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What You Need to Know

CDPHP Group Medicare Advantage Plans

CDPHP Group Medicare Advantage PPO - Allows enrolled members to receive covered services without referrals from any provider in the country that accepts Medicare, along with the opportunity to reduce their costs by using in-network providers.

CDPHP Group Medicare Advantage HMO - Members select a primary care physician (PCP) and work with their PCP to coordinate routine care, including referrals to other in-network providers when necessary.

CMS Star Quality Rankings

  • CMS rated CDPHP Medicare Advantage PPO plans 4.5 out of 5 stars for 2019. Star ratings are based on quality and performance in several different categories (for example, detecting and preventing illness, ratings from patients, and customer service). Every year, Medicare evaluates plans based on a 5-star rating system.

  • HMO Medicare Star Ratings Flyer 2019

  • PPO Medicare Star Ratings Flyer 2019

  • CDPHP Medicare Advantage plans are top-rated in the state according to NCQA's Medicare Health Insurance Plan Ratings 2018-2019, having earned a 4.5 out of 5 rating.

Compliance / Certification

All members of the broker agency who communicate with the group Medicare population and Employer Group health benefit administrators in regard to the sale and product information must be certified and appointed with the Department of Financial Services. They must also be certified in the CDPHP Group Medicare Advantage program.

Brokers and sales representatives must sign the member application if they help the Medicare beneficiary complete the application.

CDPHP sales representatives and brokers representing CDPHP Medicare group plans are responsible for notifying CDPHP of any potential Medicare-related fraud by contacting the confidential CDPHP Fraud Hotline at 1-800-280-6885. 

Part D Benefit Basics

  • CDPHP group Medicare prescription riders are based on a 5-tier formulary.

  • The CDPHP Medicare pharmacy brand manager is CVS/Caremark®, which offers retail pharmacy, mail-order prescription services, and ExtraCare card discounts.

  • There is a late-enrollment penalty (LEP) for not joining a Part D plan when first eligible for Medicare Part A and/or B and not having creditable prescription drug coverage for 63 consecutive days or more. The LEP will be waived for any beneficiary eligible for the low-income subsidy.

Eligibility

  • An eligible beneficiary must meet the following criteria to join a Medicare Advantage plan:

    • have Parts A and B.

    • live in the plan's service area.

    • not have end-stage renal disease (ESRD) (some exceptions apply).

  • After joining a Medicare Advantage plan, the Medicare beneficiary must continue to pay Part B premiums.

  • A Medicare beneficiary cannot be enrolled in more than one Medicare Advantage plan at the same time.


Enrollment


  • All potential Medicare group members should receive a Medicare pre-enrollment book from their group. CDPHP sales representatives can provide you with a supply of pre-enrollment books to have on hand for potential enrollees.

  • If existing group Medicare clients change from HMO to PPO, PPO to HMO, or add/remove pharmacy, all members (existing and new) must complete new enrollment forms. CMS views this as a plan change and requires new member enrollment forms. Enrollment forms are not required for groups that are only changing the copay structure of the plan at renewal.

  • When a Medicare-eligible beneficiary from an employer group wants to move from a commercial plan (CDPHP or another carrier) into a CDPHP group Medicare option offered by their employer outside of the group's open enrollment period, CDPHP will allow, with the employer group's permission, one Special Enrollment Period (SEP) per member, per calendar/benefit year outside of the group's open enrollment.

  • Group members who are "aging in" to Medicare (turning 65) are eligible to join a Medicare Advantage plan on the first day of the month in which they turn 65 or the first of each of the three months following the month they turn 65. Medicare-eligible members can also enroll outside of their open enrollment period due to a qualifying event, (e.g., loss of group coverage).

  • Enrollment for both retirees and current (active) employees of an employer/union group must comply with all Medicare program requirements, including Medicare Secondary Payer. Medicare-eligible members may not enroll retirees/active employees contrary to Medicare Secondary Payer rules.

    • For groups with 20 or more employees, actively working Medicare eligibles (sometimes referred to as "working aged") are only permitted to voluntarily enroll in a Group Medicare plan if they also continue to maintain enrollment in the commercial group offering. This guideline is based on CMS eligibility guidelines. Because that arrangement would be financially prohibitive for both the employer group and the member, CDPHP Group Medicare will exclude any working-aged beneficiaries from enrolling.

    • The working-aged Medicare Advantage rule does not apply to groups with fewer than 20 employees.

    • More detailed information is available in CMS EGWP Chapter 9, Section 30.1.

  • The employer or broker is responsible for completing the “For Employer Group Office Use Only” portion at the top of the member application. By doing so, they are confirming the member’s eligibility to join the Medicare group plan. Completed applications should be submitted by the employer or broker by email to MedicareEligibility@cdphp.com or by fax to (518) 641-5006.

  • Groups receive an itemized bill from CDPHP with the Medicare Group enrollees listed on it.

  • Members will receive two ID cards. Both cards should be shown when obtaining services and prescriptions. 

  • Medicare Enrollment Form


Disenrollment Guidelines


Death

CMS will notify CDPHP of the member’s death and will provide the transaction to disenroll the member from the CDPHP Medicare Advantage plan. This disenrollment is effective the first day of the calendar month following the month of death. Employer groups do not need to notify CDPHP of a Medicare Advantage member’s death, as CDPHP is not permitted to submit disenrollment transactions to CMS in response to the apparent death of a member. Once the transaction is received from CMS, any premium adjustments to the group will be provided in the next billing cycle.

Voluntary disenrollment (member initiated)

The disenrollment request to CDPHP must include the member's signed written disenrollment request and must be received prior to the effective date of the termination.

Involuntary disenrollment (employer group initiated)

Eligibility criteria to participate and receive employer/union-sponsored benefits may include spouse/family status, payment to the employer/union of the individual’s part of the premium, or other criteria determined by the employer/union. The group disenrollment process must include notification to each member as follows:

  • All beneficiaries must be notified in writing no less than 21 calendar days prior to the effective date of the term that the employer or union intends to disenroll them from the employer or union’s Medicare Advantage plan.

  • Additionally, the information provided must include an explanation on how to contact Medicare for information about other Medicare Advantage plan options that may be available to the beneficiaries such as a CDPHP Individual Medicare Advantage plan.

  • Employer groups that have not sent the disenrollment letter to the member must complete the Medicare Disenrollment form and fax it to (518) 641-4606 a minimum of 30 days prior to the effective date of the termination. Employer groups must also confirm with CDPHP that the disenrollment request has been received and processed a minimum of 21 days prior to the effective date. If the involuntary disenrollment is not received and processed in the required timeframes and the employer has not sent a letter meeting the above guidelines to the member, CDPHP will be unable to process the requested disenrollment until the next available date. 

    • Example 1: Involuntary disenrollment letter mailed to member by July 8 - effective date of term is August 1. 

    • Example 2: Involuntary disenrollment letter mailed to member on July 20 - effective date of term is September 1.

  • If the employer or union-sponsored plan was a Medicare Advantage plan with Part D, the member must be advised that the disenrollment action means they will no longer have Medicare Part D drug coverage and they may potentially receive a late enrollment penalty if they do not enroll in other coverage within 63 days.

  • The disenrollment request to CDPHP must include the written notification sent to the member no less than 21 days prior to the effective date.

  • Group Medicare Disenrollment Form

Wellness

  • No-cost access to local gyms including SilverSneakers® locations, the Capital District YMCAs, the Rudy A. Ciccotti Family Recreation Center, and more through CDPHP Senior Fit®.

  • CaféWell® – This no-cost online tool creates a personalized library of resources and goal-setting tips to help members take control of their health. Many plan designs may also include an option to earn incentives for completing certain activities and screenings. Visit CaféWell to learn more.

  • Wellness classes – CDPHP offers classes year-round throughout our service area. Class offerings may include tai chi, yoga, body sculpting, healthy cooking, and more. Visit our class schedule to view the latest calendar.

  • The Healthy Weigh – Members can lose weight safely and effectively through this program. Visit our weight management page to find a variety of resources.

  • CVS Caremark ExtraCare® Health Card – CDPHP members receive extra savings on all eligible CVS-brand, over-the counter items with the CVS ExtraCare® Health Card. Visit our Wellness & Treatment for more information.

  • Doctor visits are a click away – With Doctor on Demand members can visit with a board-certified physician through live video from the comfort of their own home and anywhere they have an internet connection. The cost for a Doctor on Demand visit is the same as the copay at their primary care physician.

If you have any questions or need additional assistance, please contact CDPHP Broker Services or call 1-800-993-7299.


See forms and resources for Medicare 2018