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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 about Seamless Conversion Enrollment

CMS is providing (in the download below) background information about seamless conversion enrollments and information regarding Medicare Advantage (MA) organizations with approval to conduct such enrollments.  This information identifies the organizations that have received CMS approval to offer seamless conversion enrollment to individuals upon their initial eligibility for Medicare, as outlined in Section 40.1.4 of Chapter 2 of the Medicare Managed Care Manual.  The posted information specifies the lines of business from which these organizations are permitted to enroll members into an MA plan and the MA plans into which seamless enrollment will occur.  These data reflect all enrollments during beneficiary Medicare initial enrollment periods, including those of beneficiaries who proactively enrolled into the plan during the Medicare Advantage initial coverage election period or the initial enrollment period for Part D.  CMS currently does not have data specific to the volume of seamless enrollments.  The MA organizations listed in the aforementioned posting are the only organizations currently listed in CMS records as approved to conduct seamless conversion enrollments.  This data will be updated annually.

CMS is reviewing its policies for the optional seamless enrollment mechanism in light of recent inquiries regarding the mechanism, its use by MA organizations, and the beneficiary protections currently in place.  As a result, CMS is temporarily suspending its acceptance of any new seamless enrollment proposals.  For MA organizations currently approved to offer seamless conversion enrollments, CMS will soon issue a Health Plan Management System (HPMS) memorandum clarifying current policy and requirements.  CMS will contact MA organizations that have submitted proposals regarding next steps.  A copy of the released HPMS memo is available in the download section below.

NEW! Revisions to the MA and §1876 Cost Plan Enrollment and Disenrollment Guidance for CY 2017

On August 15, 2016, CMS issued an HPMS memo as an addendum to previously released revisions to the CY 2017 enrollment guidance.  This update includes clarifications to the definition of Application Date for the Online Enrollment Center and the period of deemed continued eligibility for Special Needs Plans.

On May 20, 2016, CMS issued an HPMS memo establishing flexibility in notification requirements for a favorable good cause determination. CMS revised the guidance to no longer require written notification of a favorable good cause determination if the plan is successful in providing this information verbally, either when the individual has already paid all the owed amounts or when the individual pays the owed amounts in full at the time he or she receives the verbal notification. In addition, CMS developed a new model notice consonant with this policy to assist plans when an individual receives a favorable determination and has already paid the amount required for reinstatement.

MA organizations and cost plans must process all enrollments with an effective date on or after January 1, 2017, in accordance with these revisions.

Good Cause Flow Process and Frequently Asked Questions

On March 9, 2016, CMS appended the Frequently Asked Questions to specifically define who is authorized to act on behalf of a former member to process good cause requests. In addition, this document highlights operational procedures for submitting reinstatement requests to the RPC under the good cause process. Additional questions will be added to the FAQs, as necessary.

On November 18, 2015, CMS hosted a Part C and Part D User Call to respond to questions and clarify policies outlined in guidance.  As a result of that call, CMS is providing some additional resources to help plans prepare and implement the operational changes for processing good cause reinstatement requests:

  • Frequently Asked Questions
  • Good Cause Triage Process Flow Chart

As plans begin to process good cause requests, they are encouraged to submit feedback and questions.  Additional questions will be added to the FAQ document, as necessary.

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. Copies of the notices are available below.