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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! Information related to Emergencies and Major Disasters

See 2019 MA Enrollment and Disenrollment Guidance for information about the SEP for Individuals Affected by a FEMA-Declared Weather Related Emergency or Major Disaster (§ 30.4.4 #18) and enrollment reminders for plans on enrollment processing, and disenrollment after an extended absence from the plan's service area and failure to pay premiums.

NEW! Revisions to the MA and §1876 Cost Plan Enrollment and Disenrollment Guidance for CY 2019

On July 31, 2018, CMS released the "Enrollment Guidance Policy Changes and Updates for Contract Year 2019" in our Health Plan Management System (HPMS) to provide guidance and model enrollment form updates. It includes policy and technical changes as a result of recently published regulation changes from CMS-4182-F:

  • The new Medicare Advantage Open Enrollment Period (MA OEP);
  • Special election period (SEP) changes for duals/LIS individuals, including limitations for this population identified as potential at-risk or at-risk for misuse or abuse of frequently abused drugs;
  • Changes to passive enrollment; and
  • Changes to default enrollment and establishing a newly simplified enrollment process as a means for MA organizations to streamline enrollments of newly Medicare-eligible individuals currently enrolled in their non-Medicare products

Other updates include provisions for enrollment communications in accessible formats, Medicare number enrollment processing, and clarification of the disaster SEP. Finally, enrollment forms and model notices were updated to incorporate these changes.

The update to the CY 2019 guidance is now available below with the file names: CY 2019 MA Enrollment and Disenrollment Guidance and CY 2019 Cost Plan Enrollment and Disenrollment Guidance. Also included is a summary of changes chart, outlining the changed sections.

All enrollments with an effective date on or after January 1, 2019, must be processed in accordance with the revised guidance requirements.

Information about Seamless Conversion/Default Enrollment

As outlined in the 2019 guidance, only MA organizations (who meet the criteria outlined and are approved by CMS) to conduct default enrollment for coverage effective dates of January 1, 2019 or later. CMS will provide additional information to MA organizations who are currently approved to conduct such enrollment in the fall.

Good Cause Flow Process and Frequently Asked Questions

Below are resources to help plans process good cause reinstatement requests:

  • Frequently Asked Questions
  • Good Cause Triage Process Flow Chart

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