How well your organization handles a new enrollment during the Annual Enrollment Period (AEP) generally sets the tone for the upcoming contract year for you and your new member. Beginning with Sales and flowing to Enrollment Operations—it’s critical to understand specific actions that trigger reconciliation challenges and member abrasion. With CMS shifting the weight of its star-rating system to more of a member-based experience, its essential Medicare Advantage (MA) plans are mindful of the enrollment process from beginning to end.
Here are a few Enrollment tips to ensure your organization has a successful AEP:
Securing the Sale
- Audit your enrollment forms and train agents on their correct use:
- Ensure the correct plan year enrollment form is used to avoid unnecessary denials.
- Emphasize the importance of using the correct form and selecting the right plan package based on the member’s preference to avoid access to care issues.
- Reconcile applications often to make sure every application is processed and reaches your enrollment intake points. This also aids with timely commissions payments!
- Assume anything! Here are a few tips for sales agents/brokers:
- Always check the plan’s online provider-finder tool to validate a provider is in-network.
- Validate plan premium before quoting rates to a prospect.
- Review Summary of Benefits (SOB) and/or Evidence of Coverage (EOC) to confirm if certain benefits are covered.
Processing the Enrollment
- Ensure unsolicited Annual Enrollment Period (AEP) applications, received October 1-14, are investigated.
- If there is an indication of sales agent or broker involvement, submit these applications on the first day of AEP, with an “application date” of October 15 of the current year.
- Know the rules for Medicare’s Annual Enrollment Period. Beneficiaries can:
- Drop a Medicare Advantage (MA) plan and return to Original Medicare
- Change from one MA plan to a different MA plan
- Change from Original Medicare to an MA plan
- Cancel Part D plan
- Change from one Part D plan to another
- Newly enroll in a Part D plan
- Pay attention to application-effective dates, as not all will be for an effective date of January 1.
- Assume the last enrollment application always “wins.” Here is what you should know when dealing with multiple transactions:
- Generally, the last application request the beneficiary submits will take effect; however, during the unsolicited period (10/1-10/14), if a beneficiary submits more-than-one application, the first application processed by CMS will take effect.
- During AEP (10/15-12/7), the last enrollment request made, determined by the application date, will be the request that takes effect.
- Should two MA plans receive applications for the same beneficiary and effective date, the first application processed by CMS will take effect.
- If the beneficiary confirms their intent is to be enrolled in the plan CMS rejected, the MA plan should advise the beneficiary that a new enrollment request must be submitted during a valid enrollment period.
Finalizing the Enrollment
- Allow the appropriate timeframe for beneficiaries and agents to resolve “Request for Information” (RFI) enrollment applications.
- For incomplete AEP applications, additional information to make the request complete must be received by December 7 or within 21 calendar days of the request (whichever is later).
- Resolve RFIs timely to avoid reconciliation issues that typically arise at the beginning of the year.
- Research all mechanisms by which a beneficiary or agent may return requested information to avoid incorrect denials and/or retro requests.
- Submit applications in effective date, in chronological order. For instance, if an application is received for Plan A for the 12/1 effective date, and another application is received for Plan B for the 1/1 effective date, submit the 12/1 application first, then submit the 1/1 effective date application the next day.
- Remember, beneficiaries may enroll in a Cost Plan or Private Fee for Service (PFFS) and a separate PDP plan simultaneously.
- Send RFIs for applications where the only information missing is a valid election period.
- For current year effective dates, contact the beneficiary to obtain the correct election period.
- Delay a member’s cancellation request while waiting on a written notice. Although MA plans can request cancellations be submitted in writing, the cancellation should be processed based on the member’s verbal request.
We’re Here to Help
CODY® team of compliance and operational consultants have years of experience in day-to-day health plan operations, CMS audits, and oversight activities. We’re here to support you, or we can do it for you.
Our Membership Suite™ Reconciliation suite provides full-service tools to streamline reconciliation tasks and deliver actionable results. Use our operational experts and our proprietary software or subscribe directly to Membership Suite™ to manage your work items in our user-friendly web portal.
To find out how CODY® can help your plan streamline your reconciliation process, contact us today for a consultation or a software demo.
About CODY: CODY® has worked with over 70 government-funded, commercial, and ACA health plans across 50 states and Puerto Rico. We help align internal operations with CMS guidelines to improve regulatory compliance, maximize performance, and streamline member/provider communications across the enterprise. CodySoft® and Membership Suite™, our proprietary suites of software are designed specifically for health plans. www.codyconsulting.com