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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! Guidance on a Special Enrollment Period for Individuals Affected by a Weather Related Emergency or Major Disaster

On September 28, 2017, CMS issued guidance to provide all beneficiaries affected by a weather related emergency or major disaster a special enrollment period (SEP) that gives them an additional opportunity to change their Medicare health and prescription drug plans in the event they were unable to make an election during another qualifying election period.  See guidance and FAQs in downloads below.

On December 14, 2017, CMS issued guidance providing information regarding additional opportunities to join, drop or switch Medicare health and prescription drug plans for individuals affected by the recent hurricanes in Puerto Rico and the U.S. Virgin Islands and the wildfires in California. See guidance in downloads below.

NEW! Revisions to the MA and §1876 Cost Plan Enrollment and Disenrollment Guidance for CY 2018

On June 15, 2017, CMS issued two HPMS memorandums outlining revisions to the CY 2018 enrollment guidance. 

The first memorandum, “Enrollment Guidance Changes for Contract Year 2018,” outlines changes to improve the efficiency of enrollment processing by organizations, by permitting the collection of financial information in CMS-approved enrollment mechanisms so that organizations can more efficiently complete the individual’s requested method for premium payment, and by eliminating the requirement to mail a copy of a completed paper enrollment request back to the individual. (We note that the cost guidance includes a conforming edit in section 40.4 to modify the second bullet to remove the requirement for mailing a copy of a completed paper enrollment request.  This conforming edit was not included in the HPMS memorandum.) These revisions are in effect for contract year 2018; all enrollments with an effective date on or after January 1, 2018, must be processed in accordance with this guidance. Organizations may implement these changes prior to this date.

The second memorandum, “Model Enrollment Form Changes for Contract Year 2018,” outlines changes to model enrollment forms in order for organizations to prepare for the new Medicare number, which CMS will begin to issue in April 2018, as part of the Social Security Number Removal Initiative. We removed a picture of the Medicare card and included a new question for the individual requesting premium withholding from Social Security or Railroad Retirement Board to indicate which agency they receive benefits. These revisions are in effect as of April 2018; all enrollments with an effective date on or after April 1, 2018, must be processed in accordance with this guidance. Organizations may implement these changes prior to this date.

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.

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.