Introduction
Most Medicare beneficiaries can change Medicare Advantage or Part D coverage only during fixed windows. The 5-Star Special Enrollment Period (SEP) is an exception. If a 5-star plan is available where you live, you may be able to switch into it outside the usual dates.
But a top rating isn't a personal recommendation. A 5-star contract can still leave out your doctor or your drugs, or cost more than your budget allows.
This guide covers eligibility, dates, plan types, coverage consequences, comparison criteria, enrollment steps, and what to verify before you submit anything.
Key Takeaways
- The SEP runs December 8 through November 30 of the following year; confirm current dates at Medicare.gov.
- You can use it once per period, and only if a qualifying 5-star plan serves your area.
- Compare networks, formularies, and total costs, not just stars.
- Switching plan types can end drug coverage or return you to Original Medicare.
- The SEP does not create Medigap guaranteed-issue rights.
What Is the Medicare 5-Star Special Enrollment Period?
The 5-Star SEP lets an eligible beneficiary join an available plan with an overall 5-star rating without waiting for Annual Enrollment. Members already in a 5-star plan may also move to another qualifying one.
Timing and Coverage Start
The window opens December 8 and closes November 30 of the following year. It's a once-per-period right, not once per calendar year. Coverage generally starts the first day of the month after the plan receives your request.
CMS reviewed its 2026 enrollment guidance in August 2025. Rules can change, so check Medicare.gov or CMS before acting.
Qualifying Plan Types
- 5-star Medicare Advantage-only (MA) plan
- 5-star Medicare Advantage plan with drug coverage (MA-PD)
- 5-star standalone Part D plan (PDP)
- Qualifying 5-star Medicare Cost Plan that is open for enrollment
What the Stars Measure
CMS rates at the contract level. An MA-PD overall rating weighs Part C and Part D measures. Categories include:
- Preventive screenings and vaccines
- Chronic condition management
- Member experience
- Complaints and performance changes
- Customer service, including appeals
Those ratings describe overall performance. They don't tell you whether your cardiologist is in network or your prescriptions are cheap.
Who Can Use the 5-Star SEP, and What Can You Switch To?
Basic Eligibility
You need access to a qualifying 5-star plan in your service area and must meet that plan's requirements. Medicare Advantage requires both Part A and Part B plus permanent residence in the service area. A standalone PDP requires Part A or Part B.
Availability varies by ZIP code, contract, and rating year. Confirm the specific plan in Medicare Plan Finder rather than trusting an older list.
Common Switches and Their Consequences
| Switch | What happens |
|---|---|
| MA plan to 5-star MA plan | Networks, benefits, and rules may change |
| MA-PD to 5-star PDP | You leave Medicare Advantage and return to Original Medicare for medical coverage |
| MA-PD to 5-star MA-only | Included drug coverage ends; you may have a gap and face a penalty |
| PDP to 5-star MA-PD | Requires both Part A and Part B |
The MA-PD to MA-only move is the riskiest. You could end up with no drug coverage and no easy way back until another enrollment window.
Medigap and Late Penalties
The 5-Star SEP is separate from Medigap rights. It doesn't give you guaranteed issue, so underwriting may apply. Medigap protections come from other rules, such as the six-month Medigap Open Enrollment Period that starts when you're 65 or older and enrolled in Part B.
It also doesn't erase a Part D late enrollment penalty. According to Medicare's penalty fact sheet, a penalty can apply after 63 or more consecutive days without Part D or creditable drug coverage. It's 1% of the national base beneficiary premium for each full uncovered month, and it generally follows you across plan switches.
How to Evaluate a 5-Star Plan Before Switching
One rated contract can contain plans with different benefits, costs, and networks. Check the details below.
- Rating and availability. Confirm the plan holds a 5-star overall rating for the relevant year and is accepting enrollment in your ZIP code.
- Provider access. Check your primary care doctor, specialists, hospitals, and pharmacies against the plan's current directory. Ask about referral and prior authorization rules.
- Prescriptions. Look up each drug's tier, then check prior authorization, step therapy, and quantity limits. Use Medicare Plan Finder to estimate yearly drug costs from your list.
- Total cost. Premium is one piece. Add deductibles, copayments, coinsurance, and drug costs.
- Benefits. Compare dental, vision, hearing, transportation, telehealth, and care management.
Know the 2026 Cost Ceilings
Medical and drug limits are separate:
- MA in-network maximum out-of-pocket ceiling: $9,250
- PPO combined in- and out-of-network ceiling: $13,900
- Part D annual out-of-pocket cap: $2,100
Plans can set lower medical limits. These are ceilings, not premium quotes.
Benefits and formularies also change yearly, even when a plan keeps its 5-star rating. Review the plan's Annual Notice of Change each fall.
How to Use the 5-Star SEP
- Search. Enter your ZIP code in Medicare Plan Finder and look for the high-performing icon.
- Confirm. Verify the plan's current rating and that you meet its enrollment rules.
- Compare. Match the plan against your doctors, medications, costs, and coverage needs.
Submitting the Request
You can enroll through:
- Medicare.gov
- The plan's website or phone line
- A paper form
- A licensed agent
- 1-800-MEDICARE (1-800-633-4227)
Have your Medicare Number and Part A/Part B start dates handy.
Coverage generally begins the first day of the month after the plan gets your request. Keep your confirmation number, plan name, and plan phone number.
Muneris Benefits' licensed agents can help eligible clients compare Medicare options, review enrollment implications, and understand deadlines. Confirm plan availability and the agent's representation before enrolling.
After You Enroll
- Check that your new member ID card arrives.
- Confirm your doctors and pharmacy participate.
- Test that prescriptions are covered.
- Review your first month's premium and billing.
If results differ from what you expected, contact Medicare, the plan, or your State Health Insurance Assistance Program (SHIP). Counselors offer free help and don't sell insurance.
- Virginia (VICAP): 1-800-552-3402
- West Virginia SHIP: 1-877-987-4463
Common Mistakes and Important Limitations
- Assuming 5 stars means cheapest. Quality and affordability are separate. So are quality and provider fit.
- Losing drug coverage by accident. Moving between MA-PD, MA-only, and PDP can drop prescription coverage or end Medicare Advantage.
- Overlooking the limits. The SEP is usable once, needs a qualifying plan, and may not apply to every plan you want.
- Trusting last year's materials. Ratings, formularies, networks, and premiums change. Plans can change formularies at any time, so rely on current documents.
Check current CMS guidance before you act.
Frequently Asked Questions
What counts as a special enrollment period?
A Medicare SEP is a time-limited chance to enroll, switch, or leave coverage after a qualifying circumstance or under a specific rule, like the 5-Star SEP. It's separate from Annual Enrollment (October 15 to December 7) and MA Open Enrollment (January 1 to March 31).
What is a Medicare Supplement Special Enrollment Period?
Medigap rights follow different rules than the 5-Star SEP. Switching plans through the 5-Star SEP doesn't guarantee Medigap eligibility or issue rights.
Does Medicare Advantage have a special enrollment period?
Yes, several, including the 5-Star SEP. Each has its own eligibility rules, timing, and permitted plan changes.
Can you enroll in Part D at any time?
Generally no. You need an enrollment period or a qualifying SEP, including the 5-Star SEP when an eligible 5-star plan is available. Late enrollment penalties may still apply.
Does Medicare Part A and B automatically renew each year?
Original Medicare continues without yearly plan selection. Medicare Advantage and Part D plans renew, but their benefits and costs can change. Review your Annual Notice of Change each year.
