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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 August 19, 2015, 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 2016. This HPMS memo is the second policy memo CMS issued to update guidance for plan year 2016.  It amends current reinstatement processes for good cause to permit an entity (i.e. the plan) to act on behalf of CMS to effectuate reinstatements when a beneficiary meets good cause criteria.  The memo also establishes 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.

Previously, 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 including 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 50.2.1.2 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 8-19-2015 and CY 2016 Cost Plan Enrollment and Disenrollment Guidance 8-19-2015.  CMS plans to release the last updates to the CY 2016 guidance in the coming weeks, following additional HPMS memoranda.

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.