Common use of State Level Enrollment Operations Requirements Clause in Contracts

State Level Enrollment Operations Requirements. a. Eligible Populations/Excluded Populations - As described in the body of the MOU. b. Enrollment and Disenrollment Processes - All Enrollment and Disenrollment- related transactions, including transfers between Demonstration Plans, will be processed through the Illinois Client Enrollment Services (CES). The State or its vendor will submit enrollment transactions to the CMS Medicare Advantage Prescription Drug (XXXx) enrollment system directly or via a third party CMS designates to receive such transactions. CMS will also submit a file to the State identifying individuals who have elected to enroll in another type of available Medicare coverage. The State or its designated contractor will share enrollment and disenrollment transactions with Demonstration Plans. c. Uniform Enrollment and Disenrollment Letter and Forms - Letters and forms will be agreed to by both CMS and the State. Over-the-phone Enrollment through the CES is the primary method of Enrollment. Beneficiaries may only receive a paper Enrollment form by requesting one from the CES. d. Enrollment Effective Date(s) - All enrollment effective dates are prospective. Beneficiary-elected enrollments are effective the first day of the month following a beneficiary’s request to enroll, so long as the request is received by the 12th of the month. Enrollment requests, including requests to change among Demonstration Plans, received after the 12th of the month will be effectuated the first of the second month following the request. Passive Enrollment is effective not sooner than 60 days after beneficiary notification. CMS and the State will monitor input received by the Ombudsman and Demonstration Plans about the time between the beneficiary’s Enrollment request and the effective date of Enrollment. After the first year of the Demonstration, or when the State updates its eligibility systems, the State and CMS will also revisit the timeline for processing enrollments and, if necessary, will shorten the time period between the beneficiary’s Enrollment request and the effective date of enrollment. All disenrollment requests will be effective the first day of the month following a beneficiary’s request to disenroll from the Demonstration. i. Demonstration Plans will be required to accept opt-in enrollments no earlier than 90 days prior to the initial effective date of October 1, 2013, and Demonstration Plans must begin providing coverage for those enrolled individuals on October 1, 2013. Each Demonstration Plan’s ability to accept opt-in enrollments, however, is contingent upon successfully passing the Readiness Review. The earliest effective date for Passive Enrollment will be January 1, 2014 as discussed below in d.ii. 1. CMS will provide an initial notice of the Demonstration opt-in enrollment period to all Demonstration eligible beneficiaries no earlier than 90 days prior to the start of the opt-in enrollment period. 2. The effective dates for opt-in and Passive Enrollment are subject to Demonstration Plans meeting CMS and State requirements, including Demonstration Plans’ capacity to accept new Enrollees. ii. The State will conduct monthly Passive Enrollments for those eligible beneficiaries who have not made a Demonstration Plan selection for effective enrollment beginning January 1, 2014 or otherwise opted out of the Demonstration. 1. During October 1, 2013 to December 31, 2013, CMS and the State will monitor each Demonstration Plans’ ability to manage the opt- in enrollments. Dependent on each Demonstration Plan’s capacity, as determined by its ability to manage the opt-in enrollments and the prior month’s Passive Enrollments (once applicable), the State will passively enroll a number of beneficiaries into Demonstration Plans that takes into consideration the number of opt-in Enrollments and the opt-out rate for each Demonstration Plan. Furthermore: a. In the Greater Chicago service area, the Passive Enrollment phase-in will not exceed 5,000 beneficiaries per month per Demonstration Plan and will occur over at least a 6-month period. However, the goal of the Passive Enrollment phase-in is to limit the number of beneficiaries assigned to each Demonstration Plan on a monthly basis without extending the phase-in beyond 6 months unless required to by the 5,000 monthly cap; and b. In the Central Illinois service area, the Passive Enrollment phase-in will occur over a 6 month period and will not exceed 3,000 beneficiaries per month per Demonstration Plan. 2. The State will provide notice of Passive Enrollments at least 60 days and no more than 90 days prior to the effective date of a Passive Enrollment period, and will accept opt-out requests prior to the effective date of enrollment. 3. The 60-day notice will include the name of the Demonstration Plan in which the beneficiary would be enrolled unless he/she selects another Demonstration Plan or indicates the option to opt out of the Demonstration. 4. At least thirty days prior to the enrollment effective dates above, the State will send a second notice to beneficiaries who have not responded to the initial notice or opted in. The CES may choose to call beneficiaries in addition to sending a notice, if appropriate. The State will proceed with Passive Enrollment into the identified Demonstration Plan for beneficiaries who do not make a different choice. iii. Beneficiaries who otherwise are included in Medicare reassignment to a different Medicare Prescription Drug Plan (PDP) effective January 1 of a given year (whether due to their previous year’s PDP’s premium increase or because their current PDP or Medicare Advantage Prescription Drug Plan (MA-PD) is terminating) will be eligible for Passive Enrollment, with an opportunity to opt out, into a Demonstration Plan. For example, those reassigned to a new PDP effective January 1, 2013, will be eligible for Passive Enrollment into a Demonstration Plan effective January 1, 2014, provided the individual meets the requirements of this Demonstration. iv. The State and CMS must agree in writing to any changes to the enrollment effective dates. CMS will provide identifying information to the State about beneficiaries that CMS anticipates will be reassigned for a January 1 of the following year effective date, no later than 120 days prior to the date of the first Passive Enrollment period. v. Beneficiaries who do not opt out of the Demonstration, and who are enrolled in a Medicare Advantage plan that is operated by the same parent organization that operates a Demonstration Plan, will be eligible for Passive Enrollment into the parent organization’s Demonstration Plan effective January 1, 2014. Eligible beneficiaries enrolled in a Medicare Advantage plan that is operated by a parent organization that is not offering a Demonstration Plan may enroll into the Demonstration if they elect to disenroll from their current Medicare Advantage plan. e. Disenrollment Effective Date(s) – Disenrollments are effective the first of the month following the request to opt-out of the Demonstration. The CES will also accept cancellations of opt-in enrollment requests, where the beneficiary submits an enrollment request but then cancels the enrollment prior to the effective date. f. Upon CMS’ or the State’s written determination that the Demonstration will not be renewed, no enrollments will be accepted within six months of the end of the Demonstration. g. Passive Enrollment activity will be coordinated with CMS activities such as Annual Reassignment and daily auto- and facilitated enrollment for individuals with the Medicare Part D LIS. h. The State will develop an “intelligent assignment” algorithm for Passive Enrollment (e.g. that prioritizes continuity of providers and/or services). The algorithm will consider beneficiaries’ previous managed care enrollment and historic provider utilization. i. The State or its Client Enrollment Services (CES) will provide customer service and options counseling, including mechanisms to counsel beneficiaries notified of Passive Enrollment. The CES will also receive and communicate beneficiary choice of opt-outs to CMS’s contractor, who will communicate the choice to CMS via transactions to CMS’ XXXx system. Beneficiaries will also be provided a notice upon completion of the opt-out process. Medicare resources, including 1-800-Medicare, will remain available to Medicare beneficiaries that disenroll from the Demonstration. Beneficiary requests made to 1-800-Medicare for Enrollment, changes among Demonstration Plans, or Disenrollment (when possible) will be referred to the State or its designated CES. j. The State or its vendor will provide notices, as approved by CMS, to ensure complete and accurate information is provided in concert with other Medicare communications, such as Medicare & You and Medicare Plan Finder. CMS may also send a notice to beneficiaries and will coordinate such notice with any State notice(s). k. Enrollment data in State and CMS systems will be reconciled on a timely basis to prevent discrepancies between such systems.

State Level Enrollment Operations Requirements. a. Eligible Populations/Excluded Populations - As described in the body of the MOU. b. Enrollment and Disenrollment Processes - All Enrollment enrollments and Disenrollment- disenrollment- related transactions, including transfers between Demonstration Plans, transactions will be processed through the Illinois Client Enrollment Services Medi-Cal Eligibility Data System (CESMEDS), except those transactions related to non- Demonstration plans participating in Medicare Advantage. Medi-Cal operates a Health Care Options program via an enrollment broker contract for Two-Plan and Geographic Managed Care counties (see Appendix 3). The State or its vendor This supports the enrollment process. California will submit enrollment transactions to the CMS Medicare Advantage Prescription Drug (XXXx) enrollment system directly or via a third party CMS designates to receive such transactions. CMS will also submit a file to the State identifying individuals who have elected to enroll in another type of available Medicare coverage. The State or its designated contractor Medi-Cal will share enrollment enrollment, disenrollment, and disenrollment opt-out transactions with Demonstration Participating Plans. i. In San Mateo and Orange counties, the Participating Plans will submit enrollment transactions directly to CMS or via the third party processor that CMS designates, consistent with how Medi-Cal enrollment is processed today. c. Uniform Enrollment and Disenrollment Letter and Forms - Letters and forms will be made available to stakeholders when they are completed and agreed to by both CMS and the State. Over-the-phone Enrollment through the CES is the primary method of Enrollment. Beneficiaries may only receive a paper Enrollment form by requesting one from the CESCalifornia. d. Enrollment Effective Date(s) - All enrollment effective dates are prospective. Beneficiary-elected enrollments are effective enrollment is the first day of the month following a beneficiary’s request to enroll, so long as or the request is received by the 12th of the month. Enrollment requests, including requests to change among Demonstration Plans, received after the 12th first day of the month will be effectuated the first of the second month following the requestmonth in which the beneficiary is eligible, as applicable for an individual enrollee. Passive Enrollment enrollment is effective not sooner than 60 days after beneficiary notification. CMS and the State will monitor input received by the Ombudsman and Demonstration Plans about the time between the beneficiary’s Enrollment request and the effective date of Enrollment. After the first year notification of the Demonstration, or when the State updates its eligibility systems, the State and CMS will also revisit the timeline for processing enrollments and, if necessary, will shorten the time period between the beneficiary’s Enrollment request and the effective date of enrollment. All disenrollment requests will be effective the first day of the month following right to select a beneficiary’s request to disenroll from the DemonstrationParticipating Plan. i. Demonstration Participating Plans will be required to accept opt-in enrollments beginning no earlier than 90 days prior to the initial August 1, 2013 for an effective date of no sooner than October 1, 2013, 2013 and Demonstration Plans must begin providing coverage for those enrolled individuals on October 1, 2013. Each Demonstration Plan’s ability to accept opt-in enrollments, however, is contingent upon successfully passing the Readiness Review. The earliest effective date for Passive Enrollment will be January 1, 2014 as discussed below in d.ii. 1. CMS will provide an initial notice of the Demonstration opt-in enrollment period to all Demonstration eligible beneficiaries no earlier than 90 days prior to the start of the opt-in enrollment period. 2. The effective dates for opt-in and Passive Enrollment are subject to Demonstration Plans meeting CMS and State requirements, including Demonstration Plans’ capacity to accept new Enrolleesdate. ii. The State Beneficiaries who are eligible for passive enrollment into the Demonstration will conduct monthly Passive Enrollments for those eligible beneficiaries who have not made a receive an informational notice about the Demonstration Plan selection for effective and process of passive enrollment beginning January 1, 2014 or otherwise opted out of the Demonstration. 1. During October 1, 2013 to December 31, 2013, CMS and the State will monitor each Demonstration Plans’ ability to manage the opt- in enrollments. Dependent on each Demonstration Plan’s capacity, as determined by its ability to manage the opt-in enrollments and the prior month’s Passive Enrollments (once applicable), the State will passively enroll a number of beneficiaries into Demonstration Plans that takes into consideration the number of opt-in Enrollments and the opt-out rate for each Demonstration Plan. Furthermore: a. In the Greater Chicago service area, the Passive Enrollment phase-in will not exceed 5,000 beneficiaries per month per Demonstration Plan and will occur over at least a 6-month period. However, the goal of the Passive Enrollment phase-in is to limit the number of beneficiaries assigned to each Demonstration Plan on a monthly basis without extending the phase-in beyond 6 months unless required to by the 5,000 monthly cap; and b. In the Central Illinois service area, the Passive Enrollment phase-in will occur over a 6 month period and will not exceed 3,000 beneficiaries per month per Demonstration Plan. 2. The State will provide notice of Passive Enrollments at least 60 days and no more than 90 days prior to the effective date of a Passive Enrollment period, and will accept opt-out requests prior to the effective date of enrollment. 3iii. The Sixty (60-day ) days prior to the effective date of enrollment, beneficiaries will receive a notice will include that identifies the name of the Demonstration Participating Plan in which the beneficiary would be enrolled unless he/she selects another Demonstration Plan plan or indicates the option to opt out of the Demonstration. The notice will include an enrollment packet with information about other health plan choices in their county. 4iv. At least thirty A third notice sent 30 days prior to effective enrollment date will remind beneficiaries of their options and the enrollment effective dates above, the State will send assigned Participating Plan for individuals who do not select a second notice to beneficiaries who have plan or do not responded to the initial notice or opted inopt out. The CES may choose to call beneficiaries in addition to sending a notice, if appropriate. The State California will proceed with Passive Enrollment passive enrollment into the identified Demonstration Plan plan for beneficiaries who do not make a different choicechoice or opt out. CMS communication on the Demonstration will be coordinated with the State. iii1. Beneficiaries who otherwise are included in Medicare reassignment to a different Medicare Prescription Drug Plan (PDP) effective January 1 of a given year (whether due to their previous year’s PDP’s premium increase or because their current PDP or Medicare Advantage Prescription Drug Plan (MA-PD) is terminating) Enrollment materials will be eligible written at no more than a sixth-grade reading level in the threshold languages and available upon request in alternative formats. 2. This information will include, at a minimum: how the beneficiary’s system of care would change, when the changes will occur, how to contact the State’s enrollment broker for Passive Enrollmentquestions or assistance with choosing a Participating Plan, with an opportunity and how to opt out of the Demonstration. v. Requests to change Participating Plans, opt out, into or enroll with a Demonstration Plan. For example, those reassigned to a new PDP effective January 1, 2013, Participating Plan will be eligible for Passive Enrollment into a Demonstration Plan accepted at any point after the notification of passive enrollment has been provided and are effective January 1, 2014, provided on the individual meets the requirements of this Demonstration. iv. The State and CMS must agree in writing to any changes to the enrollment effective dates. CMS will provide identifying information to the State about beneficiaries that CMS anticipates will be reassigned for a January 1 first of the following year effective date, no later than 120 days prior month. Any time an individual requests to the date of the first Passive Enrollment period. v. Beneficiaries who do not opt out of the Demonstration, the State will send a letter confirming the opt-out and providing information on the benefits available to the beneficiary once they have opted out. Any time an individual requests to disenroll from the Demonstration, the State will send a letter confirming the disenrollment and providing information on the benefits available to the beneficiary once they have disenrolled from the Participating Plan. vi. The State will conduct passive enrollment periods specific to each county for those beneficiaries who are have not made a plan selection as described below. Beneficiaries included in Medicare reassignment or currently enrolled in a Medicare Advantage plan that is operated by the same parent organization that operates a Demonstration Plan, Plan will be eligible for Passive Enrollment passive enrollment as detailed in Appendix 7, section II.D.vii and Appendix 7, section II.D.viii, immediately following this section. The enrollment periods below are only applicable to beneficiaries in Medicare fee-for- service. 1. Alameda County: Beneficiaries that have enrolled in Medi-Cal managed care will have an enrollment effective date of no sooner than October 1, 2013. Beneficiaries in FFS Medi-Cal will have an enrollment effective date on the 1st of the month of birth, beginning no sooner than October 1, 2013 and ending after twelve months. Beneficiaries with a birth month of January 2014 will be enrolled into the parent organization’s Demonstration Plan effective January plans on February 1, 2014. Eligible beneficiaries enrolled in a Medicare Advantage plan that is operated by a parent organization that is not offering a Demonstration Plan may enroll into the Demonstration if they elect to disenroll from their current Medicare Advantage plan. e. Disenrollment Effective Date(s) – Disenrollments are effective the first of the month following the request to opt-out of the Demonstration. The CES will also accept cancellations of opt-in enrollment requests, where the beneficiary submits an enrollment request but then cancels the enrollment prior to the effective date. f. Upon CMS’ or the State’s written determination that the Demonstration will not be renewed, no enrollments will be accepted within six months of the end of the Demonstration. g. Passive Enrollment activity will be coordinated with CMS activities such as Annual Reassignment and daily auto- and facilitated enrollment for individuals with the Medicare Part D LIS. h. The State will develop an “intelligent assignment” algorithm for Passive Enrollment (e.g. that prioritizes continuity of providers and/or services). The algorithm will consider beneficiaries’ previous managed care enrollment and historic provider utilization. i. The State or its Client Enrollment Services (CES) will provide customer service and options counseling, including mechanisms to counsel beneficiaries notified of Passive Enrollment. The CES will also receive and communicate beneficiary choice of opt-outs to CMS’s contractor, who will communicate the choice to CMS via transactions to CMS’ XXXx system. Beneficiaries will also be provided a notice upon completion of the opt-out process. Medicare resources, including 1-800-Medicare, will remain available to Medicare beneficiaries that disenroll from the Demonstration. Beneficiary requests made to 1-800-Medicare for Enrollment, changes among Demonstration Plans, or Disenrollment (when possible) will be referred to the State or its designated CES. j. The State or its vendor will provide notices, as approved by CMS, to ensure complete and accurate information is provided in concert with other Medicare communications, such as Medicare & You and Medicare Plan Finder. CMS may also send a notice to beneficiaries and will coordinate such notice with any State notice(s). k. Enrollment data in State and CMS systems will be reconciled on a timely basis to prevent discrepancies between such systems.