Medicare Managed Care Eligibility and Enrollment

This page contains information for current and future contracting Medicare Advantage (MA) Organizations, other health plans and other parties interested in the operational and regulatory aspects of Medicare health plan enrollment and disenrollment.

NEW! CY 2013 Chapter 17D §1876 Cost Plan Guidance Update Now Available

The Centers for Medicare & Medicaid Services is issuing the CY2013 update of the Medicare Managed Care Manual, Chapter 17, Subsection D – Medicare Cost Plan Enrollment and Disenrollment Guidance document. We are also providing a summary document for the update that highlights the final changes to assist reviewers in identifying the areas that have been modified.

Due to the delay in releasing the 2013 guidance update, the effective date for implementing the majority of policies outlined in this guidance, as well as model notices, is January 31, 2013. The exceptions to this effective date are changes outlined in sections 10.3, 50.2.5, 50.3.1, 60.6, 60.6.3, and exhibits 19 through 23 (regarding disenrollment due to failure to pay premiums/Part D Income Related Monthly Adjustment Amount (Part D-IRMAA) and "good cause" policies), which are effective for any disenrollment on or after January 1, 2013. Cost organizations may, at their option, implement any aspect of this guidance (e.g. new model forms/notices) prior to the required implementation date.

CMS Notice to Individuals Enrolled in Plans with Fewer Than Three Stars for Three or More Consecutive Years

CMS will further the goals of facilitating beneficiary enrollment into higher quality plans by issuing notices to individuals enrolled in plans with fewer than three stars for three consecutive years.  The notices inform enrollees of an opportunity to contact CMS to request a special enrollment period (SEP) to move into a higher quality plan in 2013.  Plans are not able to effectuate enrollments for this one-time SEP; all requests must come into CMS via 1-800-MEDICARE by the beneficiary and will be handled on a case-by-case basis. Spanish and English notices were  mailed in October and notices were sent to new members in February. Copies of the notices are available below.

Revisions to the 2012 MA Enrollment and Disenrollment Guidance for CY 2013

CMS has released a memo in our Health Plan Management System (HPMS) that revises the 2012 MA Enrollment and Disenrollment Guidance (previously revised on November 16, 2011) for CY 2013. The CY 2012 guidance has been updated and is now available below with the file name: Final MA Enrollment and Disenrollment Guidance Update for CY2012-Revised 8.7.2012 for CY 2013. The HPMS memo summarizing all the clarifications is also available below.

Notes Regarding the Revised MA Enrollment and Disenrollment Guidance for CY 2013 (Note: Updated on September 4, 2012):
CMS has corrected some unintentional inconsistencies between the August 7, 2012 HPMS memorandum and  the CY 2013 guidance revisions. The final guidance revisions have been replaced below and include all items outlined within the HPMS memorandum. Some areas of the guidance did not show the text being removed or changed from the last update; this has been corrected. In addition, the following sections were corrected to match the guidance outlined in the HPMS memorandum:  Introduction language at the beginning of the chapter, §10 – definition for “completed election”, §40.4, and Exhibit 20.  Please use the corrected version as of September 4, 2012. We apologize for any inconvenience.

All enrollments with an effective date on or after January 1, 2013, must be processed in accordance with the revised guidance requirements, including new model enrollment forms and notices provided.