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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! Revisions to the MA and §1876 Cost Plan Enrollment and Disenrollment Guidance for CY 2015

On August 14, 2014, CMS released a memo in our Health Plan Management System (HPMS) that revised the MA Enrollment and Disenrollment Guidance and the Cost Plan Enrollment and Disenrollment Guidance for CY 2015. The CY 2015 guidance is now available below with the file names: CY 2015 MA Enrollment and Disenrollment Guidance and CY 2015 Cost Plan Enrollment and Disenrollment Guidance. The HPMS memo summarizing all the clarifications is also available below. Please note that the HPMS memo contained an inadvertent error regarding section 60.2.4 (MA)/section 60.5.3 (cost). The memorandum indicated that the cancellation notice was to be sent within 7 calendar days, however it should have stated 10 calendar days to be consistent with the timing of other cancellation notices. The guidance documents include the correct timing within its text.

All enrollments with an effective date on or after January 1, 2015, must be processed in accordance with the revised guidance requirements, including revised model notices provided.

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.  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 are  mailed to current members in October and notices are sent to new members in February. Copies of the notices are available below.