Medicare Managed Care Manual - cms.gov

1 1 Medicare Managed Care Manual Chapter 17, Subchapter D Medicare Cost Plan Enrollment and Disenrollment Instructions Updated: November 21, 2012 (Revised: August 30, 2013, August 14, 2014, July 6, 2015, September 1, 2015, September 14, 2015, December 30, 2015, May 27, 2016, August 25, 2016, June 15, 2017 & July 31, 2018) This guidance update is effective for contract year 2019. All enrollments with an effective date on or after January 1, 2019, must be processed in accordance with the revised requirements, including new model enrollment forms and notices, as appropriate.

2 Cost organizations may, at their option, implement any new requirement consistent with this guidance ( new model forms/notices) prior to the required implementation. It is expected that cost organizations will assure compliance with all cost plan requirements described in this subchapter regarding communications made with beneficiaries/members, including the use of the model notices and the requirements outlined in the Medicare Communications and Marketing Guidelines (MCMG). Organizations are required to provide information to individuals in accessible/alternate formats (for example, Large Print, Braille), upon request and thereafter, as outlined in Section 504 of the Rehabilitation Act of 1973 (and subsequent revisions).

3 Such individuals must have an equal opportunity to participate in enrollment, paying premium bills, and communicating with the plan, as members who do not request accessible/alternate formats. Table of Contents 10 General Information .. 6 Definitions .. 6 General Requirements .. 9 Cost Plans Offering Medicare Prescription Drug Coverage as an Optional Supplemental Benefit .. 9 20 Eligibility for Enrollment in a Medicare Cost Plan .. 10 Conversion Enrollments .. 11 End Stage Renal Disease.

4 11 Background on ESRD Entitlement .. 12 Exceptions to Eligibility Rule for Individuals with ESRD .. 12 Hospice .. 13 Citizenship or Lawful Presence Status .. 14 30 Enrollment Periods and Effective Date of Enrollment .. 15 General Open Enrollment Requirements .. 15 2 Waivers for Open Enrollment .. 16 Determining Enrollment Availability for Medicare Beneficiaries .. 16 Utilization Adjustment Factor .. 17 Reserved Vacancies .. 17 Special Requirements When Reaching Capacity.

5 18 Effective Date of Enrollment in Cost Plans .. 18 Cost Plan Enrollment Effective Date Option 1 .. 18 Cost Plan Enrollment Effective Date Option 2 .. 19 Effective Date of Optional Supplemental Part D Benefit .. 20 Effect of the MA and PDP 5-Star Special Enrollment Period (SEP) on Cost Plans .. 20 Effect of the Duals/Low Income Subsidy (LIS) SEP on Cost Plans Offering a Part D Optional Supplemental Benefit .. 21 40 Enrollment Procedures .. 23 Format of Enrollment Requests.

6 23 Paper Enrollment Forms .. 23 Enrollment via Telephone .. 24 Electronic Enrollment .. 25 Medicare Online Enrollment Center (OEC) .. 26 Auto and Facilitated Enrollment .. 27 Group Enrollment Request Mechanism for Employer/Union Sponsored Coverage .. 35 Verifying Enrollment Information .. 36 Who May Complete a Cost Plan Enrollment or Disenrollment 38 When the Enrollment Form Has Missing or Erroneous Information .. 39 ESRD and Enrollment .. 39 Processing 40 Information Provided to the Beneficiary.

7 41 Cost Plan Denial of Enrollment .. 41 Cost Plan Denial of Enrollment in Optional Supplemental Part D Benefit .. 42 Re-enrollment .. 42 50 Disenrollments .. 43 Voluntary Disenrollments .. 43 Effective Date of Voluntary Disenrollment .. 43 Group Disenrollment for Employer/Union Sponsored Cost Plans .. 44 Required Involuntary Disenrollments .. 44 Permanent Move Out of the Plan s Service Area .. 45 Retention of Members Who Temporarily Leave the Plan s Service Area.

8 45 Death .. 46 Loss of Entitlement to Part B .. 47 Plan Termination/Non-Renewal or Reduction of Plan Service Area .. 47 3 Failure to Pay Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA) 48 Unlawful Presence Status .. 48 Other Involuntary Disenrollments .. 49 Failure to Pay Premium .. 49 Fraud in Enrollment or Abuse of Membership Cards .. 50 Disenrollment for Cause (Disruptive Behavior) .. 50 60 Post-Enrollment/Disenrollment Activities .. 53 Retroactive Enrollments.

9 53 Enrollment Retroactive to Date of Initial Medicare Entitlement .. 53 Errors in Social Security Administration (SSA) Records and/or CMS Medicare Entitlement Data .. 53 Retroactive Disenrollment .. 54 Failure of Employer Group to Notify Plan of Requested Disenrollment .. 55 Multiple Transactions .. 55 Storage of Enrollment 56 Cancellations .. 56 Cancellation of Enrollment .. 57 Cancellation of Disenrollment .. 57 Cancellation Due to Notification from CMS (TRC 015).

10 58 Reinstatements .. 58 Reinstatements for Disenrollment Due to Erroneous Death Indicator, or Erroneous Loss of Medicare Part B, Erroneous Incarceration Information, or Erroneous Unlawful Presence Information .. 59 Reinstatements Based on Beneficiary Cancellation of New 60 Reinstatements Based on a Determination of Good Cause for Failure to Pay Cost Plan Premiums, Optional Supplemental Part D Benefit Premiums or Part D-IRMAA Timely .. 61 - Process for Good Cause Determinations for Nonpayment of Plan Premiums (or other charges) or Optional Supplemental Part D Benefit Premiums.