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.

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 benefit manager is Capital Rx. Prescription mail order services are offered by multiple providers. Details can be found on our mail order page.

• 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.

• 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.

  • It is a CMS requirement for members to be provided with this information prior to their effective date of coverage, so please make sure to hand out these books accordingly.

• 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. 

• 2024 Medicare Enrollment Form | 2025 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.

• 2024 Medicare Group Disenrollment Form | 2025 Medicare Group Disenrollment Form

No-Cost Fitness and Wellness Options

• SilverSneakers offers online fitness classes and a national network of gyms and fitness centers where members can use equipment and attend fitness and wellness classes.

• CDPHP® Fitness Connect at the Ciccotti Center

  • Next Steps Fitness Program^™
    Members have access to a fitness center with cardio and resistance equipment, a 25-yard lap pool, group exercise studios, massage therapy, and more.

  • MyFitRx^TM

    This eight-week individualized medical fitness program gives you an exercise plan, two 60-minute group workout sessions a week, health assessments at the start and end of the program, unlimited access to the Ciccotti Center, and a program summary report for you and your doctor.

  • Group Exercise Classes

    From yoga to Zumba, group exercise classes at the Ciccotti Center are taught by certified instructors who want to motivate you toward achieving your fitness goals.

• Customer Connect^SM
  Meet with a customer relations specialist to get answers to your claims and benefit questions, request ID cards, sign up for health insurance, and more.

• Members can use the CDPHP Health Hub to:

  • Get customized tips to help them eat healthy, stay active, reduce stress, and more!

  • Earn up to $125 in Life Points Rewards, redeemable for gift cards, for completing healthy activities

• Weight Management Reimbursement
  Members can receive a reimbursement of up to $100 for participating in at least eight weeks of a qualifying weight management program, or four sessions with a registered dietitian.

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