analyzed by Medicare, which you can view on its official website.

How Medicare Parts C and D Rated for 2016

A total of 17 Medicare plans received the coveted 5-star rating for 2016; 12 were Medicare Advantage plans with prescription drug coverage (MA-PD), three were Medicare Advantage only plans (MA-only), and two were standalone prescription drug plans (PDP).

5-star MA-PD Plans

  • Kaiser Foundation HP, Inc. (California)
  • Cigna Healthcare of Arizona Inc.
  • Kaiser Foundation HP of CO (Colorado)
  • Group Health Plan Inc. (Minnesota and Wisconsin)
  • Kaiser Foundation HP Inc. (Hawaii)
  • Tufts Associated Health Maintenance Organization (Massachusetts)
  • Kaiser Foundation HP of the Mid-Atlantic STS (District of Columbia, Maryland, and Virginia)
  • Gundersen Health Plan (Iowa and Wisconsin)
  • Essence Healthcare Inc. (Illinois and Missouri)
  • Kaiser Foundation HP of the Northwest (Oregon and Washington)
  • Sierra Health and Life Insurance Company (many states, including Texas and New Jersey)
  • Martin’s Point Generations, LLC (Maine and New Hampshire)

5-star MA-only Plans

  • Dean Health Plan Inc. (Wisconsin)
  • Medical Associates Clinic Health Plan (Wisconsin)
  • Medical Associates Health Plan, Inc. (Iowa and Illinois)

5-star PDP Plans

  • Wisconsin Physicians Service Insurance Corporation (Wisconsin)
  • Tufts Insurance Company[3]

Overall Impressions

Overall Star Ratings performance of Part C and D plans for 2016 improved from 2015. Forty-nine percent of MA-PD plans earned 4 stars or more in 2016 compared to just 40 percent in 2015.

Consumers have also begun to more widely adopt and value the rating system: 71 percent of Medicare enrollees are in a 4-star plan, up from 60 percent in 2015 and 52 percent in 2014.[4]

Unfortuantely, six plans received less than three stars for three consecutive years. These plans could now technically face elimination from the Medicare program due to consistently poor performance. CMS issued a final notice to these plans in 2015, saying that nonrenewal letters would be sent to the offending plan providers in February 2016 if they failed to improve their star ratings. Contracts with these providers are scheduled to end on December 31, 2016.[5]

The plans in question are:

  • Touchstone Health HMO, Inc.
  • Cuatro LLC (also known as Access Medicare)
  • WellCare of Louisiana
  • Windsor Health Plan Inc.
  • GHS Managed Health Plans, Inc.
  • Sierra Health and Life Insurance Company, Inc.[6]

Although two PDP plans made the 5-star grade, standalone Part D plans as a group averaged just 3.4 in 2016, down from 3.75 in 2015. One of the primary providers has outdated technology that incorrectly rejects prescriptions, which has led to the decline in scores.[7]

How to Use the Ratings

Although it is tempting to opt for a 5-star plan if it is available, star rating is just one of many factors. You also need to determine whether the plan is within your budget, if it includes your local pharmacy in its network, and if it covers all the drugs and services that you require.

You can spot low performers by looking for a flag on the Medicare Plan Finder; you’ll see an icon of an upside-down red triangle with an exclamation point inside. If you wish to enroll in one of these plans, you must call the provider directly, as you cannot do so via the Plan Finder.

If you are already on a low-performing plan, Medicare will send you a letter to inform you of this. Although you will not face removal from it, receiving this letter should be a signal to review the plan and confirm if it is still the best fit for you.

You can only change or enroll in Medicare Advantage and Part D plans at certain times of the year. However, a Special Enrollment Period (SEP) may be available if you wish to switch to a plan in your service area with an overall rating of 5 stars.

It is only possible to use the SEP once per calendar year; it begins on December 8 of the year before the plan receives 5-star status and ends November 30 in the year after the plan gets the coveted rating. All enrollments become effective on the first day of the following month.[8]











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