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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 2016

On September 14, 2015, CMS issued a Health Plan Management System (HPMS) memo that revised the MA Enrollment and Disenrollment Guidance and the Cost Plan Enrollment and Disenrollment Guidance for CY 2016.  This HPMS memo is the third policy memo CMS issued to update the guidance for plan year 2016.  It establishes a new ineligibility criterion for enrollment into an MA, Part D and Cost Plan on the basis of unlawful presence status in the U.S.  In addition, it outlines changes in the policy and processes for incarcerated individuals, as they reside outside the plans’ service areas. 

Previously, the second policy memo released on August 19, 2015, amended current reinstatement processes for good cause to permit an entity (i.e. the plan) to act on behalf of CMS to effectuate reinstatements when good cause criteria are met.  The memo also established operational policy and processes for the application of the good cause standard to assist plans; with the expectation plans will independently conduct this activity from start to finish.

The first memo released by CMS on July 6, 2015, in HPMS for plan year 2016, clarified current policies permitting the use of downstream entities to facilitate and capture electronic enrollment requests. It reiterated that plans’ overall responsibility for compliance with CMS security requirements includes any aspect of the enrollment process that has been delegated to a third party.  The memo also incorporated text that was inadvertently removed in a previous update to section of the MA Enrollment and Disenrollment Guidance.

The updates to the CY 2016 guidance are now available below with the file names: CY 2016 MA Enrollment and Disenrollment Guidance and CY 2016 Cost Plan Enrollment and Disenrollment Guidance.

All enrollments with an effective date on or after January 1, 2016, 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.