You absolutely don’t need to move to a plan with five stars. Let me make this clear right away. All Advantage Plans are regulated by the Centers for Medicare and Medicaid (CMS). Every company and every plan must cover the same services as Original Medicare and as good or better than Original Medicare. There would never be a situation where services related to heart conditions, cancer, arthritis, mental health, etc., would be covered by one company or plan and not another, regardless of monthly premium or star ratings. In other words, the highest cost Advantage Plans or star rated plans on the market cover the same categories of services that cheaper plans and those with less than five stars do. A $300/month or a 5-star rated plan cover no more or less than the $0 or 4-star rated plan. The only differences are going to be what the co-pays are for each service, the amount of the Maximum Out of Pocket (MOOP) which represents the most money one can be billed in a calendar year, and what and how much ancillary benefits are offered such as dental, vision, OTC, etc. The fear that seniors have of certain services not being covered by another company’s plan or one with a lower premium has cost literally hundreds of thousands of Western Pennsylvania seniors millions upon millions of dollars in premiums and medical bills over the past 10 years. There are still far too many people who stay on overpriced and non-competitive plans because they’re afraid if they need a surgery or are hospitalized, they could get billed tens of thousands of dollars. That’s simply not possible due to all plans being regulated to have a MOOP. Our clients who have HMO and PPO Advantage plans can only reach their MOOP if the following services are needed: Chemotherapy and/or lots of radiation, a 40-day or longer stay in a Skilled Nursing Facility, ongoing injection or infusion therapy, or a couple of far less common scenarios where a prosthetic device or very high dollar piece of durable medical equipment was needed. The MOOP can’t be reached with a lengthy hospitalization, outpatient surgeries, CT scans, an air ambulance ride, etc. With HMO’s and PPO’s that we recommend, these services have co-pays from $100 to $350. I don’t want people to think that a 5-star rated plan will cover anything more for them than one that is rated a half or one star less. It won’t!!!

It will make a difference for the insurance companies as far as what they’re reimbursed however, and in turn often provide extra value to consumers. Remember, for every person who enrolls in an Advantage Plan, the company that’s chosen is subsidized approximately $10,000 per year. The more dollars Medicare Advantage Plan companies are reimbursed by the Federal Government, the likelier it is that they will provide lower co-pays, premiums, MOOP, and ancillary benefits that we’re seeing currently. When four or five-stars ratings are reached, the companies are paid extra money in addition to their guaranteed allotment. Although companies aren’t forced to give these extra dollars back to the consumer in the form of lower costs and better benefits, they must spend a minimum of 85 cents on every dollar they receive from the Feds on claims. If they’re paying out less than 85%, they must refund the difference back to the Centers for Medicare and Medicaid (CMS). Therefore, companies are motivated to offer better plans and remain competitive in order to get more Medicare beneficiaries enrolled.

Higher Star ratings are awarded when companies and plans do the following:
1) Keep their members healthy by ensuring as many as possible have an in-home health assessment completed, receive their preventative services, and get their flu and pneumonia vaccines. So, when your Advantage Plan company keeps bugging you to have a nurse come visit your home, don’t ignore those calls. Schedule that appointment. In the end, if HMO’s and PPO’s are going to continue to be judged in this manner, you’re helping ensure the excellent value Advantage Plans are currently offering carry on in the coming years.
2) Manage chronic and longer-term conditions their members have such as diabetes, heart disease, etc.
3) Provide good member experience which is determined by the number of complaints that are made by those they insure, and changes in the health plan’s performance. I find this a bit vague, but that is how it’s often described by the sources I researched for this column and have had it explained to me by others who have knowledge on the topic of star ratings.
4) The quality of the company’s customer service, which I have no idea how is measured. There are indeed companies that offer much better member services than others. However, those that don’t provide the same quality still have many plans rated five stars. I will say it’s my opinion that those companies with less than four stars have earned the lower designation. There are a couple that make us want to tear our hair out trying to get a problem solved for clients.

Did you notice what isn’t included in the determination? Plan value in regards to premium costs, co-pays, number and amount of ancillary services and benefits offered, and the size of the MOOP. There’s an Advantage Plan rated five stars that costs upwards of $300 and has the highest allowable MOOP. That’s absolutely ridiculous in my opinion when there are $0 premium plans offered by the same company where those who had the same exact Chemo treatments would be billed the exact same amount as those who are on the $300 plan, $7,550. There are also available plans that cost $250 less per month where bills for those Chemo treatments would only be $4,500. My point again is stars don’t matter! I’m not saying that customer service Isn’t important. But not having an algorithm that calculates what I like to refer to as, “total cost of ownership” which takes into account both annual cost of premiums, best value in co-pays on services such as five day or longer hospitalizations, outpatient surgeries, CT scans, MRI’s, drug costs, as well as the size of the MOOP etc., is a disservice to senior citizens. It tells me that the people running the show at CMS either don’t know what they’re doing, don’t have Medicare beneficiaries’ best interests in mind, or are protecting the insurance companies. I find all three possibilities troublesome.
In addition to this misstep, there’s no mention of star ratings being determined by how many times a plan denied a claim, made someone get physical therapy before being allowing them to have an MRI, CT scan, or surgery, or been told their insurance company was no longer paying for additional days in the hospital or Skilled Nursing Facility, something that doesn’t happen often, but can and does occur from time to time with Advantage Plans. And people are likely to not make a complaint in these scenarios, which means it will never be a determining factor. If I were in charge, these would be at the top of my list in how start ratings are calculated and awarded.
There are no star ratings for Supplements and they aren’t needed because Medigap plans are perfectly Federally regulated in my opinion. There currently are only nine choices in plans labeled with letters A through N and they all must offer the same medical benefits and access to doctors and hospitals nationwide. The only difference between companies selling the same letter plan is price. And because the insurance companies aren‘t allowed to be involved in deciding what’s covered, and Medicare doesn’t require prior authorizations for virtually all services, rather allowing doctors to make the determination of what is medically necessary, there are almost zero complaints about Supplement insurance companies. And Medicare almost never denies a claim, eliminating issues there as well.
What Medicare and a Supplement company can’t do, that some of our local companies can, is find you a specialist and make an appointment or help you navigate other issues such as available community programs, offering health coaches, provide a nurse hotline, among other conveniences.

If you have any questions or concerns regarding this column topic, or would like to make an appointment for a no-cost consultation, please feel free to give us a call – we would be happy to help. I’d like to remind everyone that I do a live call-in talk show called Medicare A to Z every 1st and 3rd Monday of the month on WMBS Uniontown, 590AM and 101.1FM, from 1 to 3 PM. You can listen in on their website, wmbs590.com.