As part of its continued efforts to incentivize Medicare Advantage (MA) Organizations to achieve a 5-star quality rating, the Centers for Medicare and Medicaid Services (CMS) announced the creation of a special enrollment period (SEP) to permit enrollment into 5-star rated MA Plans at any time during the benefit year.

The SEP will be available beginning in calendar year (CY) 2012 to all Medicare beneficiaries who:

  1. Are enrolled in an MA Plan with a quality rating of 4.5 stars or less, or enrolled in traditional Medicare fee-for-service and eligible to enroll in an MA Plan, and
  2. Reside in the service area of a 5-star rated MA Plan.

MA Plans with a quality rating of 4.5 stars or less seem to be limited to enrolling Medicare beneficiaries during the annual election period or a beneficiary’s initial enrollment period or another SEP. Thus, in addition to competing for new members with 5-star MA Plans in the same service area, MA Plans with a 4.5-star or less rating will be vulnerable to potentially losing members during the year.

A copy of the Health Plan Management System (HPMS) memo regarding the SEP can be found here. Additional guidance on this SEP is expected in the CY 2012 Call Letter.

What This Means

This new SEP is one of several benefits for 5-star MA Plans in CY 2012, in addition to higher quality bonus payments and enhanced access to MA rebate dollars. All MA Organizations, and particularly those serving areas in which other 5-star MA Plans are operating, need to be identifying and implementing changes to enhance their quality rating.

Next Steps

CY 2012 star ratings, issued in Fall 2010, are based on data collected in 2009 and 2010. Thus, MA Organizations should focus on quality improvement activities that will positively impact 2011 data elements, and thus CY 2013 and CY 2014 star-quality ratings, such as provider-driven elements and other beneficiary “touch points” evaluated under the surveys that contribute to star-quality ratings