Print
Skip left navigation

Medicare Advantage (MA) Enrollment, Eligibility and Transfers, and Disenrollment - Capitation and/or Delegation Supplement, 2018 UnitedHealthcare Administrative Guide

We can provide member eligibility information using an electronic 834 file containing eligibility changes daily. We can provide a full eligibility file monthly.

Startng electronic eligibility requires coordination with your software vendor and us.

Some of the advantages of receiving electronic eligibility are:

  • An eligibility upload may reduce the administrative overhead by minimizing the effort currently required to maintain eligibility manually.
  • Eligibility updates can be loaded into your system in a timely manner.

Please contact your Physician Advocate for more information.

Upon your request, we send each medical group/IPA a monthly eligibility list of all its assigned members. This may contain:

• Member ID number
• Name
• Date of birth
• Plan code
• Employer group number (if applicable)
• Care provider effective date
• Benefit plan effective date
• Care provider name
• Group number
• Gender
• Eligibility status (currently eligible, newly eligible)
• Effective dates of terminations and transfers

• Benefits, including copayments and deductible
• Address (including ZIP code)
• Managed care plan/benefit plan selected
• Identity of third party coverage (if known)
• Enrollment/ disenrollment date
• Type of change to coverage
• PCP
• Member copay total
• Member copay max date
• Member deductible total
• Member deductible max date

The most common eligibility report used is the EL915. This report is available electronically. It is sent to the capitated care provider through a file transfer protocol and viewed on UHCprovider.com. We generally provide eligibility information once per month. We can provide it weekly if needed.

Medicare beneficiaries who elect to become members of a UnitedHealthcare MA plan must meet the following qualifications:

  • Beneficiaries must be entitled to Medicare Part A and enrolled in Medicare Part B
  • Beneficiaries must reside in our MA service area. To maintain permanent residence, the beneficiary must not continuously reside outside the applicable service area for more than six months (nine months if utilizing the UnitedHealth Passport® benefit)
  • Beneficiaries must not have End Stage Renal Disease (ESRD), unless they meet one of the following exceptions:
    • Beneficiary with ESRD, whose enrollment with another MA plan was impacted by the plan’s termination or service area reduction, is allowed to enroll in UnitedHealthcare MA.
    • Member who developed ESRD after enrollment may remain on the program.
    •  Beneficiary with ESRD covered under a UnitedHealthcare commercial plan is eligible to join UnitedHealthcare MA, as long as there is no lapse in coverage. The beneficiary with ESRD must be a member of the Commercial plan at the time he/she developed ESRD to be considered a true rollover and become eligible for benefits. A beneficiary who developed ESRD prior to their enrollment in the Commercial plan would not meet the eligibility criteria.
  • Exceptions have been made for a UnitedHealthcare group retiree member with ESRD:
    • If an employer or union group offers an MA plan as a new option to its employees and retirees, a retiree with ESRD may select this new MA plan option (regardless of whether it has been an option in the past) as the employer’s or union’s open enrollment rules allow.
    • If an employer or union group that has been offering a variety of coverage options consolidates its employee/ retiree offerings (i.e., it terminates one or more plans), current members of the dropped plans may be accepted into a MA plan that is offered by the group.
    • If an employer or union group has contracted locally with an MA organization in more than one geographic area (for example, in two or more states), an ESRD retiree who relocates permanently from one geographic location to another may remain with the MA organization in the local employer or union MA plan.

ESRD information is accessible on UHCprovider.com.

  • Beneficiaries receiving Medicare hospice benefits are eligible to join UnitedHealthcare MA.
    • We are financially responsible for covered additional and optional supplemental benefits not covered under original Medicare.
    • All Medicare-covered services related to the terminal illness coverage through original Medicare.
  •  Beneficiaries must maintain monthly premiums in geographic areas, where applicable.

If a Medicare beneficiary is an inpatient at any of the following facilities at the time the beneficiary’s membership becomes effective with us, the previous carrier is financially responsible for Part A services (inpatient facility care) until the day after the member is discharged to a lower level of care:

  • An acute facility,
  • A psychiatric facility,
  • A long–term care facility, or
  • A rehabilitation facility.

The member’s assigned medical group/IPA assumes financial responsibility for Part B services (medical care) on the member’s membership effective date. If the member is an inpatient at a skilled nursing facility at the time of their effective date, the medical group/IPA and capitated
facility become financially responsible for Part A and Part B services on the member’s effective date.

If a member’s coverage terminates while the member is an inpatient at any of the facilities identified above, the medical group/IPA is no longer financially responsible for Part B (medical care) services. The capitated facility remains financially responsible for Part A (inpatient facility care) services until the day after the member’s discharge to a lower level of care (e.g., home health or skilled nursing facility).

Refer to the Medicare Advantage Coverage Summary titled Change of Membership Status while Hospitalized (Acute, LTC and SNF) or Receiving Home Health on UHCprovider.com/policies > Medicare Advantage Policies > Coverage Summaries.

When an MA member has a benefit plan change, they must complete and submit an Individual Enrollment Request Form and Statement of Understanding. If the member completes the form over the phone, we make the plan changes the first of the following month. The member does not have to submit paperwork. A benefit plan change occurs when the member:

  • Moves from one service area to another, within the same state. The member must complete the form and return it within 30 calendar days. If they do not return the form within 30 calendar days, the member is considered to be out of the service area and will be disenrolled on the 1st of the month following the 30 calendar days;
  • Changes from one benefit plan to another. If the member does not return a completed form, they will remain on the existing plan. The member may only change benefit plans using their annual election period or during the MA Disenrollment Period defined by CMS.

If the member has exhausted these elections, and does not qualify for a Special Election Period, they are locked in to the current benefit plan for the remainder of the calendar year. They may not change benefit plans.

CMS requires that we treat a member who experiences a benefit plan change as a new member, rather than as an existing member. Therefore, the member’s enrollment to another PCP or medical group/IPA is effective the first of the month following receipt of the completed form.

To enroll for membership in MA, an applicant must do one of the following:
• Complete and sign an Individual Enrollment Request Form and Statement of Understanding;
• Call UnitedHealthcare Medicare Advantage and complete a telephonic enrollment;
• Meet with a licensed sales representative;
• Log on to UHCMedicareSolutions.com, or AARPMedicarePlans.com for online enrollment;
• Log on to medicare.gov to enroll online (may not apply for all SNPs); or
• Call 800-MEDICARE or 800-633-4227 to enroll (may not apply for all SNPs).

CMS has defined specific enrollment periods during which individual plan members may enroll in a health plan, change to another health plan, change benefit plans, or return to Medicare. Details on the different types of enrollment periods and the requirements of each type are outlined on the CMS website at cms.hhs.gov.

Enrollment periods for UnitedHealthcare Group MA members are dictated by the employer group’s annual renewal date with us. A group retiree annual enrollment period will coincide with the employer’s annual enrollment cycle.

UnitedHealthcare Group MA processes eligible Individual Enrollment Request Forms and Statement of Understanding Forms. Forms received by the end of the month are processed for eligibility on the first of the following month.

Coverage begins at 12:01 a.m. on the effective date, provided the enrollment request form received is complete. The effective date is delayed if the enrollment request form is incomplete, needs additional information, or lacks documentation of proof of entitlement to Medicare Parts A and B. We will try to resolve any outstanding issues with the enrollment request form to complete the enrollment process.

We may process a group retiree member’s enrollment into UnitedHealthcare Group MA plan with a retroactive effective date. The retroactive window allows the group retiree member to enroll with an effective date up to 90 calendar days retroactive. The effective date can never be earlier than the signature date on the enrollment request form.

We will let the member know the effective date in writing in an enrollment confirmation letter.

For most plans, the member must select a PCP or medical group/IPA as outlined in Chapter 4: Medicare Products, Medicare Product Overview Tables

In accordance with CMS, a member may not change medical groups/IPAs or PCPs for any reason, such as the following:

  • The member is an inpatient in a facility, a skilled nursing facility or other medical institution at the time of request to transfer;
  • The change may have an adverse effect on the quality of the member’s health care;
  • The member is an organ transplant candidate; or
  • The member has an unstable, acute medical condition for which he/she is receiving active medical care. In the following instances, a member may request a medical group/IPA or PCP change, outside the 15/30 rule, that will be effective the first of the following month:
  • The member calls to request a change within 30 calendar days of the effective date with UnitedHealthcare due to the wrong medical group/IPA or PCP being assigned;
  • The member calls to request a change within 30 calendar days of the effective date with UnitedHealthcare and has not received services with the originally assigned care provider; or
  • The member calls to request a change within 30 calendar days due to a household move over 30 miles and the member has not received services with the originally assigned care provider.

If a member changes his or her medical group/IPA or PCP while an inpatient at any the following facilities, the capitated entity at risk for Part A services at the time of the admission will retain financial risk until discharge to home or another care setting.

  • An acute care facility
  • A critical access facility
  • A long-term care facility
  • A psychiatric facility
  • An inpatient rehabilitation facility

Financial responsibility for Part B services will be the responsibility of the new medical group/IPA or PCP on the effective date of the transfer.

Refer to UHCprovider.com/poicies > Medicare Advantage Policies and look to UnitedHealthcare Medicare Advantage Coverage Summaries for additional information about coverage of ambulance transfers due to a medical group/ IPA change while the member is an inpatient.

If the member/care provider relationship has been seriously impaired, an involuntary transfer from the Current PCP/Medical Group/IPA to another PCP/Medical Group/ IPA is implemented by the following the guidelines:

First Occurrence
At the first occurrence, you should send the member a certified/return receipt-warning letter advising him/her of the issue and potential consequences of dismissal. Document the specific information including the care provider’s name, date of occurrence, and issue. The letter must tell the member that PCP/medical group/IPA is notifying us regarding the matter and offer the member the right to respond to the allegations. PCP/Medical group/IPA must maintain full documentation. Send a copy of the letter directly to your provider advocate.

Second Occurrence
Send the member a second certified/return-receipt warning letter advising them of the continued issue and potential consequences of dismissal. Your documentation should include the additional issues, care provider’s name and date of occurrence. The letter to the member must state the PCP/medical group/IPA’s recommendation for cooperation, indicate that the PCP/medical group/ IPA will be requesting our intervention in initiating a medical group transfer and offer the member the right to grieve the allegations. Send a copy of the letter and full documentation directly to your provider advocate.

Third Occurrence
On the third occurrence, immediately notify your provider advocate with a request to remove the member from the PCP/medical group/IPA. Be sure to include all prior documentation. We will review the PCP/medical group/ IPA documentation outlining the continued issues. Based on the documentation, we may reassign the member to a new PCP/medical group/IPA. If so, we will contact the member and arrange for a PCP/medical group/IPA transfer or disenrollment from the plan.

Note: If you receive notification of a member’s intent to sue, please notify your provider advocate.

Member Elected Disenrollment
If a member requests disenrollment through the care provider, refer the member to our Member Service Department. Once the disenrollment is processed, we will send a letter with the effective date of disenrollment to the member. If the member submits a request for disenrollment during the month, the disenrollment will be effective the 1st day of the following month.

Disenrollment for Cause (MA)
We may initiate disenrollment, as dictated by CMS, for the following reasons:

  • Failure by the member to pay plan premiums, subject to the 90 calendar day grace period and appropriate notification;
  • Disruptive, unruly, abusive or uncooperative behavior that seriously impairs the organization’s ability to furnish services to either the member or other members;
  • The member provides fraudulent information when enrolling or permits others to use the member’s health care ID card to obtain services;
  • The member resides outside the service area for over six months (or nine months if using the UnitedHealth Passport® benefit) as defined by the evidence of coverage;
  • The beneficiary loses entitlement to Medicare Part A or dis-enrolls from Part B.

If you receive notification of a member’s intent to sue, please notify your provider advocate. Send copies of all notification letters, request for removal and supporting documentation directly to your provider advocate.

Once we receive a completed “Incident Report for Removal of Members” and related documentation, we will respond to the member as appropriate and copy the PCP or medical group/IPA on all correspondence.