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Is there any risk associated with using the 5-star Special Enrollment Period?


Maybe.  The key is that you must be aware of the type of Medicare plan you currently have and what type of 5-star Medicare plan you are choosing (read more below) as part of the 5-star Special Enrollment Period (SEP) - because it is possible to lose your prescription drug coverage by joining a 5-star Medicare Advantage plan that does not include prescription drug coverage.

As background ...
  • If available in your state or area (ZIP code region), you can switch to a 5-star Medicare Advantage plan that does not include drugs (MA), a 5-star Medicare Advantage plan with prescription drug coverage (MAPD), or a 5-star Medicare Part D prescription drug plan (PDP) at any time during the year, provided you meet the plan’s enrollment requirements (for example, you live within the plan's service area).

  • People already enrolled in a Medicare plan with a 5-star overall rating may also switch to a different plan with a 5-star overall rating.

  • The effective date of your new Medicare plan enrollment is the first day of the month following the month that the 5-star plan receives the enrollment request.

  • You may also use this 5-star Special Enrollment Period to disenroll from a Medicare Advantage plan or prescription drug plan and enroll in an open Medicare Cost Plan that has a 5-star rating.
It’s Important That You Make a Careful 5-star SEP Decision

CMS also created a coordinating special enrollment period for prescription drug plans to allow people who enroll in certain types of 5-star Medicare Advantage plans that do not provide drug coverage to select a stand-alone Medicare prescription drug plan (PDP), when this combination is permitted under CMS rules, such as with a Medicare Advantage PFFS plan, but not a Medicare Advantage (HMO or PPO).

So, you may lose your prescription drug coverage if you move from a Medicare Advantage plan that has drug coverage (MAPD) to a Medicare Advantage plan (HMO or PPO) that does not provide drug coverage. If this occurs, you may need to wait until the next open enrollment period (starting October 15) to get drug coverage, and you may have to pay a Medicare Part D late enrollment penalty.

Also, if you move from a Medicare Advantage health-only or Medicare Advantage-Prescription Drug coordinated care plan to a 5-star rated stand-alone Medicare Part D prescription drug plan, you will lose your Medicare Advantage coverage and will revert to Original Medicare for Medicare Part A and Medicare Part B medical coverage.

Example 1: Acme Medicare Advantage plan has an overall rating of 4.5 stars in 2012 and a 5-star rating for 2013. You could use the 5-star special enrollment period to enroll in the Acme Plan starting on December 8, 2012 (after the December 7 close of the annual Open Enrollment Period (AEP), for an effective date of January 1, 2013. But you could not use the 5-star special enrollment period to enroll in the Acme Plan for an effective date on or before December 1, 2012. The enrollment effective dates available during that period are before the calendar year for which Acme Plan has received a 5-star overall rating.

Example 2: Acme Medicare Advantage plan has an overall rating of 5-stars for 2013 but loses the 5-star rating for 2014. You could use the 5-star special enrollment period to request enrollment in the Acme Plan for the first day of the next month until November 30, 2013, with the last possible effective date available being December 1, 2013. You could not use the 5-star special enrollment period to enroll in Acme Plan on or after December 1, 2013, as the enrollment effective dates available during that period are after the calendar year for which Acme Plan has received a 5-star overall rating.

Example 3: Mr. Miller enrolls in a 5-star Medicare Cost Plan without prescription drug coverage. Under the updated 5-star special enrollment policy, Mr. Miller can enroll in the Cost Plan's optional Part D benefit (if the plan offers one).

(Source: CMS 5-Star Plan Rating Overview - with additions)





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Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
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  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
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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.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • 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.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • 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.