Understanding the Latest Updates to Medicare Managed Care Program Enrollment

For professionals and organizations involved in Medicare Managed Care Programs, staying informed about the most recent policy and operational changes is crucial. This article outlines key updates concerning Medicare health plan enrollment and disenrollment, directly sourced from recent CMS (Centers for Medicare & Medicaid Services) announcements. These revisions are essential for Medicare Advantage (MA) organizations, health plans, and all parties engaged in Medicare health plan administration.

Key Revisions to Medicare Cost Plan Enrollment and Disenrollment Instructions

Effective January 8, 2025, CMS issued updated guidelines for “Medicare Cost Plan Enrollment and Disenrollment Instructions.” These changes, communicated via HPMS memoranda, primarily address a revised Special Election Period (SEP) for individuals dually eligible for Medicare and Medicaid, as well as those qualifying for the Low-Income Subsidy (LIS). This SEP has particular implications for cost plans that offer a Part D Optional Supplemental Benefit.

Beyond the SEP updates, several general revisions have been implemented to enhance clarity and consistency across all medicare managed care programs. These include:

• Reference Updates: Aligning references with the latest Medicare Advantage (MA) and Part D Enrollment and Disenrollment Guidance to ensure all documentation is current.
• Language Consistency: Adopting uniform language, referring to “individuals/enrollees” and expressing numeric values as words, mirroring the MA and Part D Enrollment and Disenrollment Guidance for improved readability and understanding.
• Model Enrollment Form Revisions: Modifying model enrollment forms to more closely resemble the language and structure of MA and Part D model forms, aiming for a more streamlined and user-friendly enrollment process.
• Removal of Outdated Information: Eliminating references to the Part D benefit coverage gap phase, which concluded on December 31, 2024, and removing outdated contact information for the Social Security Administration from exhibits, ensuring the guidance remains relevant and accurate.

Updated MA and Part D Enrollment and Disenrollment Guidance for 2025

Further updates were announced on August 8, 2024, with the release of the “Medicare Advantage and Part D Enrollment and Disenrollment Guidance” memorandum. These updates are pertinent to medicare managed care programs operating as MA and Part D plans and are effective for the 2025 plan year. Detailed appendices, model notices, and exhibits accompanying this guidance are available in separate documents.

It is imperative for plans to implement this new guidance for all enrollment requests received on or after January 1, 2025. Plans have the option to adopt these updated guidelines for Annual Enrollment Period (AEP) enrollments effective January 1, 2025, allowing for early adoption of best practices.

The improvements in this updated guidance are designed to make medicare managed care programs easier to navigate and administer. Key improvements include:

• Reduced Duplication: Streamlining the guidance by removing redundant language between chapters, significantly reducing the overall document length by approximately 130 pages, making it more concise and efficient to use.
• Plain and Consistent Language: Employing clear and consistent language across both MA and Part D programs, minimizing ambiguity and promoting better comprehension.
• Enhanced Clarity with Visuals: Incorporating graphics, tables, and text boxes to visually break down information and improve overall clarity, making complex information more accessible.
• Content Updates Reflecting 2025 Rulemaking: Integrating content updates to reflect recent regulatory changes effective in 2025, ensuring the guidance is fully aligned with the current regulatory landscape.

New Data Fields on the 2025 MA Model Enrollment Request Form

Adding to these significant updates, on July 2, 2024, CMS announced the “Advance Announcement of January 2025 Software Release” memorandum. This announcement details additions to the model individual enrollment request form for Medicare Advantage (MA) and Medicare Prescription Drug Plan (Part D), OMB No. 0938-1378. These changes are particularly relevant for medicare managed care programs focused on inclusivity and data collection.

The updated form now includes new fields for:

• Sexual Orientation and Gender Identity (SOGI): Collecting data on sexual orientation and gender identity to better understand and serve the diverse needs of enrollees.
• Enrollee Assistance: Gathering information related to enrollee assistance needs, allowing plans to provide more tailored support.
• Data Compact Disc (CD) Format Option: Introducing a data CD format option for enrollment submissions, providing flexibility in data handling.

MA plans are mandated to utilize this new form for all enrollment requests received on or after January 1, 2025. It’s important to note that these changes apply to all model enrollment forms included in the enrollment guidance, ensuring consistency across all enrollment processes within medicare managed care programs.

Overview of Medicare Health Plan Enrollment

For those seeking a broader understanding, Medicare health plan enrollment is governed by specific eligibility and election provisions outlined in 42 CFR § 417, Subpart K, 42 CFR § 422, Subpart B, and 42 CFR § 423, Subpart B. These regulations define the framework for eligibility, election processes, election periods, and effective coverage dates for Medicare Advantage (MA) organizations, other Medicare health plans, and Part D plan sponsors – all integral components of medicare managed care programs.

To enroll in a Medicare health plan, individuals must meet specific criteria:

• Medicare Parts A and B: Enrollees must have both Medicare Part A (Hospital Insurance) and Part B (Medical Insurance).
• Service Area Residency: Individuals must reside within the service area of the specific plan they wish to join.
• U.S. Citizenship or Lawful Presence: Enrollees must be U.S. citizens or lawfully present in the United States.
• Valid Enrollment Period: Enrollment requests must be completed during a recognized valid election period.

The six recognized types of election periods are:

1. Initial Enrollment Period for Part D (Part D IEP)
2. Initial Coverage Election Period (ICEP)
3. Annual Coordinated Election Period (AEP)
4. Medicare Advantage Open Enrollment Period (MA OEP)
5. Open Enrollment Period for Institutionalized Individuals (OEPI)
6. Special Election Periods (SEPs)

Understanding these enrollment periods and eligibility rules is fundamental for both beneficiaries and administrators within medicare managed care programs.

Conclusion

These updates from CMS represent significant changes for medicare managed care programs in 2025. Staying abreast of these revisions to enrollment and disenrollment guidelines, model forms, and data collection is essential for all stakeholders in the Medicare landscape. By understanding and implementing these changes, organizations can ensure compliance, improve operational efficiency, and ultimately provide better service to Medicare beneficiaries.