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40.1.5 – Default Enrollment Option for Medicaid Managed Care Plan Enrollees who are Newly Eligible for Medicare – Part C only 42 CFR §§ 422.66(c) and 422.68(a)

Default enrollment is an enrollment process that allows an MA Organization (MAO), following approval by the state and CMS, to enroll an enrollee of an affiliated Medicaid managed care plan into its Medicare Dual Eligible Specials Needs Plan (D-SNP) when that enrollee becomes newly eligible for Medicare (i.e., has both Medicare Part A and Part B for the first time) - unless the enrollee chooses otherwise.

Default enrollment is permitted only for individuals who: • Are newly eligible for Medicare Advantage; • Are currently enrolled in a Medicaid managed care plan offered by the MAO, or by an entity under the same parent organization as the MAO; and • Will remain enrolled in the Medicaid managed care plan upon their conversion to Medicare.

Default enrollment is not available if an individual is enrolled in a more limited Medicaid prepaid inpatient health plan or prepaid ambulatory health plan, in a plan that only covers Medicare cost-sharing, or in a managed fee-for-service model such as primary care case management, health home, or accountable care organization. Some states apply additional conditions for default enrollment approval in their state Medicaid agency contract (SMAC).

CMS approval of default enrollment To qualify for default enrollment, an MAO must have an affiliated Medicaid managed care plan. An affiliated Medicaid managed care plan is one that is offered by the MAO that also offers the D-SNP (or is offered by an entity under the same parent organization as the MAO).

MAOs may apply for default enrollment only where states have approved the use of the default enrollment process through its SMAC as defined in 42 CFR § 422.107.

MAOs must have a minimum overall quality rating from the most recently issued ratings of at least 3-stars (or be a low enrollment contract or new MA plan as defined in 42 CFR § 422.252) and must not have any prohibition on new enrollment imposed by CMS. MAOs must submit proposals to CMS via the HPMS default enrollment module and receive CMS approval before beginning any default enrollments under this authority.

MAOs must be able to demonstrate the state’s agreement to provide prospective Medicare eligibility information for its Medicaid managed care plan enrollees. The information is necessary for CMS to add those individuals to its records as enrollees of the D-SNP within the timeframes to meet the noticing requirements specified under 42 CFR § 422.66(c)(2)(iv).

State role • A state approves the use of default enrollment in its SMAC with the MAO; and • Provide a description of its data sharing process and agreement to provision of prospective Medicare eligibility data to the MAO in a policy document from the state.