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Questions and Answers about the Special Enrollment Period for 5-Star Rated Medicare Plans

Category: Star Ratings & plan quality
Published: Mar, 29 2012 10:03:12


Question: My insurance agent told me that I could get out of my current Medicare Advantage plan and join a Medicare plan with a “5-star” rating anytime during 2012.

Yes, if a 5-star rated plan is available in your service area. Starting this year, there is a new Special Enrollment Period (or SEP) that allows people a one-time chance to switch from their current Medicare plan to a Medicare plan with a "5 Star" quality rating at any time during the 2012 plan year (up to November 30th). 5-Star plans are available for stand-alone Medicare Part D plans and Medicare Advantage plans. As a note, if you are currently enrolled in a Medicare Advantage plan and decide to join a 5-Star Medicare Part D plan (a plan that only provides prescription drugs drug coverage), you would automatically be dis-enrolled from your Medicare Advantage plan and go back to your Original Medicare coverage along with your newly selected Medicare Part D prescription drug plan. You can click here to read more about the 5-Star Special Enrollment Period.

Question: I want to change to one of the 5-Star Medicare Part D plans, are they available in every state?

No. "5 Star" Medicare Part D and Medicare Advantage plans are available only in a limited number of states across the country. Currently, the only "5 Star" stand-alone Medicare Part D prescription drug plans (or PDPs) available in 2012 are the:

  • EXCELLUS HEALTH plans – statewide in New York, and
  • WELLMARK Blue Cross Blue Shield plans – statewide in IA, MN, MT, NE, ND, SD, and WY.

The 5-Star Medicare Advantage plans available in 2012 are:
  • Kaiser – select counties in CA, CO, HI, OR and WA;
  • Group Health Cooperative – select counties in WA;
  • Gundersen Lutheran Health Plan – select counties in IA and WI;
  • Martin’s Point Generations – select counties in ME; and
  • Providence Health Plans – select counties in OR and WA.
So if you do not live in select counties in California (30 counties), Colorado (17 counties), Hawaii (3 counties), Iowa (5 counties), Maine (16 counties), Oregon (10 counties), Washington (16 counties), Wisconsin (11 counties) for Medicare Advantage plans - or statewide in New York, Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota, Wyoming for stand-alone Medicare Part D prescription drug plans, you cannot take advantage of the "5 Star" Special Enrollment Period in 2012.  The number of 5-Star rated plans can change each year and we expect to see a wider selection of 5-Star plans in 2013, as plans strive to increase their overall plan quality ratings.







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  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
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  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
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  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.