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Medicare Advantage (MA) Enrollment, Eligibility and Transfers, and Disenrollment, Capitation and/or Delegation - 2020 UnitedHealthcare Administrative Guide

For more information and instructions for confirming eligibility refer to 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 members’ identification information, their enrollment date, and benefit plan information. This includes benefit plan type and effective date and any member cost- sharing.

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

Medicare beneficiaries who join an MA plan must:

  • Be entitled to Medicare Part A and enrolled in Medicare Part B.
  • 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 using the UnitedHealth Passport® benefit).
  • Not have End Stage Renal Disease (ESRD). Under certain scenarios, beneficiaries with ESRD may enroll. See Chapter 2, section 20.2 in the CMS Medicare Managed Care Manual for more information.

MA plans include a Contract ID, Plan ID (the plan benefit package or PBP) and Segment ID from CMS that corresponds to CMS filings, including CMS OD universe submissions. If you need help finding a Contract ID or Plan ID 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. If an MA member permanently moves outside of the service area (regardless of state), or the plan receives indication that the member may have moved outside the service area, the plan will disenroll the member at:
  1. The end of the month in which they report/confirm the move
  2. The end of the month in which they move (if they report the move in advance)

If a member fails to respond to an address confirmation request, the plan will disenroll the member at the end of the sixth month following notification of potential move from the service area. See Chapter 2, sections 50.2-50.2.1.5 in the CMS Medicare Managed Care Manual for more information.

  • Changes from one benefit plan to another. If the member does not return a completed form, they remain on the existing plan. The member may only change benefit plans using their CMS-defined annual enrollment period from Oct. 15-Dec. 7, or during the open enrollment period from Jan. 1-March 31 each year.

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

CMS requires us to treat a member whose benefit plan changes as a new member, rather than as an existing member, for the purpose of determining the new plan’s effective date. 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.

Individual

CMS has 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 types of enrollment periods and the requirements of each type are outlined on cms.hhs.gov.

Group Retiree Plans

Enrollment periods for UnitedHealthcare Group MA members are dictated by the employer group’s annual renewal date with us. Employers may establish their own enrollment dates. See Chapter 2, section 30.4.4, item 1 - SEPs for Exceptional Conditions in the CMS Medicare Managed Care Manual for more information. A group retiree annual enrollment period aligns with the employer’s annual enrollment cycle.

Enrollment requests received by the end of the month are processed for eligibility on the first of the following month. Plan effective dates vary based on the election period used and applicant Medicare Part A/B eligibility dates.

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.