Part D drug plans and Medicare Advantage Plans vary greatly in terms of costs and coverage. Each January, plans change their coverage and costs for the new calendar year. Every fall, you should go over your plan’s coverage and compare it with other plans in your area to make sure you have the coverage that is best for you. Examine a plan’s coverage, costs, drug coverage and the pharmacies in its network to see if it best meets your needs. After considering those factors, you can use the plan’s star rating from Medicare to help you select a plan that’s right for you.
What are the Medicare Star Ratings?
Medicare uses a Star Rating System to measure how well Medicare Advantage and prescription drug (Part D) plans perform. Medicare scores how well plans did in several categories, including quality of care and customer service. Ratings range from 1 to 5 stars, with five being the highest and one being the lowest score. Medicare assigns plans one overall star rating to summarize the plan’s performance as a whole. Plans also get separate star ratings in each individual category reviewed. The overall star rating score provides a way to compare performance among several plans. To learn more about differences among plans, look at plans’ ratings in each category.
Medicare reviews plan performances each year and releases new star ratings each fall. This means plan ratings change from one year to the next. Medicare sets the categories and reviews each plan the same way. You should look at coverage and plan costs, such as if the Part D plan covers all the drugs you take and has a premium you can afford before you consider the star rating.
Medicare health plans are rated on how well they perform in five different categories:
1. Staying healthy: screenings, tests, and vaccines
2. Managing chronic (long-term) conditions
3. Plan responsiveness and care
4. Member complaints, problems getting services, and choosing to leave the plan
5. Health plan customer service
Medicare drug plans are rated on how well they perform in four different categories:
1. Drug plan customer service
2. Member complaints, problems getting services, and choosing to leave the plan
3. Member experience with drug plan
4. Drug pricing and patient safety
Where can I find information on my plan’s star rating?
The star ratings can be found in the Medicare Plan Finder tool (www.medicare.gov/find-a-plan) or by calling 1-800-MEDICARE. New plan quality ratings come out each October and apply to the next calendar year (for example, plan ratings for 2017 will be available in October of 2016).
Note: The quality ratings stars found on Plan Finder and by calling 1-800-MEDICARE are the most up-to-date and may differ from the ratings listed in the Medicare and You handbook you received in the mail.
How can I use the star ratings to inform my plan choice this year?
A plan’s star ratings is only one factor to look at when you compare plans in your area. Even though a plan has a high star rating, it may not be right for you. You must also consider how much the plan is going to cost, and if it covers all the drugs and services you need and includes the pharmacy you need in its preferred network.
If Medicare gives a plan less than three stars (only one or two stars) for three years in a row, Medicare’s Plan Finder tool will flag the plan as low performing. The flag looks like a caution sign; an upside down red triangle with an exclamation point inside of it. You cannot use the Plan Finder tool to enroll into one of these low-performing plans. You will have to call the plan directly to enroll. If you are enrolled in a plan that gets one or two stars for three years in a row, Medicare will mail you a letter telling you this. You will not be removed from the plan, but if you receive this letter, check the plan’s costs and coverage to make sure it is still a good plan for you.
The five-star Special Enrollment Period (SEP)
Generally, you are limited in the times of year you can enroll in and change Medicare Advantage and Part D plans. A Special Enrollment Period (SEP) allows you to enroll in plans outside of these times. If you want to enroll in a plan or change plans, you can take advantage of an SEP to join or switch to a five-star Medicare Advantage or Part D plan. You can enroll into a Medicare Advantage Plan or stand-alone Part D plan in your service area that has an overall plan performance rating of five stars. You may only use this SEP once per calendar year. The five-star SEP starts Dec. 8 of the year before the plan is considered a five-star plan, and ends Nov. 30 of the year the plan is considered a five-star plan. Enrollments are effective the first of the following month.