Medicare Managed Care Manual - Centers for Medicare ...

1 Medicare Managed care Manual Chapter 2 - Medicare advantage Enrollment and disenrollment Rev. 66, 08-05-05 Table of Contents 10 - Definitions 20 - Eligibility for Enrollment in MA Plans - Entitlement to Medicare Parts A and B - End-Stage Renal Disease (ESRD) - Background on ESRD Entitlement - Exceptions to Eligibility Rule for Persons Who Have ESRD - Optional Employer Group Waiver for ESRD Enrollees - Place of Permanent Residence - State and County Code (SCC) Corrections - Completion of Enrollment Election - Alternate Employer Group Election Mechanism - Passive Elections - Enrollment via the Internet - Enrollment Via Telephone for Current MA Plan Enrollees - Seamless Conversion Enrollment Option for Newly Medicare Eligible Individuals - Auto-enrollment of Full-Benefit Dual Eligible Individuals - Facilitated Enrollment of Other LIS Eligible Individuals - Group Enrollment for Employer or Union Sponsored Plans - Agreeing to Abide by MA Organization Rules - Grandfathering of Members on January 1, 1999 - Eligibility and the Hospice Benefit - Continuation of Enrollment Option for MA Local Plans - Additional Eligibility Requirements for MA Religious Fraternal Benefit (RFB)

2 Plans - Eligibility Requirements for Medicare Medical Savings Account (MSA) Plans - Additional Eligibility Requirements for MA Special Needs Plans 30 - Election Periods and Effective Dates - Annual Election Period (AEP) - Initial Coverage Election Period (ICEP) - Initial Enrollment Period for Part D (IEP for Part D) - Open Enrollment Period (OEP) - OEP Through 2005 - OEP in 2006 and Beyond - Open Enrollment for Newly Eligible Individuals (OEPNEW) - Open Enrollment Period for Institutionalized Individuals (OEPI) - Special Election Period - (SEP) - SEPs for Changes in Residence - SEPs for Contract Violation - SEPs for Nonrenewals or Terminations - SEPs for Exceptional Conditions - SEPs for Beneficiaries Age 65 (SEP65) - Effective Date of Coverage - Effective Date of Auto- and Facilitated Enrollments - Effective Date of Voluntary disenrollment - Election Periods and Effective Dates for Medicare MSA Plans - Closed Plans, Capacity Limits.

3 And Reserved Vacancies - MA Plan Closures 40 - Enrollment Procedures - Format of Enrollment Elections - Enrollment Form - Optional Employer Group MA Enrollment Election - Enrollment via the Internet - Enrollment Via Telephone for Current MA Plan Enrollees - Seamless Conversion Enrollment Option for Newly Medicare Eligible Individuals - Auto-enrollment of Full-Benefit Dual Eligible Individuals - Facilitated Enrollment of Other LIS Eligible Individuals - Group Enrollment for Employer or Union Sponsored Plans - Completing the Enrollment - Who May Sign An Election Form or Complete an Election Method - When the Enrollment Election Is Incomplete - MA Organization Denial of Enrollment - ESRD and Enrollment - Transmission of Enrollments to CMS - Information Provided to Member - Prior to the Effective Date of Coverage - After the Effective Date of Coverage - Enrollment Processing During Closed Periods - Procedures After Reaching Capacity - Procedures After Closing During the OEP - Enrollments Not Legally Valid - Enrollment Procedures for Medicare MSA Plans 50 - disenrollment Procedures - Voluntary disenrollment by Member - Requests Submitted via Internet - Request Signature and Date - Effective Dates - Notice Requirements - Optional Employer Group MA disenrollment Election - Group disenrollment for Employer or Union Sponsored Plans - Medigap Guaranteed Issue Notification Requirements for Disenrollments to Original Medicare during a SEP.

4 Required Involuntary disenrollment - Members Who Change Residence - General Rule - Effective Date - Researching and Acting on a Change of Address - Notice Requirements - Loss of Entitlement to Medicare Part A or Part B - Death - Terminations/Nonrenewals - Optional Involuntary Disenrollments - Failure to Pay Premiums - Disruptive Behavior - Fraud and Abuse - Processing Disenrollments - Voluntary Disenrollments - Involuntary Disenrollments - Disenrollments Not Legally Valid - disenrollment of Grandfathered Members - disenrollment Procedures for Employer Group Health Plans - disenrollment Procedures for Medicare MSA Plans 60 - Post-Election Activities - Multiple Transactions - Cancellations - Cancellation of Enrollment - Cancellation of disenrollment - Reinstatements - Reinstatements for disenrollment Due to Erroneous Death Indicator or Due to Erroneous Loss of Medicare Part A or Part B Indicator - Reinstatements Due to Mistaken disenrollment Made By Member - Retroactive Enrollments - Retroactive Disenrollments - Retroactive Transactions for Employer Group Health Plan (EGHP) Members - EGHP Retroactive Enrollments - EGHP Retroactive Disenrollments - Election of the Continuation of Enrollment Option for MA Local Plans - Storage of Enrollment and disenrollment Records - Medicare MSA Plans - Special Needs Plans (SNPs) Appendix 1: Summary of Notice Requirements (3 Pages) Appendix 2.

5 Data Elements Required to Complete the Enrollment Election Appendix 3: Timeframes for Required Enrollment & disenrollment Monitoring Elements Exhibit 1: Model Individual Enrollment Form ( Election may also be used) Exhibit 2: Model Employer Group Health Plan Enrollment (the term Election may also be used) Form (5 Pages) Exhibit 3: Model Short Enrollment Form ( Election may also be used) (2 Pages) Exhibit 3a: Model Selection Form - Switch From Plan to Plan Within M+C Organization Exhibit 4: Model Notice to Acknowledge Receipt of Completed Enrollment Election Exhibit 4a: Model Notice to Acknowledge Receipt of Completed Enrollment Election Enrollment in another Plan Within the Same M+C Organization Exhibit 5: Model Notice to Request Information Exhibit 6: Model Notice to Confirm Enrollment Exhibit 6a: Model Notice to Confirm Enrollment - Plan to Plan Within M+C Organization Exhibit 7: Model Notice for M+C Organization Denial of Enrollment Exhibit 8: Model Notice for CMS Rejection of Enrollment Exhibit 9: Model Notice to Send Out disenrollment Form Exhibit 10: Model disenrollment Form Exhibit 11: Model Notice to Acknowledge Receipt of Voluntary disenrollment Request from Member Exhibit 12: Model Notice to Confirm Voluntary disenrollment Identified Through Reply Listing Exhibit 13: Model Notice of disenrollment Due to Death Exhibit 14: Model Notice of disenrollment Due to Loss of Medicare Part A and/or Part B Exhibit 15.

6 Model Notice to Offer Beneficiary Services, Pending Correction of Erroneous Death Status Exhibit 16: Model Notice to Offer Beneficiary Services, Pending Correction of Erroneous Medicare Part A and/or Part B Termination Exhibit 17: Model Notice to Offer Reinstatement of Beneficiary Services, Pending Correction of disenrollment Status Due to Enrolling in Another M+C Organization Exhibit 18: Model Notice to Close Out Request for Reinstatement Exhibit 19: Model Notice on Failure to Pay Plan Premiums - Advance Notification of disenrollment or Reduction in Coverage Exhibit 20: Model Notice on Failure to Pay Plan Premiums - Notification of Involuntary disenrollment Exhibit 21: Model Notice on Failure to Pay Plan Premiums - Confirmation of Involuntary disenrollment Exhibit 22: Model Notice on Failure to Pay Plan Premiums - Notice of Reduction in Coverage Exhibit 23: Model Notices for Closing Enrollment (2 pages) Exhibit 24: Model Notice for Medigap Rights Per Special Election Period Exhibit 25: Acknowledgement of Request to Cancel Enrollment Exhibit 26: Acknowledgement of Request to Cancel disenrollment 10 - Definitions (Rev.)

7 66, Issued: 08-05-05, Effective Date: 08-05-05) For Chapter 2, a reference to an MA plan includes MA local plans, MA Regional Preferred Provider Organization (PPO) plans and MA-PD plans unless otherwise specified. The instructions provided in this chapter apply to MA plans, including MA-PD plans. Instructions for enrollment (and disenrollment ) in a Prescription Drug Plan (PDP) is provided in a separate guidance. The following definitions relate to topics addressed in this Chapter. Cancellation of Election - An action initiated by the beneficiary to cancel an election before the effective date of the election. A cancelled election has not been used and remains available for use during the applicable election period. Completed Election - An election is considered complete when: 1.

8 The form/request is signed by the beneficiary or legal representative (refer to for a discussion of who is considered to be a legal representative), or the election mechanism (described by CMS) is completed; 2. For enrollments, evidence of entitlement to Medicare Part A and enrollment in Medicare Part B is obtained by the Medicare advantage organization (see below for definition of evidence of Medicare Part A and Part B coverage. ) There are situations at the end of the month when the MA organization receives an election form from the beneficiary without any evidence of entitlement to Medicare Part A and Medicare Part B ( , copy of a Medicare card, SSA letter). The MA organization is then required to obtain verification of the beneficiary s entitlement through other means.

9 In these cases, CMS will allow for a grace period of three business days after the end of the month to obtain such verification. If it is confirmed during the grace period that the beneficiary was entitled to both Medicare Part A and Part B when the election form was received by the MA organization, the date of entitlement will suffice as the evidence and the election form will be considered complete upon receipt. For example, if an otherwise complete enrollment form was received on September 30, the MA organization has until October 3 to verify Medicare Part A entitlement and Part B enrollment to provide the enrollee with an October 1 effective date. 3. All necessary elements on the form are completed (for enrollments, see Appendix 2 for a list of elements that must be completed) or when the election mechanism is completed as CMS directs, and, when applicable; 4.

10 Certification of a legal representative s authority to make the election is obtained by attestation (refer to ). For enrollments into an MA-only (non MA-PD) plan, an MA organization may also choose to wait for the individual s payment of the plan premium, including any premiums due the MA organization for a prior enrollment before considering an enrollment complete. This does not apply when the individual has chosen to have plan premiums withheld from SSA/RRB/OPM benefits. Continuation Area/Continuation of Enrollment Option - A continuation area is an additional CMS-approved area outside the MA local plan s service area within which the MA organization furnishes or arranges for furnishing of services to the MA local plan s continuation of enrollment members.