Prohibition of Health Screening Prior to Enrollment
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This policy prohibits denying, limiting, or conditioning enrollment in Medicare Advantage plans based on health-status related factors and governs enrollment staff, agents/brokers, and enrollment procedures for Care Continuum (NHIC) MA products.
No material clinical or coverage changes in this revision.
Enrollment Coverage Criteria
Enrollment policy criteria
Covered when the following prohibitions, exceptions, and procedural requirements apply:
ALL of the following
Examples of health-status related factors (including, but not limited to):
- Claims experience
- Receipt of health care
- Medical history and medical condition including physical and mental illness
- Genetic information
- Evidence of insurability, including conditions arising out of acts of domestic violence
- Disability
Exceptions
- Medicare Medical Savings Account (MSA) plan: an individual will be denied enrollment if receiving Medicare hospice benefits prior to completing the enrollment request or if receiving Medicaid benefits
- Special Needs Plan (SNP): enrollment may be limited to individuals who meet the applicable SNP eligibility requirements
Procedural requirements for denials
- NHIC includes procedures for assessing and verifying reasons for denial in its enrollment process and follows the proper channels
- NHIC maintains appropriate documentation supporting denials
- Members of a group health plan who are in the 30-month coordination period are noted in the enrollment process
Enrollment Staff Responsibilities & Actions
Enrollment actions, verification, and staff responsibilities
Do not deny, limit, or condition enrollment based on health‑status related factors; document and verify any reasons for denial and follow established procedures. Educate all sales staff and contracted agents/brokers at orientation and annually; investigate complaints and apply corrective action (up to termination) for noncompliance.
- Prohibited bases include claims experience, receipt of health care, medical history/condition (physical or mental), genetic information, evidence of insurability (including conditions from domestic violence), and disability. [[do not include chunk refs in body]]
- Maintain documentation supporting any enrollment denials and follow NHIC procedures for assessing and verifying reasons for denial; note group health plan members in a 30‑month coordination period and SNP eligibility limits.
- Provide education to internal and external sales staff and contracted agents/brokers at orientation and annually upon CMS contract renewal.
- Investigate all complaints and implement corrective actions; failure to comply may result in disciplinary action up to and including termination.
Key Definitions
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