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Medicare Star Ratings and the 5-Star Special Election Period

Blake Hardy by Blake Hardy | Licensed since 2010
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This article was updated on: 12/06/2016

Are you unhappy with your current plan or need a change? The Medicare 5-Star Special Election Period (SEP) may be a good time to switch to a 5-star rated Medicare Advantage plan, Medicare Prescription Drug Plan, or Medicare Cost Plan.

Medicare plans are assessed for a variety of factors, including member satisfaction, customer service, use of needed services and preventive care, and more. If the plan covers prescription drug benefits, it’s also rated on the accuracy of pricing information and patient safety.

Medicare star ratings may help you compare the quality and performance of different plan options. This article will share more about the rating system and the SEP to help you find a good fit.

What are Medicare star ratings?

Medicare updates the star ratings every fall for the following year. It’s important to always check your plan’s star rating as you consider your coverage options for the coming year.

The Medicare star ratings apply to:

Each plan is rated on a scale of 1 star (“Poor”) to 5 stars (“Excellent”), using information from Medicare plans, providers, and member satisfaction surveys. Medicare rates the plans in individual categories and gives each one a single, overall star rating.

What do Medicare star ratings measure?

For plans covering health services, the overall Medicare star rating is a quality measure of services within the following categories:

  • Staying healthy: member screenings, tests, and vaccines
  • Management of chronic (long-term) conditions: how often members use certain tests and treatments
  • Member experience with the health plan: member satisfaction
  • Member complaints and changes in the health plan’s performance: problems that members found with the plan and if it improved
  • Health plan customer service: how the plan handles member calls and appeals

For plans covering prescription drug services, the overall Medicare star rating is a quality measure of the following categories:

  • Prescription drug plan customer service
  • Member complaints and subsequent changes in performance
  • Member experiences with the plan’s prescription drug services
  • Prescription drug safety and accuracy of pricing

For plans that cover both health and prescription drug services, the overall Medicare star rating covers the topics in all categories. You’ll see the star rating while browsing and comparing Medicare plan options, and it could be a quick way to judge a plan’s quality.

What is the 5-Star Special Election Period (SEP)?

You can change your Medicare Advantage plan or Medicare Part D Prescription Drug Plan during the Annual Election Period (October 15 to December 7 every year). However, the Medicare 5-Star Special Election Period is a special opportunity to switch to a 5-star rated plan during a much longer timeframe.

The 5-Star SEP takes place every year from December 8 to November 30 of the following year, and you can make a switch one time during this timeframe (if you meet the plan’s enrollment requirements). After the plan receives your application, you’re typically covered beginning the first day of the following month; this is known as your coverage “effective date.”

How do you become eligible for 5-star plans?

Generally, you can switch to a 5-star Medicare Advantage plan, Medicare Prescription Drug Plan, or Medicare Cost Plan as long as you meet the eligibility requirements. Eligibility criteria include:

  • Having Medicare Part A and Part B, if you want to switch to a Medicare Advantage plan
  • Having either Medicare Part A or Part B, if you want to enroll in a stand-alone Medicare Prescription Drug Plan
  • Having at least Part B, if you want to switch to a Medicare Cost Plan
  • Living in the service area of the plan you want to join

What changes can you make to your 5-star plan?

As you read above, Medicare star ratings are updated every fall, which determines which 5-star rated plan options you can choose. For example, if a Medicare Advantage plan has a 5-star rating for the current year, but loses a star for the following year, you can only use the 5-Star Special Election Period (SEP) to enroll in this plan up until November 30, for an effective date beginning December 1. You wouldn’t be able to enroll in the plan after December 1 (for an effective date of January 1 the following year), because the plan doesn’t have a 5-star rating for the next year.

If you’d like to enroll in a Medicare Advantage plan during the SEP, you can:

  • Disenroll from Original Medicare and enroll in a 5-star Medicare Advantage plan.
  • Switch from any Medicare Advantage plan to a 5-star Medicare Advantage plan.
  • Switch from a 5-star Medicare Advantage plan to a different 5-star Medicare Advantage plan.

If you’d like to enroll in a Medicare Prescription Drug Plan during the SEP, you can:

  • Switch from a Medicare Prescription Drug Plan to a 5-star Medicare Prescription Drug Plan.
  • Switch from a 5-star Medicare Prescription Drug Plan to a different 5-star Medicare Prescription Drug Plan.

You may also disenroll from a Medicare Advantage plan or a Medicare Prescription Drug Plan and enroll in a 5-star rated Medicare Cost Plan. As mentioned above, Medicare Costs Plans are different from Medicare Advantage plans, and you may enroll in one even if you only have Medicare Part B. Some plans include prescription drug coverage, while others only cover Part B benefits. You can check with the individual insurance company for more information.

What else should you be aware of when switching Medicare plans?

When deciding whether to switch plans during the 5-Star Special Election Period, carefully consider the consequences. Here are some Medicare plan rules that still apply to this election period:

  • If you switch from a Medicare Advantage plan with prescription drug coverage to a 5-star Medicare Advantage plan without prescription drug coverage, you may have to wait until the next Annual Election Period to receive this coverage. Then, you could pay a penalty unless you have other creditable prescription drug coverage.
  • If you have a Medicare Advantage plan that includes prescription drug coverage but also enroll in a stand-alone Medicare Prescription Drug Plan, you could be automatically disenrolled from your Medicare Advantage plan and returned to Original Medicare. You usually won’t be able to get a stand-alone Medicare Prescription Drug Plan if you have a Medicare Advantage plan, unless you have certain types of Medicare Advantage plans, such as a Medical Savings Account plan or a Private Fee-for-Service plan.

I hope this article was helpful to you, especially if you’re considering switching to a different Medicare plan option during the 5-Star Special Election Period. If you have questions about Medicare star ratings or anything else, please schedule a phone appointment or have me email you more information using the links below. Or, if you’d like to compare Medicare plan options on your own, please use the Find Plans or Compare Plans buttons on this page. To learn more about me, click on the “View profile” link. For personalized help with your Medicare questions, please call us to reach a licensed insurance agent.

Call Medicare.com’s licensed insurance agents at 1-844-847-2660 (TTY users 711) Monday through Friday, 8 AM to 8 PM ET.

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Blake Hardy |
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Licensed Insurance Agent since 2010
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