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San Francisco Marin Medical Society Blog

Seamless Conversion to Medicare Advantage

Some questions have been raised about recent press coverage on plans enrolling new Medicare beneficiaries in Medicare Advantage without the beneficiary’s knowledge. The American Medical Association (AMA) raised concerns and a number of questions with senior officials at the Centers for Medicare and Medicaid Services (CMS). Below are CMS’ answers. 

This policy was developed a number of years ago by Congress and pre-dates Medicare Advantage. The intention was to ease the pathway for low-income people with disabilities who were covered by Medicaid to remain in their same plan as they became dually eligible for Medicaid and Medicare, due either to their disability or their age. Clearly, the policy is now having an impact on patients in commercial or exchange plans, and it is apparent from the CMS responses that the agency’s policies are still evolving to address the unintended consequences of the policy. 

Q1: Is there an HPMS memo or guidance to the plans that spells out the procedures they need to follow to avoid cherry-picking and ensure patients are making informed decisions about opting out or not?

A: MA organizations are required to follow the guidance in Section 40.1.4 of Chapter 2 of the Medicare Managed Care Manual.

Q2: Is there guidance to the regional offices on what to look for in the plans’ proposals to do these conversions? 

A: An MA organization’s proposal must address all the seamless conversion enrollment requirements outlined in CMS guidance.

Q3: Are there safeguards in place to prevent cherry-picking? 

A: CMS guidance requires the MA organization to include all individuals in the health plan who are approaching initial Medicare eligibility, regardless of whether eligibility is based on disability or age.

Q4: Do the plans need to provide info to CMS about how their MA plan networks compare to their commercial or Medicaid networks, or info to the patients about how the networks differ?

A: CMS requires that information on the MA plan network be provided to new enrollees prior to the new coverage effective date. Such requirements are outlined in both Section 40.4 of Chapter 2 of the Medicare Managed Care Manual, and in Section 30.7 of the Medicare Marketing Guidelines. This enrollment mechanism does not currently require that comparative information between the non-Medicare plan and the MA plan be provided to individuals being offered seamless conversion enrollment.  We are continuing to evaluate ways to improve the seamless conversion process for beneficiaries and this is one aspect we will focus on. 

Q5: Is there any info you can share yet? 

A: CMS will soon be sharing more information on the plans that have been approved for the seamless conversion enrollment mechanism. This information will be posted publicly on the Medicare Managed Care Eligibility and Enrollment webpage.

Q6: Are these proposals from the plans reviewed by the ROs and, if so, what are they supposed to look for?

A: The proposals are reviewed by the CMS Regional Offices, with consultation by CMS Central Office. An MA organization’s proposal must address all the seamless conversion enrollment requirements outlined in CMS guidance. This includes an explanation on how the MA organization can identify both aged and disabled individuals in their non-Medicare product line(s) 90 days before Medicare eligibility, what outreach activities the MA organization will take to inform the individual of the seamless conversion (minimum must include a written notice at least 60 days prior to effective date) and ability to opt out, how the plan will process opt out requests, and the organization’s acknowledgement that they will submit the enrollment transaction to CMS at least 60 days prior to the effective date.

40.1.4 - Seamless Conversion Enrollment Option for Newly Medicare Advantage Eligible Individuals

  • MA organizations may develop processes to provide seamless enrollment in an MA plan for newly Medicare Advantage eligible individuals who are currently enrolled in other health plans offered by the MA organization (such as commercial or Medicaid plans) at the time of their conversion to Medicare. CMS will review an organization’s proposal and must approve it before use. MA organizations must send proposals to the appropriate Regional Office account manager and must meet the following conditions.
  • A description of the MA organization’s process to identify individuals currently enrolled in a health plan offered by the organization. Such process must be able to identify these individuals no later than 90 days prior to the date of initial Medicare eligibility (the conversion date) and must include individuals whose eligibility is based on disability as well as age.
  • A description of the outreach activity associated with the seamless conversion process including a written notice provided to each individual at least 60 days prior to the date of conversion. The notice must include clear information instructing the individual on how to opt-out, or decline, the seamless conversion enrollment.
  • Acknowledgement that the MA organization will send the appropriate enrollment transaction to CMS at the same time that it sends the written notice (see previous bullet point); i.e., at least 60 days prior to the conversion date.
  • The process to opt-out or decline the seamless conversion enrollment must include the opportunity to contact the MA organization either in writing or by telephone to a toll-free number. The MA organization is prohibited from discouraging declination. The process must allow for opt-out requests to be accepted up to and including the day preceding the enrollment effective date. The organization will submit opt-out requests to CMS as enrollment cancellations.
  • Enrollment transactions submitted to CMS for these cases must always use the first day of an individual’s ICEP as the application date in the transaction record. Doing so ensures that any subsequent action taken by the individual will take precedence in systems processing. In addition, the enrollment effective date must always be the date of the individual’s first entitlement to both Medicare Part A and Part B.
  • Plans must have beneficiary information, including HICN, date-of-birth and sex in order to process seamless conversion enrollments.

Aside from a few anecdotes and the beneficiary highlighted in articles, the AMA is unaware of other similarly affected beneficiaries.  If you have information regarding additional beneficiaries, please let us know. The AMA will remain engaged with CMS as this issue develops.

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