Medicare Managed Care Manual Chapter 2 - Medicare Advantage Enrollment and Disenrollment Updated: August 19, 2011 (Revised: November 16, 2011, August 7, 2012, 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 & August 12, 2020) This guidance update is effective for contract year 2021. All enrollments with an effective date on or after January 1, 2021, must be processed in accordance with the revised requirements, including the new model Medicare Advantage (MA)enrollment form for the 2021 plan year starting October 15, 2020 and model notices, as appropriate. Organizations may, at their option, implement any new requirement consistent with this guidance prior to the required implementation date. It is expected that organizations will assure compliance with all Medicare Advantage requirements described in this chapter 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). 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 - Definitions .......................................................................................................................................9 20 - Eligibility for Enrollment in MA Plans .......................................................................................16 20.1 - Entitlement to Medicare Parts A and B and Eligibility for Part D ...................................17 20.2 - Place of Permanent Residence ............................................................................................17 20.2.1 - Mailing Address .........................................................................................................19 20.2.2 – U.S. Citizenship or Lawful Presence ..............................................................................19 20.3 - Completion of Enrollment Request ....................................................................................19 20.3.1 - Optional Employer/Union Enrollment Request Mechanism ...................................20 20.3.2 - Passive Enrollment by CMS ......................................................................................20 20.3.3 - Group Enrollment for Employer or Union Sponsored Plans ...................................22 20.4 - Agreeing to Abide by MA Organization Rules .................................................................23 20.5 - Grandfathering of Members on January 1, 1999 ...............................................................23 20.6 - Eligibility and the Hospice Benefit ....................................................................................24 1 20.7 - Continuation of Enrollment Option for MA Local Plans ..................................................24 20.8 - Additional Eligibility Requirements for MA Religious Fraternal Benefit (RFB) Plans .25 20.9 - Eligibility Requirements for Medicare Medical Savings Account (MSA) Plans ............25 20.10 - Additional Eligibility Requirements for Enrollment in MA Special Needs Plans ........25 30 - Election Periods and Effective Dates...........................................................................................28 30.1 - Annual Election Period (AEP) ............................................................................................29 30.2 - Initial Coverage Election Period (ICEP) ............................................................................29 30.2.1 - Initial Enrollment Period for Part D (IEP for Part D) ..............................................30 30.3 - Open Enrollment Period for Institutionalized Individuals (OEPI) ...................................31 30.4 - Special Election Period (SEP) ............................................................................................31 30.4.1 - SEPs for Changes in Residence .................................................................................34 30.4.2 - SEPs for Contract Violation ......................................................................................35 30.4.3 - SEPs for Non-renewals or Terminations ..................................................................36 30.4.4 - SEPs for Exceptional Conditions ..............................................................................38 1. SEP EGHP (Employer/Union Group Health Plan) .....................................................38 2. SEP for Individuals Who Disenroll in Connection with a CMS Sanction .................39 3. SEP for Individuals Enrolled in Cost Plans that are Non-renewing their Contracts .39 4. SEP for Individuals in the Program of All-inclusive Care for the Elderly (PACE) ..39 5. SEP for Dual-eligible Individuals and Other LIS-Eligible Individuals......................39 6. SEP for Individuals Who Terminated a Medigap Policy When They Enrolled For the First Time in an MA Plan, and Who Are Still in a “Trial Period” ...............41 7. SEP for Individuals with ESRD Whose Entitlement Determination Made Retroactively ..........................................................................................................41 8. SEP for Individuals Whose Medicare Entitlement Determination Made Retroactively ..........................................................................................................42 9. MA SEPs to Coordinate With Part D Enrollment Periods ..........................................42 10. SEP for Individuals Who Lose Special Needs Status ...............................................43 11. SEP for Individuals Who Belong to a Qualified SPAP or Who Lose SPAP Eligibility ...............................................................................................................43 12. SEP for Individuals who Gain, Lose, or Have a Change in their Dual or LIS- Eligible Status ........................................................................................................43 13. SEP for Enrollment Into a Chronic Care SNP and for Individuals Found Ineligible for a Chronic Care SNP.........................................................................................44 14. SEP for Disenrollment from Part D to Enroll in or Maintain Other Creditable Coverage ...................................................................................44 15. SEP to Enroll in an MA Plan, PDP or Cost Plan With a Plan Performance Rating of Five (5) Stars .....................................................................................................44 16. SEP for Non-U.S. Citizens who become Lawfully Present ......................................46 17. SEP for Providing Individuals who Requested Materials in Accessible Formats Equal Time to Make Enrollment Decisions .........................................................46 18. SEP for Government Entity-Declared Disaster or Other Emergency ......................46 2 19. SEP for Individuals Enrolled in a Plan Placed in Receivership ..............................47 20. SEP for Individuals Enrolled in a Plan That Has Been Identified by CMS as a Consistent Poor Performer ...................................................................................47 21. SEP for Other Exceptional Circumstances ................................................................47 30.4.5 - SEPs for Beneficiaries Age 65 (SEP65) ...................................................................48 30.4.6 – SEP for Significant Change in Provider Network ...................................................48 30.4.7 – SEP for CMS and State-Initiated Enrollments ........................................................48 30.5 – Medicare Advantage Open Enrollment Period (MA OEP) ..............................................49 30.6 - Effective Date of Coverage .................................................................................................49 30.6.1 - Effective Date of Auto- and Facilitated Enrollments ...............................................51 30.7 - Effective Date of Voluntary Disenrollment .......................................................................52 30.8 - Election Periods and Effective Dates for Medicare MSA Plans ......................................53 30.9 - Closed Plans, Capacity Limits, and Reserved Vacancies .................................................53 30.9.1 - MA Plan Closures ......................................................................................................53 40 - Enrollment Procedures ..................................................................................................................55 40.1 - Format of Enrollment Requests ..........................................................................................56 40.1.1 - Enrollment Request Mechanisms ..............................................................................57 40.1.2 – Electronic Enrollment................................................................................................58 40.1.3 - Enrollment via Telephone ..........................................................................................59