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Medicare Advantage (MA) Enrollment, Eligibility and Transfers, and Disenrollment, Capitation and/or Delegation - 2019 UnitedHealthcare Administrative Guide

Medicare Advantage (MA) Enrollment, Eligibility and Transfers, and Disenrollment

For more information and instructions for confirming eligibility refer to to the section titled Verifying Eligibility and Effective Dates.

Upon your request, we send each medical group/IPA a monthly eligibility list of all its assigned members. This list contains the names of the members and related member identification information, their enrollment date, and benefit plan information including but not limited to benefit plan type, effective date of the benefit plan and any member cost sharing under it.

Eligibility reports are available electronically. We send them to the capitated care provider through a file transfer protocol and viewed on UHCprovider.com. We generally provide eligibility information once per month. We may provide it weekly if needed.

Medicare beneficiaries who elect to become members of an Medicare Advantage plan must:

  • Be entitled to Medicare Part A and enrolled in Medicare Part B
  • Reside in our Medicare Advantage 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)
  • Not have End Stage Renal Disease (ESRD).

Medicare Advantage plans include a Contract ID and Plan ID (also known as the plan benefit package or PBP) from CMS that corresponds to CMS filings, including CMS OD universe submissions. If you require assistance finding a Contract ID or Plan ID please email us at odag_universe@uhc.com.

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 Coverage Summaries for Medicare Advantage Plans.

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 is 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 us to 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.

An applicant must enroll for membership in a UnitedHealthcare Medicare Advantage plan.

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 Medicare Advantage 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 Medicare Advantage 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.

We may process a group retiree member’s enrollment into UnitedHealthcare Group Medicare Advantage 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 may 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.

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.