Medicare Managed Care Manual - Centers for Medicare ...

Medicare Managed Care Manual

Chapter 2 - Medicare Advantage Enrollment and Disenrollment

Updated: August 19, 2011 (Revised: November 16, 2011, August 7, 2012, August 30, 2013, August 14, 2014, July 6, 2015, September 1, 2015, September 14, 2015, December 30, 2015, May 27, 2016, August 25, 2016, June 15,

2017, July 31, 2018 & August 12, 2020)

This guidance update is effective for contract year 2021. All enrollments with an effective date on or after January 1, 2021, must be processed in accordance with the revised requirements, including the new model Medicare Advantage (MA)enrollment form for the 2021 plan year starting October 15, 2020 and model notices, as appropriate. Organizations may, at their option, implement any new requirement consistent with this guidance prior to the required implementation date.

It is expected that organizations will assure compliance with all Medicare Advantage requirements described in this chapter regarding communications made with beneficiaries/members, including the use of the model notices, and the requirements outlined in the Medicare Communications and Marketing Guidelines (MCMG).

Organizations are required to provide information to individuals in accessible/alternate formats (for example, Large Print, Braille), upon request and thereafter, as outlined in Section 504 of the Rehabilitation Act of 1973 (and subsequent revisions). Such individuals must have an equal opportunity to participate in enrollment, paying premium bills, and communicating with the plan, as members who do not request accessible/alternate formats.

Table of Contents 10 - Definitions .......................................................................................................................................9 20 - Eligibility for Enrollment in MA Plans .......................................................................................16

20.1 - Entitlement to Medicare Parts A and B and Eligibility for Part D ...................................17 20.2 - Place of Permanent Residence ............................................................................................17

20.2.1 - Mailing Address .........................................................................................................19 20.2.2 ? U.S. Citizenship or Lawful Presence..............................................................................19 20.3 - Completion of Enrollment Request ....................................................................................19

20.3.1 - Optional Employer/Union Enrollment Request Mechanism...................................20 20.3.2 - Passive Enrollment by CMS......................................................................................20 20.3.3 - Group Enrollment for Employer or Union Sponsored Plans...................................22 20.4 - Agreeing to Abide by MA Organization Rules .................................................................23 20.5 - Grandfathering of Members on January 1, 1999 ...............................................................23 20.6 - Eligibility and the Hospice Benefit ....................................................................................24

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20.7 - Continuation of Enrollment Option for MA Local Plans..................................................24 20.8 - Additional Eligibility Requirements for MA Religious Fraternal Benefit (RFB) Plans.25 20.9 - Eligibility Requirements for Medicare Medical Savings Account (MSA) Plans............25 20.10 - Additional Eligibility Requirements for Enrollment in MA Special Needs Plans........25 30 - Election Periods and Effective Dates...........................................................................................28 30.1 - Annual Election Period (AEP)............................................................................................29 30.2 - Initial Coverage Election Period (ICEP) ............................................................................29

30.2.1 - Initial Enrollment Period for Part D (IEP for Part D) ..............................................30 30.3 - Open Enrollment Period for Institutionalized Individuals (OEPI) ...................................31 30.4 - Special Election Period (SEP) ............................................................................................31

30.4.1 - SEPs for Changes in Residence.................................................................................34 30.4.2 - SEPs for Contract Violation ......................................................................................35 30.4.3 - SEPs for Non-renewals or Terminations ..................................................................36 30.4.4 - SEPs for Exceptional Conditions ..............................................................................38

1. SEP EGHP (Employer/Union Group Health Plan) .....................................................38 2. SEP for Individuals Who Disenroll in Connection with a CMS Sanction.................39 3. SEP for Individuals Enrolled in Cost Plans that are Non-renewing their Contracts .39 4. SEP for Individuals in the Program of All-inclusive Care for the Elderly (PACE) ..39 5. SEP for Dual-eligible Individuals and Other LIS-Eligible Individuals......................39 6. SEP for Individuals Who Terminated a Medigap Policy When They Enrolled For

the First Time in an MA Plan, and Who Are Still in a "Trial Period" ...............41 7. SEP for Individuals with ESRD Whose Entitlement Determination Made

Retroa ctively ..........................................................................................................41 8. SEP for Individuals Whose Medicare Entitlement Determination Made

Retroa ctively ..........................................................................................................42 9. MA SEPs to Coordinate With Part D Enrollment Periods..........................................42 10. SEP for Individuals Who Lose Special Needs Status ...............................................43 11. SEP for Individuals Who Belong to a Qualified SPAP or Who Lose SPAP

Eligibility ...............................................................................................................43 12. SEP for Individuals who Gain, Lose, or Have a Change in their Dual or LIS-

Eligible Status ........................................................................................................43 13. SEP for Enrollment Into a Chronic Care SNP and for Individuals Found Ineligible

for a Chronic Care SNP.........................................................................................44 14. SEP for Disenrollment from Part D to Enroll in or Maintain

Other Creditable Coverage ...................................................................................44 15. SEP to Enroll in an MA Plan, PDP or Cost Plan With a Plan Performance Rating

of Five (5) Stars .....................................................................................................44 16. SEP for Non-U.S. Citizens who become Lawfully Present ......................................46 17. SEP for Providing Individuals who Requested Materials in Accessible Formats

Equal Time to Make Enrollment Decisions.........................................................46 18. SEP for Government Entity-Declared Disaster or Other Emergency ......................46

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19. SEP for Individuals Enrolled in a Plan Placed in Receivership ..............................47 20. SEP for Individuals Enrolled in a Plan That Has Been Identified by CMS as a

Consistent Poor Performer ...................................................................................47 21. SEP for Other Exceptional Circumstances ................................................................47 30.4.5 - SEPs for Beneficiaries Age 65 (SEP65) ...................................................................48 30.4.6 ? SEP for Significant Change in Provider Network ...................................................48 30.4.7 ? SEP for CMS and State-Initiated Enrollments ........................................................48 30.5 ? Medicare Advantage Open Enrollment Period (MA OEP)..............................................49 30.6 - Effective Date of Coverage.................................................................................................49 30.6.1 - Effective Date of Auto- and Facilitated Enrollments...............................................51 30.7 - Effective Date of Voluntary Disenrollment .......................................................................52 30.8 - Election Periods and Effective Dates for Medicare MSA Plans ......................................53 30.9 - Closed Plans, Capacity Limits, and Reserved Vacancies .................................................53 30.9.1 - MA Plan Closures ......................................................................................................53 40 - Enrollment Procedures..................................................................................................................55 40.1 - Format of Enrollment Requests ..........................................................................................56 40.1.1 - Enrollment Request Mechanisms..............................................................................57 40.1.2 ? Electronic Enrollment................................................................................................58 40.1.3 - Enrollment via Telephone..........................................................................................59 40.1.4 - Default Enrollment Option for Medicaid Managed Care Plan Enrollees who are

Newly Eligible for Medicare Advantage ...................................................................60 40.1.5 - Auto- and Facilitated Enrollment ..............................................................................62 40.1.6 ? Additional Enrollment Request Mechanisms for Employer/Union Sponsored

Coverage.......................................................................................................................71 40.1.6.1 - Group Enrollment Mechanism .........................................................................72 40.1.6.2 - Optional Mechanism For MA Group-sponsored plan Enrollment ................73 40.1.7 - Enrollment for Beneficiaries in Qualified State Pharmaceutical Assistance

Programs (SPAPs) .......................................................................................................74 40.1.8 ? Re-Assignment of Certain LIS Beneficiaries ..........................................................74 40.1.9 ? Simplified (Opt-In) Enrollment Mechanism............................................................76 40.2 - Processing the Enrollment Request ....................................................................................78 40.2.1 - Who May Complete an Enrollment or Disenrollment Request...............................85 40.2.2 - When the Enrollment Request Is Incomplete ...........................................................86 40.2.3 - MA Organization Denial of Enrollment ...................................................................87 40.2.4 - MA-PD Enrollment When an Individual has Other Qualified Prescription Drug

Coverage through an Employer or Union Retiree Drug Subsidy (RDS) Plan Sponsor .........................................................................................................................88 40.3 - Transmission of Enrollments to CMS ................................................................................89 40.4 - Information Provided to Member .......................................................................................90 40.4.1 - Prior to the Effective Date of Coverage....................................................................90 40.4.2 - After the Effective Date of Coverage........................................................................92

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40.5 - Enrollment Processing During Closed Periods..................................................................92 40.5.1 - Procedures After Reaching Capacity Limit ..............................................................93 40.5.2 - Procedures After Closing During the OEP and OEPI..............................................94

40.6 - Enrollments Not Legally Valid...........................................................................................95 40.7 - Enrollment Procedures for Medicare MSA Plans .............................................................96

40.7.1 - Establishing the MSA Banking Account during the Enrollment Process ..............97 50 - Disenrollment Procedures.............................................................................................................98

50.1 - Voluntary Disenrollment by Member ................................................................................98 50.1.1 ? Requests Submitted via Internet ...............................................................................99 50.1.2 - Request Signature and Date.......................................................................................99 50.1.3 - Effective Date of Disenrollment............................................................................. 100 50.1.4 - Notice Requirements............................................................................................... 100 50.1.5 - Optional Employer/Union MA Disenrollment Request Mechanism................... 101 50.1.6 - Group Disenrollment for Employer/Union Sponsored Plans ............................... 102 50.1.7 - Medigap Guaranteed Issue Notification Requirements for Disenrollments to Original Medicare during a SEP .............................................................................. 102

50.2 - Required Involuntary Disenrollment ............................................................................... 102 50.2.1 - Members Who Change Residence ......................................................................... 104 50.2.1.1 - General Rule................................................................................................... 104 50.2.1.2 - Effective Date of Disenrollment ................................................................... 105 50.2.1.3 - Researching and Acting on a Change of Address........................................ 106 50.2.1.4 - Procedures for Developing Addresses for Members Whose Mail is Returned as Undeliverable ................................................................................................. 107 50.2.1.5 - Notice Requirements...................................................................................... 108 50.2.2 - Loss of Medicare Part A or Part B ......................................................................... 109 50.2.3 - Death ........................................................................................................................ 110 50.2.4 - Terminations/Nonrenewals..................................................................................... 110 50.2.5 ? Loss of Special Needs Status ................................................................................. 111 50.2.6 ? Failure to Pay a Part D-Income Related Monthly Adjustment Amount (Part DIRMAA) .................................................................................................................... 112 50.2.7 ? Unlawful Presence Status....................................................................................... 113

50.3 - Optional Involuntary Disenrollments.............................................................................. 114 50.3.1 - Failure to Pay Premiums......................................................................................... 114 50.3.2 - Disruptive Behavior ................................................................................................ 120 50.3.3 - Fraud and Abuse...................................................................................................... 123

50.4 - Processing Disenrollments ............................................................................................... 123 50.4.1 - Voluntary Disenrollments....................................................................................... 123 50.4.2 ? When the Disenrollment Request is Incomplete .................................................. 124 50.4.3 - Involuntary Disenrollments .................................................................................... 125

50.5 - Disenrollments Not Legally Valid................................................................................... 125

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50.6 - Disenrollment of Grandfathered Members ..................................................................... 126 50.7 - Disenrollment Procedures for Employer/Union Sponsored Coverage Terminations .. 126 50.8 - Disenrollment Procedures for Medicare MSA Plans ..................................................... 128 60 - Post-Enrollment Activities ........................................................................................................ 129 60.1 - Multiple Transactions....................................................................................................... 129

60.2 - Cancellations............................................................................................................... 130 60.2.1 - Cancellation of Enrollment..................................................................................... 130 60.2.2 - Cancellation of Disenrollment................................................................................ 131 60.2.3 ? When A Cancellation Transaction is Rejected by CMS Systems (Transaction

Reply Code (TRC) 284) ........................................................................................... 132 60.2.4 ? Cancellation Due to Notification from CMS (TRC 015)..................................... 132 60.3 - Reinstatements............................................................................................................ 132 60.3.1 - Reinstatements for Disenrollment Due to Erroneous Death Indicator, or Erroneous

Loss of Medicare Part A or Part B, Erroneous Incarceration Information, or Erroneous Unlawful Presence Information ............................................................. 133 60.3.2 - Reinstatements Based on Beneficiary Cancellation of New Enrollment ............ 135 60.3.3 - Reinstatements Due to Mistaken Disenrollment Due to Plan Error .................... 135 60.3.4 - Reinstatements Based on a Determination of Good Cause for Failure to Pay Plan Premiums or Part D-IRMAA Timely ............................................................................ 136 60.3.4.1 - Process for Good Cause Determinations for Nonpayment of Plan

Premiums ............................................................................................................ 138 60.3.4.2 ? Process for Good Cause Determinations for Nonpayment of Part D-

IRMAA ............................................................................................................... 140 60.4 - Retroactive Enrollments................................................................................................... 142 60.5 - Retroactive Disenrollments.............................................................................................. 143 60.6 - Retroactive Transactions for Employer/Union Group Health Plan (EGHP) Members 144

60.6.1 - EGHP Retroactive Enrollments.............................................................................. 144 60.6.2 - EGHP Retroactive Disenrollments......................................................................... 145 60.7 ? User Interface (UI) Transactions Reply Codes (TRC) ? Communications with

Beneficiaries.................................................................................................................... 145 60.8 - Election of Continuation of Enrollment Option for MA Local Plans ........................... 148 60.9 - Storage of Enrollment and Disenrollment Records........................................................ 148 Appendices ......................................................................................................................................... 149 Appendix 1: Summary of Notice Requirements........................................................................ 150 Appendix 2: Summary of Data Elements Required for Plan Enrollment Mechanisms and

Completed Enrollment Requests.................................................................................... 156 Appendix 3: Setting the Application Date on CMS Enrollment Transactions........................ 159 Appendix 4: Examples of Good Cause Determinations ........................................................... 160 EXHIBITS.......................................................................................................................................... 165 Exhibit 1: MODEL INDIVIDUAL ENROLLMENT REQUEST FORM TO ENROLL IN A

MEDICARE ADVANTAGE PLAN (PART C) ................................................................. 166

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