Summary of CMS Changes to Enrollment Requirements for CY2021

By September 30, 2020AEP, Enrollment

Plans may have noticed that CMS has been busy this season making changes to certain Enrollment policies, materials, and software releases to keep up with the changing environment of today and also to ease up on some restrictions for Medicare beneficiaries. While the recent changes will have a positive impact on beneficiaries, this also brought about some notable changes that will require all Medicare Advantage, Prescription Drug Plan, Cost, PACE, and Demonstration Organizations to ensure their Enrollment Applications and Enrollment software are updated to be compliant with these changes.

New Model Enrollment Form

CMS has published a new “shortened” model enrollment request form in order to simplify the process and only include the necessary information Plan Sponsors need to complete the enrollment request.  Plans will need to ensure they have implemented the updated enrollment form in time for the start of Annual Enrollment Period (AEP) on October 15, 2020 for all 2021 enrollment effective dates. The new “shortened” enrollment request form (OMB No. 0938-1378) includes the following:

  • Cover Page – includes information for the enrollee on Medicare enrollment and instructions for completing the application.
  • Section 1 of Enrollment Application – contains only the necessary information Plan Sponsors need in order to process the application.
  • Section 2 of Enrollment Application – Section 2 includes mandatory elements that Plan Sponsors are required to include, and optional data elements that are not required to be included. Plans should note that although the mandatory elements are required to be on the enrollment application, they are optional for the enrollee to complete and should not hinder the completion of the enrollment request. The updated elements in Section 2 are as follows:
    1. Mandatory Data Element – Beneficiary’s preferred language and other accessible formats such as Braille, or Audio (CD).
    2. Optional Data Elements – This contains information that may be useful for Plans Sponsors while processing the enrollment request such as plan premium payment options, primary care doctor (PCP), and any other information that is helpful for the plan.

Enrollment of Individuals with End-Stage Renal Disease (ESRD)

CMS first released a memo on August 11, 2020 announcing that beginning with AEP enrollments for January 1, 2021 (or later), beneficiaries with ESRD are no longer prohibited from joining an MA or PDP plan.  This guidance also required that Plan Sponsors make material changes to their Enrollment Request Forms to remove the ESRD question.

On August 19, 2020, CMS released an additional clarifying memo that notified MA and MA-PD Plans of the changes noted in Section 17006 of the 21st Century Cures Act (Cures Act) (Pub. L. 114-255). Plans were also notified that they will no longer be able to deny an enrollment request based on a beneficiary’s ESRD status. Previously, the MARx system would notify the Plan of a rejection of enrollment and will now be changed to accept enrollments for beneficiaries flagged as ESRD starting with January 1, 2021 enrollment effective dates and forward.

CMS also asked that Plans ensure their staff, including sales and brokers, enrollment staff, case management and/or utilization management, and claims staff are trained on this new change and advised that Plans should consider removing ESRD rejected enrollments from their internal enrollment systems. Plan Sponsors should also consider analyzing how they will handle the financial and clinical implications, as well as ensuring that any ESRD, transplant claims,  and ESRD medications pay correctly. Plans should also ensure that, for beneficiaries with ESRD who are currently on dialysis or under the care of a nephrologist, all parties to the beneficiary’s care team are participating with the Plan to ensure continuity of care or give the enrollee adequate time to transition to participating providers.

Special Election Periods (SEP)

This announcement also included the addition of new SEPs for exceptional circumstances, as well as codifying and expanding on existing SEPs, notably the SEP for Individuals Affected by a FEMA-declared Weather-Related Emergency. On May 5, 2020, CMS released a memo notifying Plan Sponsors of the expansion of this SEP to also include “or Other Major Disaster: Applicable for COVID-19”.  Due to the approval of major disaster declarations in all 50 states including Washington D.C., tribes, and territories, this SEP will be applicable to all residents who were eligible to enroll in an MA or PDP plan but were unable to make an election due to the COVID-19 pandemic and who meet the terms of this SEP. As outlined in the memo, this SEP was made available effective March 1, 2020 and impacted beneficiaries will be given a one-time opportunity to make a missed election.  This SEP will be available to beneficiaries for four full months after the start of the incident period.

The two newly added SEPs are as follows:

  • Individuals Enrolled in a Plan Placed in Receivership – this SEP is for beneficiaries enrolled in a plan that is experiencing financial difficulties to such an extent that a state or territorial regulatory authority has placed the organization in receivership.
  • Individuals Enrolled in a Plan that has been identified by CMS as a Consistent Poor Performer – this SEP is for beneficiaries enrolled in a plan with the Low Performing Icon (LPI) on Plan Finder.

In addition to the updates and newly added SEPs, CMS also removed information from Chapter 2, Exhibit 22 regarding the option to use an SEP to disenroll from the plan due to the loss of optional supplemental benefits due to nonpayment of optional supplemental premiums. An enrollee would be able to disenroll from the plan only if they are eligible for one of the existing SEPs. Plan Sponsors should refer to the updated CY2021 Enrollment and Disenrollment Guidance for the full description and requirements for any updated or newly added SEPs that can be found here for MA Plans, and here for PDP Plans.

Electronic Signatures

CMS also added flexibility for electronic enrollments and allows electronic signatures, not just “enroll now” or “I agree”.  Plans should note this change only applies to electronic enrollments, whereas signature requirements are not changing for telephonic and paper enrollments. Plans should ensure they are utilizing the updated CY2021 Enrollment and Disenrollment Guidance, which is now posted on the CMS website and can be found here for MA Plans, and here for PDP Plans.

October Enrollment Software Update

In order to accommodate the additions for the enrollee’s Preferred Language and Accessible Formats (Braille, Large Print, or Audio), CMS released memos on August 25, 2020 and September 1, 2020 outlining enrollment software updates and new data field changes in the MARx system, as well as enrollment transactions to be implemented for the October 2020 release. All MA and Part D sponsors will be expected to include the new data fields for Preferred Language other than English, and Accessible Format (Braille, large print, or Audio) no later than October 15, 2020 for CY2021. These new fields will be optional for the beneficiary to complete on the Enrollment Request form; however, if supplied by the beneficiary, plans will be required to include these fields in their enrollment transactions to CMS. Due to the late timing of these announcements, plans will have a short turnaround time to implement these changes in their Enrollment systems, include time for testing, and be ready to submit transactions using the new file layouts in time for the upcoming AEP season. Plans will need to ensure they have conducted a thorough review of the new Transaction Type 61 Layout and Transaction Type Code 92, and in addition the new Transaction Reply Codes of 394, 395, and 396. It is imperative for Plans to prepare for these changes.  Plans that do not adequately prepare may see a rise in avoidable enrollment transaction rejections.