SSA - POMS: HI 00208.067 - Eligibility and Elections in Medicare Advantage Plans

A. Policy — MA eligibility requirements

1. Eligibility for an MA plan

To be eligible for an MA plan the beneficiary must:

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Be entitled to hospital insurance (Part A) and supplementary medical insurance (Part B) when coverage under the MA plan begins;
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Not have End-State Renal Disease, or ESRD (some exceptions apply). Beneficiaries who develop ESRD while a member of an MA plan may remain enrolled.
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Live in the service area of an MA plan.

2. Beneficiaries entitled to Part B only

a.

Beneficiaries entitled to Part B only who were enrolled in a Managed Care Plan prior to 01/99 were “grandfathered” into the MA program, that is, they were allowed to continue enrollment in the plan. However, if these individuals elect to disenroll from the MA organization, they are not eligible to enroll in any MA plan until or unless they meet all MA eligibility requirements.
b.

Beneficiaries may enroll in Premium-HI during the Transfer Enrollment Period (TEP) Refer to HI 00801.142 - HI 00801.144 for information on the TEP.

B. Policy — enrollment in an MA plan

1. Application requirement

An eligible individual must complete an enrollment request to enroll in an MA plan, even if that individual is electing an MA plan in the same MA organization in which the individual is enrolled.. MA organizations must have, at minimum, a paper enrollment form process. At their discretion, organizations may offer enrollment via telephone and internet, as well. Individuals may call 1-800-MEDICARE to submit enrollment requests to organizations that offer enrollment via the internet. MA elections CANNOT be made at SSA FOs.

2. Specific times for elections

The MMA provides specific periods referred to as “election periods” during which a beneficiary can elect an MA plan. There are four types of election periods during which individuals may make elections. They are:

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The Initial Coverage Election Period (ICEP);
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The Open Enrollment Period (OEP);
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The Annual Election Period (AEP); and
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All Special Election Periods (SEP)

3. MA election periods

a. Initial Coverage Election Period (ICEP)

The ICEP is the period during which an individual newly eligible for MA may make an initial election to enroll in an MA plan. This period begins three months immediately before the individual’s first entitlement to both Medicare Part A and Part B and ends on the later of:

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The last day of the month preceding entitlement to both Part A and Part B, or;
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The last day of the individual’s Part B initial enrollment period.

The initial enrollment period for Part B is the seven (7) month period that begins 3 months before the month an individual meets the eligibility requirements for Part B, and ends 3 months after the month of first eligibility.

Once an ICEP election is made and enrollment takes effect, the ICEP election has been used.

b. Open Enrollment Period (OEP)

In addition to their opportunities during the AEP, SEP, or ICEP, MA eligible individuals may make one MA OEP election from January 1^st through March 31st. MA organizations are not required to open their MA plans for enrollment during an OEP. However, MA organizations must accept valid requests for disenrollment from MA-only plans during the OEP since Original Medicare is always open during an OEP. In addition, if an MA organization has more than one MA plan, the MA organization is not required to open each plan for enrollment during the same time frames.

OEP elections must be made to the same type of plan (regarding Medicare prescription drug coverage) in which the individual is already enrolled.

EXCEPTION: Beneficiaries may not elect an MA MSA plan during the Open Enrollment Period.

c. Annual Election Period (AEP)

The AEP occurred November 15 through December 31 of every year through 2010. Beginning in 2011, the AEP runs from October 15 through December 7 of each year. During the AEP, MA eligible individuals may enroll in or disenroll from an MA plan. The last election made will be the election that takes effect.

d. Special Election Periods (SEP)

The MMA provides special election periods during which an individual may enroll in, disenroll from or switch MA plans outside of other election periods. Inquiries regarding SEP eligibility should be referred to 1-800-MEDICARE (TTY 1-877-486-2048). Examples of SEPs include:

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Individuals who permanently move out of the plan's service area or are affected by plan termination or reduction of the plan's service area are eligible for a SEP.
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Individuals eligible for both Medicare and Medicaid (“dual eligibles”) and individuals who qualify for the low income subsidy have an ongoing SEP.
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Individuals who have employer sponsored coverage, or who are losing such coverage, are eligible for a SEP.
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Individuals who enrolled in an MA plan based on misleading or incorrect information from plan employees, agents or brokers.
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Other SEPs may apply.

e. Special rules for MA MSA plans

Eligible beneficiaries may enroll in an MA MSA plan (should one be offered in their area) only during their initial coverage election period or the annual election period.

C. Policy — effective date of MA enrollment

1. Election made during initial coverage election period

An election made during the initial coverage election period is effective the first day of the month following the month in which the enrollment request is received by the MA organization, but never earlier that the date on which the individual is entitled to Part A and Part B.

2. Election made during the open enrollment period

An election made during the Open Enrollment Period is effective the first day of the month following the month the election request is received by the MA organization.

3. Election made during annual election period

An election made during the annual election period is effective January 1st of the following year.

4. Special election periods

The effective date of elections made during special election periods is dependent upon the specific circumstances.

D. Policy — effect of election in an MA plan

A beneficiary who elects an MA plan does not give up the beneficiary's original Medicare coverage. The beneficiary's Medicare services are being paid for under a different payment system. The Medicare beneficiary keeps the Medicare card and will continue to have Medicare as long as the requirements for entitlement are met. However, while enrolled in an MA plan only the MA plan will provide coverage.

E. Policy — eligibility and enrollment in 1876 cost plan

1. Policy — eligibility requirements

To enroll in a cost plan, the beneficiary must:

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Be entitled to Part B
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Not have ESRD at time of enrollment (a beneficiary that develops ESRD after enrolling in a cost plan may not be disenrolled).
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Reside in service area of a 1876 cost plan

2. Policy — enrollment period for 1876 cost plans

The 1876 cost plans must provide open enrollment for at least 30 consecutive days during each contract year. Information about enrollment periods should be obtained from the cost plan.

3. Policy — effective date of coverage in 1876 cost plan

The cost plan will notify the individual of the effective date of enrollment, which is generally the first of the first or second month after the individual requests enrollment. However, the beneficiary can choose an effective date of up to three (3) months into the future.

4. Policy — effect of enrollment in an 1876 plan

A beneficiary who elects an 1876 cost plan does not give up the beneficiary' Original Medicare coverage. The beneficiary’s Medicare services are being paid for under a different payment system. The beneficiary keeps the Medicare card and will continue to have Medicare as long as the requirements for entitlement are met. The bene may access Medicare fee-for-service coverage while enrolled in the cost plan.

F. References

Refer to HI 00801.142 - HI 00801.144 for information on the Transfer Enrollment Period.

Social Security

Program Operations Manual System (POMS)

HI 00208.067 Eligibility and Elections in Medicare Advantage Plans