Medicare Advantage (MA) enrollment, eligibility and transfers, and disenrollment, Capitation and/or delegation - 2021 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 6 months (9 months if using the UnitedHealth Passport® benefit).

MA plans include a Contract ID, Plan ID (the plan benefit package or PBP) and Segment ID from CMS that corresponds to CMS filings. This will be on the individual member ID card or eligibility file.

If a Medicare beneficiary is an inpatient at these facilities when their membership becomes effective, the previous carrier pays for Part A services (inpatient facility care) until the day after the member is discharged to a lower level of care:

  • Acute facility.
  • Psychiatric facility.
  • Long–term care (LTC) facility.
  • Rehabilitation facility.

The member’s assigned medical group/IPA pays for Part B services (medical care) on their membership effective date. If the member is an inpatient at a SNF at the time of their effective date, the medical group/IPA and capitated facility is 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 these facilities, 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, SNF).

Refer to the UnitedHealthcare MA Coverage Summary titled Change in Membership Status while Hospitalized (Acute, LTC and SNF) or Receiving Home Health on UHCprovider.com/policies > Medicare Advantage Policies > 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 in a UnitedHealthcare MA 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 if we receive the completed enrollment request form.

We may process a group retiree member’s enrollment into UnitedHealthcare Group MA plan with a retroactive effective date. The 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 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 5: Medicare Products, Medicare Product Overview Tables.

According to CMS guidelines, a member may not change medical groups/IPAs or PCPs if:

  • The member is an inpatient in a facility, a SNF or other medical institution at the time of the transfer request;
  • 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 they are 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 their medical group/IPA or PCP while an inpatient at any of 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.

  • Acute care facility
  • Critical access facility
  • LTC facility
  • Psychiatric facility
  • 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.

For more information about ambulance transfers due to a medical group/IPA change while the member is an inpatient, go to UHCprovider.com/policies > Medicare Advantage Policies > Coverage Summaries for Medicare Advantage Plans.

If the member’s medical group/IPA, PCP, or facility is terminated, we give prior written notice to members as applicable or when required by state or federal law. In such event, the member may qualify for continuation of care as outlined in the Continuity of care section of this supplement. For individual physician terminations, the medical group/IPA is responsible for providing the notice in the following circumstances:

  • PCP terminations in medical groups where the medical group assigns members to the PCPs; and
  • All specialist terminations.

Each Medicare member has at least 14 calendar days to select another medical group/IPA, PCP, or facility within the member’s current medical group/IPA. The member receives a new member ID card prior to the first of the month in which the transfer is effective.

When a member needs care, and their PCP terminated without proper notice, we transfer the member to another PCP. The new PCP will be in the same medical group/IPA with an effective date retroactive to the first of the current month.

For information on PCPs removing MA members from rosters, refer to Member dismissals initiated by a PCP (Medicare Advantage) in Chapter 2: Provider Responsibilities and Standards. The primary medical group/IPA is responsible for directing and managing all care until the change or transfer is effective.

Member-elected disenrollment

If a member requests disenrollment from our benefit plan through you, refer them to Member Services. Once we process the disenrollment, we send the member a letter with the effective date. If the member submits a request for disenrollment during the month, the disenrollment is effective the first day of the following month.