Questions and Answers
What must happen to a member from an MA plan in the case of a change in residence?
What does incarceration mean in the context of MA plans?
A member who is incarcerated resides outside the plan's service area.
What must MA organizations do before disenrolling a member?
For how long can members of coordinated care plans be out of the service area while still being eligible?
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MA Organizations must disenroll members who have been out of the service area for more than 6 months.
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What are some examples of disenrollments effective on the 1st day of the calendar month?
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What is an example of disenrollment effective the 1st day of the 13th month after leaving the service area?
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How many days does the MA organization have to contact a member after a move?
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What should the MA organization do upon learning of possible incarceration?
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When must the MA organization disenroll an individual confirmed as incarcerated?
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The MA organization must disenroll a member if they receive notice of a permanent change of address outside the service area.
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The MA organization can disenroll a member based on a change of address from an unspecified source.
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Study Notes
Disenrollment Criteria for MA Plans
- Disenrollment is mandatory in various situations, including a change in residence, loss of Medicare Part A or B entitlement, or upon the member's death.
- If a member loses special needs status without reestablishing eligibility, disenrollment occurs before deemed continuation eligibility expires.
- Contract termination of the MA organization or changes in the service area affecting the member also necessitate disenrollment.
- Non-payment of Part D-IRMMA leads to disenrollment after notification by CMS.
- Members not lawfully present in the U.S. must be disenrolled.
Incarceration Definition
- Incarceration leads members to be considered outside the service area, even if the correctional facility is within it.
Disenrollment Notification Process
- Members must be informed about impending disenrollment and its reasons prior to the disenrollment transaction submission to CMS.
- A notice of the right to grievance hearing must be included, except when disenrollment results from plan termination or service area reduction.
Visitor/Traveler Programs
- MA organizations can maintain extended visitor/traveler programs for coordinated care plan members for up to 12 months.
Disenrollment Timing and Conditions
- Organizations must disenroll members absent from the service area for over 6 months if not part of a visitor program.
- Effective disenrollments occur on the first day of the month for specific reasons, such as permanent moves outside the area or incarceration.
- Disenrollments become effective on the first day of the month following 6 months of temporary absence from the service area.
- A member's absence qualifying for a visitor/traveler program that exceeds 12 months results in disenrollment effective on the first day of the 13th month.
Member Communication Requirements
- MA organizations are required to attempt to confirm a member's move as permanent within 10 calendar days.
- Verification of incarceration status must involve contacting the individual or other sources about the incarceration period.
Effective Disenrollment Dates
- Organizations must disenroll a member from MA plans at the first of the month following the start date of confirmed incarceration.
- Notifying members about disenrollment must occur if a permanent change of address is reported that lies outside the service area.
Address Change Procedures
- A potential address change indication from non-member sources does not lead to automatic disenrollment without confirmation from the member or legal representative.
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Description
Explore the essential criteria under which a member must be disenrolled from a Medicare Advantage (MA) plan. This flashcard set covers crucial definitions and scenarios, including changes in residence, loss of entitlement, and special needs status. Perfect for those studying Medicare guidelines or preparing for exams related to healthcare management.
