| Managed Care On-Line™: Articles |
| Date | October 16, 1998 |
| Subject | Enrollment Processing for Section 1876 Plans Transitioning to Medicare+Choice (M+C) Plans on January 1, 1999 |
| Expiration Date | February 28, 1999 |
This policy applies only to section 1876 plans transitioning to M+C plans on January 1, 1999 or later. The transition from section 1876 accretions to M+C accretions begins October 1998. Managed care organizations (MCOs) will need to begin to scrutinize enrollment requests to determine whether an enrollment must be processed under section 1876 eligibility or M+C eligibility rules. This OPL provides guidance on determining whether an accretion should be made under section 1876 or M+C rules.
This policy primarily affects accretions for Part B-only beneficiaries (who are only eligible to enroll in MCOs under section 1876 rules), but also affects enrollment for beneficiaries with hospice coverage (who are eligible to enroll under M+C rules, as outlined at 42CFR422.50).
This policy applies only to section 1876 plans transitioning to M+C plans on January 1, 1999 or later.
In order to comply with the M+C eligibility, election period, and effective date rules outlined at 42CFR422.50, 422.62, and 422.68, MCOs that will transition to M+C organizations on January 1, 1999 must not process enrollment applications under section 1876 eligibility rules for January 1, 1999 or later effective dates. This means that the last coverage effective date under which section 1876 enrollment rules will apply is December 1, 1998.
While the November 1998 cutoff date would typically be the last date on which December 1 effective dates can be transmitted, HCFA will accept accretions for section 1876 coverage for the December cutoff date (close of business, December 2, 1998) with a current month (i.e., December 1, 1998) effective date. In particular:
Elections for M+C coverage can begin as early as October 1, 1998, for individuals electing plans under the Initial Coverage Election Period, in which the earliest coverage effective date is January 1, 1999. Elections for M+C coverage may also occur in November and December, for January 1, 1999 coverage effective dates. (Refer to 42CFR422.62 and 422.68, and example number 5 below).
Examples:
An MCO receives an enrollment form from a Medicare beneficiary with Medicare Part A and B entitlement on October 16, 1998. In this case, the beneficiary would be eligible under section 1876 or M+C rules. Therefore, the MCO may accrete the beneficiary before the November cutoff date with a December, January, or February effective date.
An MCO receives an enrollment form from a Medicare beneficiary with Medicare Part B-only coverage on October 20, 1998. In this case, the beneficiary would not be eligible for enrollment under M+C rules because the beneficiary does not have Medicare Part A (42CFR422.50). Therefore, the MCO may only accrete the beneficiary under section 1876 rules with a December 1, 1998 effective date.
An MCO receives an enrollment form from a Medicare beneficiary with Medicare Part B-only coverage on November 15, 1998. The MCO must accrete the beneficiary by the December cutoff date with a December 1, 1998 effective date in order to enroll the beneficiary under section 1876 rules. (The beneficiary is not eligible for enrollment under M+C rules because the beneficiary does not have Medicare Part A.)
An MCO receives an enrollment form from a Medicare beneficiary with Medicare Part B-only coverage on December 15, 1998. The beneficiary is not eligible under M+C rules because she/he does not have Medicare Part A. In addition, the MCO must deny the enrollment request under section 1876 rules because the December cutoff date has passed and the MCO cannot provide coverage in 1998.
An MCO receives an enrollment form on October 20, 1998 from a Medicare beneficiary who already has Medicare Part A and B-entitlement and who has hospice coverage. In this case, the beneficiary would not be eligible to enroll under section 1876 rules because he has hospice coverage. In addition, the beneficiary would not be eligible to enroll under M+C rules because the beneficiary is not in his/her Initial Coverage Election Period. (The only M+C enrollments that can be accepted in October 1998 are ICEP enrollment requests.) If the MCO were to receive that same enrollment form in November or December, then the MCO could accrete the enrollment with a January 1 effective date because the beneficiary would be eligible for enrollment under M+C rules (i.e., the beneficiary has Medicare Part A and B and hospice coverage is allowed, as outlined at 42CFR422.50).
HCFA Regional Office Managed Care Staff
This OPL was prepared by the Center for Beneficiary Services.
Source: HCFA www.hcfa.gov
This file has been prepared for MCOL members only