Chapter 2 - Medicare Advantage Enrollment and Disenrollment

Medicare Managed Care Manual

Updated: August 19, 2011

(Revised: November 16, 2011, August 7, 2012, August 30, 2013, August 14, 2014, July 6, 2015,

September 1, 2015, September 14, 2015, December 30, 2015, May 27, 2016, August 25, 2016, June 15,

2017, July 31, 2018 & August 12, 2020)

This guidance update is effective for contract year 2021. All enrollments with an effective date on

or after January 1, 2021, must be processed in accordance with the revised requirements,

including the new model Medicare Advantage (MA)enrollment form for the 2021 plan year

starting October 15, 2020 and model notices, as appropriate. Organizations may, at their option,

implement any new requirement consistent with this guidance prior to the required

implementation date.

It is expected that organizations will assure compliance with all Medicare Advantage

requirements described in this chapter regarding communications made with

beneficiaries/members, including the use of the model notices, and the requirements outlined in

the Medicare Communications and Marketing Guidelines (MCMG).

Organizations are required to provide information to individuals in accessible/alternate formats

(for example, Large Print, Braille), upon request and thereafter, as outlined in Section 504 of the

Rehabilitation Act of 1973 (and subsequent revisions). Such individuals must have an equal

opportunity to participate in enrollment, paying premium bills, and communicating with the plan,

as members who do not request accessible/alternate formats.

Table of Contents

10 - Definitions .......................................................................................................................................9

20 - Eligibility for Enrollment in MA Plans .......................................................................................16

20.1 - Entitlement to Medicare Parts A and B and Eligibility for Part D ...................................17

20.2 - Place of Permanent Residence ............................................................................................17

20.2.1 - Mailing Address .........................................................................................................19

20.2.2 – U.S. Citizenship or Lawful Presence ..............................................................................19

20.3 - Completion of Enrollment Request ....................................................................................19

20.3.1 - Optional Employer/Union Enrollment Request Mechanism ...................................20

20.3.2 - Passive Enrollment by CMS ......................................................................................20

20.3.3 - Group Enrollment for Employer or Union Sponsored Plans ...................................22

20.4 - Agreeing to Abide by MA Organization Rules .................................................................23

20.5 - Grandfathering of Members on January 1, 1999 ...............................................................23

20.6 - Eligibility and the Hospice Benefit ....................................................................................24

20.7 - Continuation of Enrollment Option for MA Local Plans ..................................................24

20.8 - Additional Eligibility Requirements for MA Religious Fraternal Benefit (RFB) Plans .25

20.9 - Eligibility Requirements for Medicare Medical Savings Account (MSA) Plans ............25

20.10 - Additional Eligibility Requirements for Enrollment in MA Special Needs Plans ........25

30 - Election Periods and Effective Dates...........................................................................................28

30.1 - Annual Election Period (AEP) ............................................................................................29

30.2 - Initial Coverage Election Period (ICEP) ............................................................................29

30.2.1 - Initial Enrollment Period for Part D (IEP for Part D) ..............................................30

30.3 - Open Enrollment Period for Institutionalized Individuals (OEPI) ...................................31

30.4 - Special Election Period (SEP) ............................................................................................31

30.4.1 - SEPs for Changes in Residence .................................................................................34

30.4.2 - SEPs for Contract Violation ......................................................................................35

30.4.3 - SEPs for Non-renewals or Terminations ..................................................................36

30.4.4 - SEPs for Exceptional Conditions ..............................................................................38

1. SEP EGHP (Employer/Union Group Health Plan) .....................................................38

2. SEP for Individuals Who Disenroll in Connection with a CMS Sanction .................39

3. SEP for Individuals Enrolled in Cost Plans that are Non-renewing their Contracts .39

4. SEP for Individuals in the Program of All-inclusive Care for the Elderly (PACE) ..39

5. SEP for Dual-eligible Individuals and Other LIS-Eligible Individuals......................39

6. SEP for Individuals Who Terminated a Medigap Policy When They Enrolled For

the First Time in an MA Plan, and Who Are Still in a “Trial Period” ...............41

7. SEP for Individuals with ESRD Whose Entitlement Determination Made

Retroactively ..........................................................................................................41

8. SEP for Individuals Whose Medicare Entitlement Determination Made

Retroactively ..........................................................................................................42

9. MA SEPs to Coordinate With Part D Enrollment Periods ..........................................42

10. SEP for Individuals Who Lose Special Needs Status ...............................................43

11. SEP for Individuals Who Belong to a Qualified SPAP or Who Lose SPAP

Eligibility ...............................................................................................................43

12. SEP for Individuals who Gain, Lose, or Have a Change in their Dual or LIS-

Eligible Status ........................................................................................................43

13. SEP for Enrollment Into a Chronic Care SNP and for Individuals Found Ineligible

for a Chronic Care SNP.........................................................................................44

14. SEP for Disenrollment from Part D to Enroll in or Maintain

Other Creditable Coverage ...................................................................................44

15. SEP to Enroll in an MA Plan, PDP or Cost Plan With a Plan Performance Rating

of Five (5) Stars .....................................................................................................44

16. SEP for Non-U.S. Citizens who become Lawfully Present ......................................46

17. SEP for Providing Individuals who Requested Materials in Accessible Formats

Equal Time to Make Enrollment Decisions .........................................................46

18. SEP for Government Entity-Declared Disaster or Other Emergency ......................46

19. SEP for Individuals Enrolled in a Plan Placed in Receivership ..............................47

20. SEP for Individuals Enrolled in a Plan That Has Been Identified by CMS as a

Consistent Poor Performer ...................................................................................47

21. SEP for Other Exceptional Circumstances ................................................................47

30.4.5 - SEPs for Beneficiaries Age 65 (SEP65) ...................................................................48

30.4.6 – SEP for Significant Change in Provider Network ...................................................48

30.4.7 – SEP for CMS and State-Initiated Enrollments ........................................................48

30.5 – Medicare Advantage Open Enrollment Period (MA OEP) ..............................................49

30.6 - Effective Date of Coverage .................................................................................................49

30.6.1 - Effective Date of Auto- and Facilitated Enrollments ...............................................51

30.7 - Effective Date of Voluntary Disenrollment .......................................................................52

30.8 - Election Periods and Effective Dates for Medicare MSA Plans ......................................53

30.9 - Closed Plans, Capacity Limits, and Reserved Vacancies .................................................53

30.9.1 - MA Plan Closures ......................................................................................................53

40 - Enrollment Procedures ..................................................................................................................55

40.1 - Format of Enrollment Requests ..........................................................................................56

40.1.1 - Enrollment Request Mechanisms ..............................................................................57

40.1.2 – Electronic Enrollment................................................................................................58

40.1.3 - Enrollment via Telephone ..........................................................................................59

40.1.4 - Default Enrollment Option for Medicaid Managed Care Plan Enrollees who are

Newly Eligible for Medicare Advantage ...................................................................60

40.1.5 - Auto- and Facilitated Enrollment ..............................................................................62

40.1.6 – Additional Enrollment Request Mechanisms for Employer/Union Sponsored

Coverage.......................................................................................................................71

40.1.6.1 - Group Enrollment Mechanism .........................................................................72

40.1.6.2 - Optional Mechanism For MA Group-sponsored plan Enrollment ................73

40.1.7 - Enrollment for Beneficiaries in Qualified State Pharmaceutical Assistance

Programs (SPAPs) .......................................................................................................74

40.1.8 – Re-Assignment of Certain LIS Beneficiaries ..........................................................74

40.1.9 – Simplified (Opt-In) Enrollment Mechanism ............................................................76

40.2 - Processing the Enrollment Request ....................................................................................78

40.2.1 - Who May Complete an Enrollment or Disenrollment Request...............................85

40.2.2 - When the Enrollment Request Is Incomplete ...........................................................86

40.2.3 - MA Organization Denial of Enrollment ...................................................................87

40.2.4 - MA-PD Enrollment When an Individual has Other Qualified Prescription Drug

Coverage through an Employer or Union Retiree Drug Subsidy (RDS) Plan

Sponsor .........................................................................................................................88

40.3 - Transmission of Enrollments to CMS ................................................................................89

40.4 - Information Provided to Member .......................................................................................90

40.4.1 - Prior to the Effective Date of Coverage ....................................................................90

40.4.2 - After the Effective Date of Coverage........................................................................92

40.5 - Enrollment Processing During Closed Periods ..................................................................92

40.5.1 - Procedures After Reaching Capacity Limit ..............................................................93

40.5.2 - Procedures After Closing During the OEP and OEPI..............................................94

40.6 - Enrollments Not Legally Valid ...........................................................................................95

40.7 - Enrollment Procedures for Medicare MSA Plans .............................................................96

40.7.1 - Establishing the MSA Banking Account during the Enrollment Process ..............97

50 - Disenrollment Procedures.............................................................................................................98

50.1 - Voluntary Disenrollment by Member ................................................................................98

50.1.1 – Requests Submitted via Internet ...............................................................................99

50.1.2 - Request Signature and Date .......................................................................................99

50.1.3 - Effective Date of Disenrollment............................................................................. 100

50.1.4 - Notice Requirements ............................................................................................... 100

50.1.5 - Optional Employer/Union MA Disenrollment Request Mechanism ................... 101

50.1.6 - Group Disenrollment for Employer/Union Sponsored Plans ............................... 102

50.1.7 - Medigap Guaranteed Issue Notification Requirements for Disenrollments to

Original Medicare during a SEP .............................................................................. 102

50.2 - Required Involuntary Disenrollment ............................................................................... 102

50.2.1 - Members Who Change Residence ......................................................................... 104

50.2.1.1 - General Rule ................................................................................................... 104

50.2.1.2 - Effective Date of Disenrollment ................................................................... 105

50.2.1.3 - Researching and Acting on a Change of Address ........................................ 106

50.2.1.4 - Procedures for Developing Addresses for Members Whose Mail is Returned

as Undeliverable ................................................................................................. 107

50.2.1.5 - Notice Requirements...................................................................................... 108

50.2.2 - Loss of Medicare Part A or Part B ......................................................................... 109

50.2.3 - Death ........................................................................................................................ 110

50.2.4 - Terminations/Nonrenewals ..................................................................................... 110

50.2.5 – Loss of Special Needs Status ................................................................................. 111

50.2.6 – Failure to Pay a Part D-Income Related Monthly Adjustment Amount (Part D-

IRMAA) .................................................................................................................... 112

50.2.7 – Unlawful Presence Status ....................................................................................... 113

50.3 - Optional Involuntary Disenrollments .............................................................................. 114

50.3.1 - Failure to Pay Premiums ......................................................................................... 114

50.3.2 - Disruptive Behavior ................................................................................................ 120

50.3.3 - Fraud and Abuse ...................................................................................................... 123

50.4 - Processing Disenrollments ............................................................................................... 123

50.4.1 - Voluntary Disenrollments ....................................................................................... 123

50.4.2 – When the Disenrollment Request is Incomplete .................................................. 124

50.4.3 - Involuntary Disenrollments .................................................................................... 125

50.5 - Disenrollments Not Legally Valid ................................................................................... 125

50.6 - Disenrollment of Grandfathered Members ..................................................................... 126

50.7 - Disenrollment Procedures for Employer/Union Sponsored Coverage Terminations .. 126

50.8 - Disenrollment Procedures for Medicare MSA Plans ..................................................... 128

60 - Post-Enrollment Activities ........................................................................................................ 129

60.1 - Multiple Transactions ....................................................................................................... 129

60.2 - Cancellations ............................................................................................................... 130

60.2.1 - Cancellation of Enrollment ..................................................................................... 130

60.2.2 - Cancellation of Disenrollment ................................................................................ 131

60.2.3 – When A Cancellation Transaction is Rejected by CMS Systems (Transaction

Reply Code (TRC) 284) ........................................................................................... 132

60.2.4 – Cancellation Due to Notification from CMS (TRC 015) ..................................... 132

60.3 - Reinstatements ............................................................................................................ 132

60.3.1 - Reinstatements for Disenrollment Due to Erroneous Death Indicator, or Erroneous

Loss of Medicare Part A or Part B, Erroneous Incarceration Information, or

Erroneous Unlawful Presence Information ............................................................. 133

60.3.2 - Reinstatements Based on Beneficiary Cancellation of New Enrollment ............ 135

60.3.3 - Reinstatements Due to Mistaken Disenrollment Due to Plan Error .................... 135

60.3.4 - Reinstatements Based on a Determination of Good Cause for Failure to Pay Plan

Premiums or Part D-IRMAA Timely ............................................................................ 136

60.3.4.1 - Process for Good Cause Determinations for Nonpayment of Plan

Premiums ............................................................................................................ 138

60.3.4.2 – Process for Good Cause Determinations for Nonpayment of Part D-

IRMAA ............................................................................................................... 140

60.4 - Retroactive Enrollments ................................................................................................... 142

60.5 - Retroactive Disenrollments .............................................................................................. 143

60.6 - Retroactive Transactions for Employer/Union Group Health Plan (EGHP) Members 144

60.6.1 - EGHP Retroactive Enrollments .............................................................................. 144

60.6.2 - EGHP Retroactive Disenrollments......................................................................... 145

60.7 – User Interface (UI) Transactions Reply Codes (TRC) – Communications with

Beneficiaries .................................................................................................................... 145

60.8 - Election of Continuation of Enrollment Option for MA Local Plans ........................... 148

60.9 - Storage of Enrollment and Disenrollment Records ........................................................ 148

Appendices ......................................................................................................................................... 149

Appendix 1: Summary of Notice Requirements........................................................................ 150

Appendix 2: Summary of Data Elements Required for Plan Enrollment Mechanisms and

Completed Enrollment Requests .................................................................................... 156

Appendix 3: Setting the Application Date on CMS Enrollment Transactions ........................ 159

Appendix 4: Examples of Good Cause Determinations ........................................................... 160

EXHIBITS.......................................................................................................................................... 165

Exhibit 1: MODEL INDIVIDUAL ENROLLMENT REQUEST FORM TO ENROLL IN A

MEDICARE ADVANTAGE PLAN (PART C) ................................................................. 166

Exhibit 1a: Information to include on or with Enrollment Mechanism – Attestation of Eligibility

for an Enrollment Period....................................................................................................... 169

Exhibit 1b: Model MA MSA Plan Enrollment Request Form (“Election” may also be used) .... 171

Exhibit 1c: Model PFFS Individual Enrollment Request Form (“Election” may also be used) . 175

Exhibit 1d: Model Simplified Enrollment Form.............................................................................. 180

Exhibit 2: Model Employer/Union Group Health Plan Enrollment Request Form (“Election” may

also be used) .......................................................................................................................... 182

Exhibit 3: Model Short Enrollment Request Form (“Election” may also be used) ...................... 186

Exhibit 3a: Model Plan Selection Form for MA-PD - Switch From Plan to Plan Within Parent

Organization .......................................................................................................................... 190

Exhibit 4: Model Notice to Acknowledge Receipt of Completed Enrollment Request............... 195

Exhibit 4a: Model Notice to Acknowledge Receipt of Completed Enrollment Request –

Enrollment in another Plan Within the Same Parent Organization.................................... 198

Exhibit 4b: Model Notice to Acknowledge Receipt of Completed Enrollment Request and to

Confirm Enrollment .............................................................................................................. 201

Exhibit 4d: Model Notice to Acknowledge Receipt of Completed PFFS Enrollment Request and

to Confirm Enrollment in a PFFS Plan ................................................................................ 208

Exhibit 4e: Model Notice to Acknowledge Receipt of Completed Enrollment Request and to

Confirm Enrollment in Another Plan Within the Same Parent Organization ................... 212

Exhibit 5: Model Notice to Request Information ........................................................................... 216

Exhibit 6: Model Notice to Confirm Enrollment (MA-PD) .......................................................... 217

Exhibit 6a: Model Notice to Confirm Enrollment - Plan to Plan Within Parent Organization ... 219

Exhibit 6b: Model Notice for MA-PD Plans for Individuals Identified on CMS Records As

Members of Employer or Union Group Receiving the Retiree Drug Subsidy (RDS)...... 221

Exhibit 6c: Model Notice to Confirm PFFS Enrollment................................................................. 222

Exhibit 6d: Model Notice to Confirm Enrollment (MA-only) ....................................................... 225

Exhibit 7: Model Notice for MA Organization Denial of Enrollment .......................................... 226

Exhibit 8: Model Notice for CMS Rejection of Enrollment .......................................................... 228

Exhibit 9: Model Notice to Send Out Disenrollment Form (MA-PD enrollee) ........................... 230

Exhibit 9a: Model Notice to Send Out Disenrollment Form (MA-only enrollee) ........................ 232

Exhibit 10: Model Disenrollment Form .......................................................................................... 234

Exhibit 10a: Information to include on or with Disenrollment Form – Attestation of Eligibility for

an Election Period ................................................................................................................. 235

Exhibit 11: Model Notice to Acknowledge Receipt of Voluntary Disenrollment Request from

Member .................................................................................................................................. 236

Exhibit 11a: Model Notice to Request Information (Disenrollment) ............................................ 238

Exhibit 12: Model Notice to Confirm Voluntary Disenrollment Following Receipt of Daily

Transaction Reply Report (DTRR) ...................................................................................... 240

Exhibit 12a: Model Notice for MA Organization Denial of Disenrollment ................................. 242

Exhibit 12b: Model Notice for CMS Rejection of Disenrollment................................................. 244

Exhibit 12c: Confirmation of Disenrollment Due to Passive Enrollment into a Medicare-

Medicaid Plan ........................................................................................................................ 245

Exhibit 13: Model Notice of Disenrollment Due to Death ............................................................ 246

Exhibit 14: Model Notice of Disenrollment Due to Loss of Medicare Part A and/or Part B ...... 247

Exhibit 15: Model Notice to Offer Beneficiary Services, Pending Correction of Erroneous Death

Status ...................................................................................................................................... 248

Exhibit 16: Model Notice to Offer Beneficiary Services, Pending Correction of Erroneous

Medicare Part A and/or Part B Termination ........................................................................ 249

Exhibit 17: Model Notice to Offer Reinstatement of Beneficiary Services, Pending Correction of

Disenrollment Status Due to Plan Error .............................................................................. 250

Exhibit 18: Model Notice to Close Out Request for Reinstatement ............................................. 251

Exhibit 19: Model Notice on Failure to Pay Plan Premiums - Advance Notification of

Disenrollment or Reduction in Coverage of Optional Supplemental Benefit(s) .............. 252

Exhibit 20: Model Notice on Failure to Pay Plan Premiums - Notification of Involuntary

Disenrollment ........................................................................................................................ 254

Exhibit 21: Model Notice on Failure to Pay Plan Premiums - Confirmation of Involuntary

Disenrollment ........................................................................................................................ 256

Exhibit 21a: Notification of Involuntary Disenrollment by the Centers for Medicare & Medicaid

Services for Failure to Pay the Part D-Income Related Monthly Adjustment Amount.... 258

Exhibit 22: Model Notice on Failure to Pay Optional Supplemental Benefit Premiums - Notice of

Reduction in Coverage of Optional Supplemental Benefit(s) Within the Same Plan

(PBP) ...................................................................................................................................... 260

Exhibit 22a: Model Notice on Favorable Good Cause Determination for Disenrollment Due to

Nonpayment of Part D-IRMAA – Notification of Plan Premium Amount Due for

Reinstatement ........................................................................................................................ 262

Exhibit 22b: Model Notice on Favorable Good Cause Determination for Disenrollment Due to

Nonpayment of Plan Premiums – Notification of Plan Premium Amount Due for

Reinstatement ........................................................................................................................ 264

Exhibit 22c: Model Notice on Unfavorable Good Cause Determination for Disenrollment Due to

Nonpayment of Plan Premiums ............................................................................................ 266

If you have any questions, please call us at <phone number> between <hours and days of

operation>. TTY users should call <TTY number>. ......................................................... 266

Exhibit 22d: Model Notice to Close Out Good Cause Reinstatement Request – Failure to Pay Plan

Premiums within 3 Months of Disenrollment ..................................................................... 267

Exhibit 22e: Model Notice on Favorable Good Cause Determination for Disenrollment Due to

Nonpayment of Plan Premiums (No Plan Premium Amount Due for Reinstatement) .... 269

Referenced in section: 60.3.4.1 ............................................................................................ 269

Exhibit 23: Model Notices for Closing Enrollment........................................................................ 270

Exhibit 24: Model Notice for Medigap Rights Per Special Election Period ................................ 272

Exhibit 25: Acknowledgement of Request to Cancel Enrollment ................................................. 273

Exhibit 25a - Model Acknowledgment of Reinstatement ............................................................... 274

Exhibit 25b: Confirmation of Cancellation of Enrollment Due to Notice from CMS (TRC 015) 275

Exhibit 26: Acknowledgement of Request to Cancel Disenrollment ............................................ 276

Exhibit 27a: MA-PFFS Model Notice to Inform Full-Benefit Dual Eligible Member of Auto-

Enrollment in PDP ................................................................................................................ 280

Exhibit 28: MA Model Notice to Inform Member of Facilitated Enrollment into MA-PD plan 282

Exhibit 28a: MA Model Notice to Inform Member of Facilitated Enrollment into PDP ............ 284

Exhibit 29: Acknowledgement of Request to Opt Out of Auto/Facilitated Enrollment ............... 286

Exhibit 30: Model Notice for Enrollment Status Update ................................................................ 287

Exhibit 31: Model Employer/Union Sponsored MA Plan Group Enrollment Mechanism

Notice ..................................................................................................................................... 289

Exhibit 32: Model Notice for Loss of Special Needs Status.......................................................... 291

Exhibit 33: Model Notice for Loss of SNP Status - Notification of Involuntary Disenrollment . 293

Exhibit 34: MA Model Notice to Research Potential Out of Area Status .................................... 295

Exhibit 35: MA Model Notice for Disenrollment Due to Out of Area Status (No Response to

Request for Address Verification) ....................................................................................... 297

Exhibit 36: MA Model Notice for Disenrollment Due to Confirmation of Out of Area Status

(Upon New Address Verification from Member) ............................................................... 299

Exhibit 37: Notification of Involuntary Disenrollment by the Centers for Medicare & Medicaid

Services due to Incarceration................................................................................................ 301

Exhibit 38: Notification of Involuntary Disenrollment by the Centers for Medicare & Medicaid

Services due to Loss of Lawful Presence ............................................................................ 303

For Chapter 2, a reference to an “MA plan” includes MA local plans, MA Regional Preferred

Provider Organization (PPO) plans and MA-PD plans (including special needs plans), unless

otherwise specified.

The instructions provided in this chapter apply to MA plans, including MA-PD plans.

Instructions for enrollment (and disenrollment) in a Prescription Drug Plan (PDP) or an 1876

cost plan are provided in a separate guidance.

10 - Definitions

The following definitions relate to topics addressed in this guidance.

Application Date – For paper enrollment forms and other enrollment request mechanisms, the

application date is the date the enrollment request is initially received by the organization as defined

below. Plans must use this date in the appropriate field when submitting enrollment transactions to

CMS. A summary of application dates for CMS enrollment transactions is provided in Appendix 3 of

this guidance.

• For requests sent by mail, the application date is the date the application is received by the

organization (i.e., arrives in the organization’s mailbox or mailroom); the postmark is irrelevant).

• For requests received by fax, the application date is the date the fax is received on the

organization’s fax machine.

• For requests submitted to sales agents, including brokers, the application date is the date the

agent and/or broker receives (accepts) the enrollment request and not the date the organization

receives the enrollment request from the agent and/or broker. For purposes of enrollment,

receipt by the agent or broker employed by or contracting with the organization, is considered

receipt by the plan, thus all CMS required timeframes for enrollment processing begin on this

date.

• For requests accepted by approved telephonic enrollment mechanisms, the application date is the

date of the call. The call must have followed the approved script, included a clear statement that

the individual understands he or she is requesting enrollment, and have been recorded.

• The Medicare.gov Online Enrollment Center (OEC) uses coordinated Universal Time (UTC,

which was formerly known as Greenwich Meant Time and is four hours ahead of Eastern

Daylight Time and five hours ahead of Eastern Standard Time) as the system time to generate the

timestamp of when an enrollment was received. For requests made via the (OEC), the application

date to be used for processing the enrollment request is the time and date that is 11 hours earlier

than the time and date CMS “stamps” on the enrollment request at the time the individual

completed the OEC process. This is true regardless of when an organization ultimately retrieves

or downloads the request.

Example: An individual completes an enrollment request and submits it via the OEC at

9:00 p.m. EST on December 7. The OEC will “stamp” this request as having been

completed on December 8 at 2:00 a.m., which is the UTC equivalent time and date. The

organization will use December 7, 3:00 p.m., as the application date for the purpose of

addressing CMS enrollment policy requirements (e.g. application date, determination of

election period, etc.).

• For electronic enrollment requests made using the organization’s system instead of the OEC, the

application date is the date the applicant completes the request through the organization’s

electronic enrollment process. This is true regardless of when an organization ultimately

retrieves or downloads the request.

• For all enrollments into employer group or union sponsored plans using the Special Enrollment

Period for Employer or Union Group Health Plans (SEP EGHP), the application date used on the

transaction submitted to CMS will always be the

first of the month prior to the effective date of

enrollment for all mechanisms at all times. For the purposes of providing notices and meeting

other timeframe requirements provided in this guidance, use the date the organization receives

the request. For example, if a valid group enrollment mechanism file is received by the

organization on January 24

for enrollments effective February 1

, the receipt date for the

provision of required notices is January 24

and the application date submitted on the enrollment

transactions is January 1

• For auto- or facilitated enrollment, as described in §40.1.5, the application date is the first day of

the month prior to the effective date of the auto/facilitated enrollment. This will ensure that any

subsequent beneficiary-generated enrollment request will supersede the auto- or facilitated

enrollment in CMS systems.

At-risk Beneficiary – A Part D eligible individual who is determined to be at-risk for misuse or abuse

of a frequently abused drug in accordance with the requirements for drug management programs at 42

CFR 423.153(f). Additional guidance about Part D drug management programs is available at

https://www.cms.gov/Medicare/Prescription-Drug-

Coverage/PrescriptionDrugCovContra/RxUtilization.html

(Rev. 1, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

Authorized Representative/Legal Representative – An individual who is the legal representative or

otherwise legally able to act on behalf of an enrollee, as the law of the State in which the beneficiary

resides may allow, in order to execute an enrollment or disenrollment request; e.g., court appointed

legal guardians, persons having durable power of attorney for health care decisions, or individuals

authorized to make health care decisions under state surrogate consent laws, provided they have the

authority to act for the beneficiary in this capacity (see §40.2.1). Form CMS-1696 may not be used to

appoint an authorized representative for the purposes of enrollment and disenrollment. This form is

solely for use in the claims adjudication or claim appeals process, and does not provide broad legal

authority to make another individual’s healthcare decisions.

Cancellation of Enrollment Request – An action initiated by the beneficiary to cancel an enrollment

request. To be valid, the cancellation request must be received by the organization before the

enrollment effective date. An enrollment request that has been appropriately cancelled is considered

not to have been used and the election remains available for use within the time frame of the

applicable election period.

Completed Election – An enrollment request is considered complete when:

1. The form/request is signed by the beneficiary or legal representative (refer to §40.2.1 for a

discussion of who is considered to be a legal representative), or the enrollment request

mechanism is completed;

2. For enrollments, evidence of entitlement to Medicare Part A and enrollment in Medicare Part B

is obtained by the Medicare Advantage organization (see below for definition of “evidence of

Medicare Part A and Part B coverage”);

3. All necessary elements on the form are completed (for enrollments, see Appendix 2

for a list of

elements that must be completed) or when the enrollment request mechanism is completed as

CMS directs, and, when applicable;

4. Certification of a legal representative’s authority to make the enrollment request is obtained by

attestation (refer to §40.2.1).

5. For Special Needs Plans (SNP), verification of SNP eligibility, as described in §20.11. Chronic

condition SNPs (C-SNP) that utilize a CMS-approved pre-enrollment qualification assessment

tool will consider the enrollment request to be complete upon receipt of the completed tool.

If an individual is involuntarily disenrolled for failure to pay premiums, to re-enroll in that plan, or

enroll into another, he or she would need to request enrollment during a valid enrollment period. In

addition, for enrollments into an MA-only (non MA-PD) plan, an MA organization may also choose to

wait for the individual’s payment of the plan premium, including any premiums due the MA

organization for a prior enrollment before considering an enrollment “complete.”

Continuation Area/Continuation of Enrollment Option – A continuation area is an additional

CMS-approved area outside the MA local plan’s service area within which the MA organization

furnishes or arranges for furnishing of services to the MA local plan’s continuation of enrollment

members. MA organizations have the option of establishing continuation areas for MA local plans.

Conversions – For individuals who are enrolled in a health plan offered by the MA organization the

month immediately before the month of their entitlement to Medicare Parts A and B, their enrollment

in an MA plan offered by the same organization is referred to as a “conversion” from non-Medicare

status to MA enrollee status. In order for the individual’s enrollment with the organization as an MA

enrollee to take effect upon becoming eligible for Medicare, conversions must take place during the

individual’s Initial Coverage Election Period (ICEP).

Denial of Enrollment Request – Occurs when an MA organization determines that an individual is

not eligible to make an enrollment request (e.g., the individual is not entitled to Medicare Part A or

enrolled in Part B, the individual is not making the enrollment request during an election period, etc.),

and therefore determines it should not submit the enrollment request transaction to CMS.

Effective Date of Coverage/Enrollment – The date on which an individual’s coverage in an MA plan

begins. The MA organization must determine the effective date of enrollment for all enrollment

requests. Instructions for determining the correct effective date of coverage are provided in §30.6.

Election – Enrollment in, or voluntary disenrollment from, an MA plan or the traditional Medicare

fee-for-service program (“Original Medicare”) constitutes an election. (Disenrollment from Original

Medicare would occur only when an individual enrolls in an MA plan.) The term “election” is used to

describe either an enrollment or voluntary disenrollment. If the term “enrollment” is used alone,

however, then the term is used deliberately, i.e., it is being used to describe only an enrollment, and

not a disenrollment. The same applies when the term “disenrollment” is used alone, i.e., the term is

being used to describe only a disenrollment, and not an enrollment.

Election Period – The time(s) during which an eligible individual may request to enroll in or disenroll

from an MA plan. The type of election period determines the effective date of MA coverage as well as

the types of enrollment requests allowed. There are several types of election periods, all of which are

defined under §30.

Enrollment Request Mechanism – A method used by individuals to request to enroll in an MA plan.

Several model individual enrollment forms are provided in the Exhibits at the end of this guidance. An

individual who is a member of an MA plan and who wishes to elect another MA plan, even if it is

offered by the same MA organization, must complete a new election during a valid enrollment

period to enroll in the new MA plan. However, that individual may use a short enrollment form

(refer to Exhibit 3) or a “plan selection” form (refer to Exhibit 3a) to make the election in place of the

comprehensive individual enrollment form, or, may complete the election via an electronic enrollment

mechanism, as described in §40.1.2 of this guidance, or by telephone, as described in §40.1.3 of this

guidance, if the MA organization offers these options. In addition, MA organizations may want to

collaborate with Employer or Union Group Health Plans (EGHPs) to use a single enrollment form (or

other CMS approved method, if available) for EGHP members; a model EGHP enrollment form for

this purpose is provided in Exhibit 2. Beneficiaries or their legal representatives must complete an

enrollment request mechanism (e.g. enrollment form) to enroll in an MA plan.

Beneficiaries are not required to use a specific form to disenroll from an MA plan; however, a model

disenrollment form is provided in Exhibit 10.

Evidence of Entitlement (Medicare Part A and Part B Coverage) – Documentation, materials or

other information that confirms an individual is entitled to coverage under Parts A and B of Medicare.

Evidence of entitlement is a requirement to determine eligibility for enrollment into a MA plan. It

includes the individual’s coverage start dates for Part A and Part B. CMS systems are updated within

two business days of SSA processing a new or changed Part A or Part B entitlement. MA

organizations must verify Medicare entitlement for all enrollment requests using either the Batch

Eligibility Query (BEQ) process or MARx online query (M232 screen). Therefore, the applicant is not

required to provide evidence with the enrollment request.

(Rev. 1, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

Evidence of Permanent Residence – A permanent residence is normally the enrollee’s primary

residence. An MA organization may request additional information such as voter’s registration

records, driver’s license records, tax records, and utility bills to verify the primary residence. Such

records must establish the permanent residence address, and not the mailing address, of the individual.

Full-Benefit Dual Eligible Individual – For purposes of Medicare Prescription Drug benefits (Part

D), is a Medicare beneficiary who is determined eligible by the state for medical assistance for full

benefits under title XIX of the Social Security Act for the month under any eligibility category

covered under the State plan or comprehensive benefits under a demonstration under section 1115 of

the Act, or medical assistance under section 1902(a)(10)(C) of the Act (medically needy) or section

1902(f) of the Act (States that use more restrictive eligibility criteria than are used by the SSI program)

for any month if the individual was eligible for medical assistance in any part of the month.

Good Cause – This term refers to the standards established in § 60.3.4 under which an individual may

be reinstated into his/her MA plan when involuntarily disenrolled for failure to pay the plan’s premium

or the Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA) premium amount.

Incarceration – This term refers to the status of an individual who is in the custody of a penal

authority and confined to a correctional facility, such as a jail or prison, or a mental health institution

as a result of a criminal offense. Such individuals reside outside of the service area for the purposes of

MA plan eligibility, even if the correctional facility is located within the plan service area. Individuals

who are confined to Institutions for Mental Disease (IMDs), such as state hospitals, psychiatric

hospitals, or the psychiatric unit of a hospital, as a result of violations of the penal code, are

incarcerated as CMS defines the term for the purpose of MA eligibility. The place of residence for

these confined individuals is therefore excluded from the service area of an MA plan on that basis.

Individuals who are confined to IMDs, such as state hospitals, psychiatric hospitals, or the psychiatric

unit of a hospital, for other reasons (e.g., because of court orders unrelated to penal violations) are not

incarcerated. Normal service area rules apply to these individuals.

Institutionalized Individual – Please refer to 42 CFR 422.2.

Involuntary Disenrollment – Disenrollments made necessary due to the organization’s determination

that the individual is no longer eligible to remain enrolled in a plan, or when an organization otherwise

initiates disenrollment (e.g. failure to pay plan premiums, plan termination). Procedures regarding

involuntary disenrollment are found in §§50.2 and 50.3.

Late Enrollment Penalty (LEP) – An amount added to the MA-PD plan premium of an individual

who did not obtain creditable prescription drug coverage when s/he was first eligible for Part D or who

had a break in creditable prescription drug coverage of at least 63 consecutive days. The LEP is

considered a part of the plan premium.

Lawfully Present Individual – Refer to 8 CFR 1.3 (Lawfully present aliens for purposes of applying

for Social Security benefits) for a definition of an alien who is considered lawfully present in the

United States. An individual who is not lawfully present in the Unites States is not eligible for any

federal public benefit, including payment of Medicare benefits. (8 U.S.C. 1611)

Medicare Advantage Organization (MA organization) - Refer to Chapter 1 (General Provisions)

for a definition of an “MA organization.”

MA Organization Error – An error or delay in enrollment request processing made under the full

control of the MA organization personnel and one that the organization could have avoided.

Medicare Advantage Plan – Refer to Chapter 1 for a definition of “MA plan.” Enrollment requests

are made at the MA plan level, not at the MA organization level.

Other Low Income Subsidy (LIS) Eligible Individuals – For purposes of Medicare Part D benefits,

individuals who are determined eligible for the Part D low-income subsidy (LIS) who are not full-

benefit dual eligible individuals as defined above. This includes individuals deemed eligible for LIS

by virtue of having QMB-only, SLMB-only, QI, SSI-only; as well as those who apply and are

determined eligible for LIS.

Out-of-Area Members - Members of an MA plan who live outside the service area and who elected

the MA plan while residing outside the service area (as allowed in §§20.0, 20.3, 50.2.1, and 50.2.4).

Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA) – A premium amount

separate from the Part D plan’s monthly premium for individuals who have incomes over a certain

amount. The Social Security Administration assesses the amount annually based on the enrollee’s

available tax information. The plan does not collect the Part D-IRMAA as part of its premium.

Typically, individuals pay the Part D-IRMAA through their Social Security, Office of Personnel

Management or Railroad Retirement Board (RRB) benefit withholding. Some enrollees are directly

billed for their Part D-IRMAA through invoices sent by CMS or the RRB. All Part D enrollees who

are assessed the Part D-IRMAA are required to pay the IRMAA even if the Part D coverage is

provided through an EGHP.

Plan Performance Rating – A CMS-assigned rating, measured in stars from one to five, which

indicates an organization’s quality and performance based on criteria established by CMS. A star

rating of one star indicates poor performance, while a star rating of five stars indicates exemplary

performance. The Plan Performance Overall Rating (or “overall rating”) is publicly available on

Medicare.gov. CMS assigns the rating in October for the following year based on the organization’s

most recent quality and performance data.

Potential At-risk Beneficiary – A Part D eligible individual who is identified as being potentially at-

risk for misuse or abuse of a frequently abused drug in accordance with the requirements for drug

management programs at 42 CFR 423.153(f). Additional guidance about Part D drug management

programs is available at

www.cms.gov/Medicare/Prescription-Drug-

Coverage/PrescriptionDrugCovContra/RxUtilization.htm

(Rev. 1, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

Receipt of Enrollment Request – MA organizations may receive enrollment requests through various

means, as described in §40.1. The MA organization must date as received all enrollment requests as

soon as they are initially received. This date will be used to determine the election period in which the

request was made, which in turn will determine the effective date of the request. Please refer to the

definition of “Application Date” in this section for specific information regarding the correct date to

report as the application date on enrollment transactions submitted to CMS.

Reinstatement of Election – An action that may be taken by CMS to correct an erroneous

disenrollment from an MA plan. The reinstatement corrects an individual’s records by canceling a

disenrollment to reflect no gap in enrollment in an MA plan. A reinstatement may result in retroactive

disenrollment from another Medicare managed care plan.

Rejection of Enrollment Request – Occurs when CMS has rejected an enrollment request submitted

by the MA organization. The rejection could be due to the MA organization incorrectly submitting the

transactions, to system error, or to an individual’s ineligibility to elect the MA plan.

Special Needs Plan – Medicare Advantage coordinated care plans that serve the special needs of

certain groups of individuals including; institutionalized individuals (as defined by CMS), those

entitled to Medical Assistance under a State Plan under Title XIX and individuals with severe or

disabling chronic conditions, as defined by CMS.

System Error – A “system error” is an unintended error or delay in enrollment request processing that

is clearly attributable to a specific Federal government system (e.g., Social Security Administration

(SSA) system, Railroad Retirement Board (RRB) system), and is related to Medicare entitlement

information or other information required to process an enrollment request.

Voluntary Disenrollment – Disenrollment initiated by a member or his/her authorized representative.

20 - Eligibility for Enrollment in MA Plans

42 CFR 422.50

(Rev. 1, Issued: August 12, 2020; Effective/Implementation: 01-01-2021)

In general, an individual is eligible to elect an MA plan when each of the following requirements is

met:

1. The individual is entitled to Medicare Part A and enrolled in Part B, provided that he or she

will be entitled to receive services under Medicare Part A and Part B as of the effective date of

coverage under the plan (see exceptions described under §20.6);

2. Effective for plan years beginning on or after January 1, 2021, a beneficiary with ESRD can

choose to join a MA plan. (For additional information on SNP eligibility criteria, see Chapter

16-B Special Needs Plans).

3. The individual permanently resides in the service area of the MA plan (see exceptions in §20.3

for persons living outside the service area at the time of the enrollment request);

4. The individual is a U.S. citizen or lawfully present in the United States (see exceptions in

§20.3.2 for persons unlawfully present at the time of the enrollment request);

5. The individual or his/her legal representative completes an enrollment request and includes all

the information required to process the enrollment or meets alternative conditions for

enrollment specified by CMS (refer to Appendix 2 for a list of items required to complete the

enrollment form, and §40.2.1 for who may sign enrollment request forms or complete other

enrollment request mechanisms);

6. The individual is fully informed of and agrees to abide by the rules of the MA organization that

were provided during the enrollment request; and

7. The individual makes a valid enrollment request that is received by the plan during an election

period, as described in §30;

8. For a Special Needs Plan (SNP) additional requirements apply as described in §20.11 of this

guidance.

9. For an MSA plan, additional requirements apply as described in §20.10 of this guidance.

An MA organization may not impose any additional eligibility requirements as a condition of

enrollment other than those established by CMS in this guidance.

An MA organization must not deny enrollment to otherwise eligible individuals covered under an

employee benefit plan. If the individual enrolls in an MA plan and continues to be enrolled in his/her

employer/union or spouse’s group health benefits plan, then coordination of benefits rules apply.

An MA eligible individual may not be enrolled in more than one MA plan at any given time.

Procedures for handling multiple transactions, cancellations, and reinstatements are described in

§§ 60.1, 60.2 and 60.3.

Individuals enrolled in an MA plan may not concurrently enroll in a PDP except for individuals

enrolled in a Medicare MSA plan or individuals enrolled in a PFFS plan that does not offer Medicare

prescription drug coverage. An individual enrolled in an MA PFFS plan that does not include a Part D

benefit may enroll in a PDP, even if under the same MA contract the organization offers another PFFS

plan that includes a Part D benefit.

20.1 - Entitlement to Medicare Parts A and B and Eligibility for Part D

To be eligible to elect an MA plan, an individual must be entitled to Medicare Part A and enrolled in

Part B, and must be entitled to Medicare Part A and Part B benefits as of the effective date of coverage

under the plan. Exceptions for Part B-only “grandfathered” members are outlined in §20.6. Part B only

individuals currently enrolled in a plan created under §1833 or §1876 of the Social Security Act (the

Act) are not considered to be “grandfathered” individuals, and must purchase Medicare Part A through

the Social Security Administration to become eligible to enroll in an MA plan.

An MA organization has the option to continue to offer Part A-equivalent coverage to Medicare Part

B-only “grandfathered” members, as described in §20.6. However, an MA organization may not offer

Part A-equivalent coverage to other individuals enrolled only in Medicare Part B (and not entitled to

Part A) in order to make them “eligible” for enrollment in an MA plan. Eligibility requirements are

met based on Part A entitlement through Medicare and not through the purchase of Part A-equivalent

benefits through the MA organization. The MA organization may refer the individual to SSA if the

individual wishes to enroll in Medicare Part A in order to be eligible to enroll in the MA plan.

Eligibility for Part D does not exist:

• When the beneficiary is incarcerated.

• When the beneficiary is not lawfully present in the United States.

• When the beneficiary lives abroad.

• For any month prior to the month of notification of the entitlement determination when the

entitlement determination for Part A and B is made retroactively.

MA-PDs may not enroll an individual who is not eligible for Part D.

20.2 - Place of Permanent Residence

42 CFR 422.2 and 422.50(a)(3)

(Rev. 1, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

An individual is eligible to elect an MA plan if he or she permanently resides in the service area of the

MA plan. A temporary move into the MA plan’s service area does not enable the individual to elect

the MA plan; the MA organization must deny such an enrollment request.

Incarcerated individuals reside outside of the plan service area for the purposes of MA eligibility, even

if the correctional facility, institution or other place of confinement is located within the plan service

area (see §10 for definition of “incarceration”).

EXCEPTIONS

• An MA organization may offer a continuation of enrollment option to MA local plan enrollees

when they no longer reside in the service area of a plan and permanently move into the

geographic area designated by the MA organization as a continuation area (refer to §20.8 for

more detail on the requirements for the continuation of enrollment option).

• Conversions: Individuals who are enrolled in a health plan of the MA organization and are

converting to Medicare Parts A and B can elect an MA local plan offered by the same MA

organization during their ICEP even if they reside in the MA organization’s continuation area.

(“Conversion” is defined in §10 and the time frames for the ICEP are covered in §30.2.)

• A member who was enrolled in an MA plan covering the area in which the member

permanently resides at the time the plan was terminated in that area, may remain enrolled in the

MA plan while living outside the plan’s new reduced service area if:

• There is no other MA plan serving the area at that time;

• The MA organization offers this option; and

• The member agrees to receive services through providers in the MA plan’s service area.

• The MA organization has the option to also allow individuals who are converting to Medicare

Parts A and B to elect the MA plan during their ICEP even if they reside outside the service

and continuation area. This option may be offered provided that CMS determines that all

applicable MA access requirements in 42 CFR 422.112 are met for that individual through the

MA plan’s established provider network providing services in the MA plan service area, and

the organization furnishes the same benefits to the individual as to members who reside in the

service area. The organization must apply the policy consistently for all individuals. These

members will be known as “out-of-area” members. This option applies both to individual

members and to employer or union sponsored group plan members of the MA organization.

Individuals who do not meet the above requirements may not elect the MA plan. The MA organization

must deny enrollment to these individuals.

A permanent residence is normally the primary residence of an individual. Proof of permanent

residence is normally established by the address of an individual’s residence, but an MA organization

may request additional information such as voter’s registration records, driver’s license records (where

such records accurately establish current residence), tax records, and utility bills. Such records must

establish the permanent residence address, and not the mailing address, of the individual. If an

individual puts a Post Office Box as his/her place of residence on the enrollment form, the MA

organization must contact the individual to confirm that the individual resides in the service area. If

there is a dispute over where the individual permanently resides, the MA organization should

determine whether, according to the law of the MA organization’s State, the person would be

considered a resident of that State.

In the case of homeless individuals, a Post Office Box, an address of a shelter or clinic, or the address

where the individual receives mail (e.g., social security checks) may be considered the place of

permanent residence.

MA organizations have the option to offer “visitor” or “traveler” programs for currently enrolled

individuals who are consecutively out of the area for up to 12 months, provided the plan includes the

full range of services available to other members (refer to §50.2.1 for more detail on the requirements

for the “visitor/traveler” option). Residence in an area designated for a “visitor” or “traveler” program

does not make an individual eligible to enroll in an MA plan, but rather applies to already enrolled

individuals.

20.2.1 - Mailing Address

As described in §20.3, an individual’s eligibility to enroll in an MA plan is in part determined by the

individual’s permanent residence in the service area of that MA plan. Some individuals may have

separate mailing addresses that may or may not be within the geographic plan service area. If an

individual requests that mail be sent to an alternate address, such as that of a relative, MA

organizations should make every effort to accommodate these requests, and should use this alternate

address to provide required notices and other plan mailings, as appropriate. The model MA plan

enrollment application forms provided in this guidance include a mechanism to collect a mailing

address. Use of an alternate address does not eliminate or change the requirement of residency for the

purposes of MA plan eligibility.

20.2.2 – U.S. Citizenship or Lawful Presence

An individual is eligible to elect enrollment in a MA plan if he or she is a U.S. citizen or lawfully

present in the United States. CMS will notify the MA organization if the individual is not eligible to

enroll on this basis at the time of enrollment. The MA organization must deny an enrollment request

from an individual who does not meet this requirement.

EXCEPTION: In the case where CMS systems show that an individual will have lawful

presence status on or before the enrollment effective date, the plan must accept and process the

enrollment request. An MA organization must not deny an enrollment request on the basis that

the applicant is not lawfully present at the time the request is received if CMS systems indicate

that he or she will be lawfully present in the United States as of the enrollment effective date.

If an individual provides evidence of their lawful presence status to the MA organization, the

organization may not consider it when determining eligibility for enrollment. The organization may

not request from an applicant any documentation of U.S. citizenship or alien status. CMS will provide

the official status to the MA organization at the time of enrollment. However, if an individual has

evidence of their lawful presence status and there is a dispute over their status, the MA organization

should refer the individual to the Social Security Administration to have their status reviewed and

adjusted, if necessary.

20.3 - Completion of Enrollment Request

42 CFR 422.50(a)(5)

(Rev. 1, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

The Medicare beneficiary (or their legal representative, as described in § 40.2.1) must complete an

enrollment request in order to enroll in an MA plan, even if switching plans in the same MA

organization. To consider an election complete, the individual must:

• Complete an enrollment request;

• Provide required information to the MA organization within the required time frames; and

• Submit the completed request to the MA organization during a valid enrollment period.

This is required for all enrollments, unless otherwise specified by CMS.

Individuals may use any of the enrollment mechanisms offered by the MA organization to make their

enrollment request. See § 40.1 for more information on the types of enrollment mechanisms allowed.

Individuals switching plans in the same MA organization may use a shortened enrollment form

(sample Exhibit 3 or 3a). Individuals new to Medicare who are already a member of the organization’s

non-Medicare coverage (commercial, Medicaid, Marketplace) may use the simplified enrollment

mechanism, if the MA organization chooses to offer it.

An MA organization must deny enrollment to any individual who does not properly complete the

enrollment form or other mechanism within required time frames. Procedures for completing the

enrollment request are provided in §40.2 and Appendix 2. Refer to §10 for a definition of “completed

enrollment request.”

20.3.1 - Optional Employer/Union Enrollment Request Mechanism

Beginning April 1, 2003, MA organizations that offer MA plans to an employer or union may choose

to accept voluntary enrollment requests directly from the employer or union (or its Third Party

Administrator (TPA)) without obtaining a paper MA enrollment request form from each individual.

The enrollment requests reported to the MA organization by the employer/union will reflect the choice

of retiree coverage individuals made using their employer’s or union’s process for selecting a health

plan. This enrollment request mechanism is optional for MA organizations, and may not be required.

Therefore, MA organizations may specify the employers and/or unions, if any, from which they will

accept this enrollment request format and may choose to accept enrollment and/or voluntary

disenrollment requests.

The record of an individual’s choice of health plan submitted by the employer or union effectively

replaces the paper MA enrollment request form(s). All eligibility, processing and notice requirements,

as outlined in this guidance and other references, that pertain to paper enrollment request forms are

applicable to this enrollment request mechanism; however, this process does not require the MA

organization to obtain a signature. Detailed information and instruction is provided in §40.1.2 for

enrollments and §50.1.5 for disenrollments.

Notices of disenrollment, cancellation or termination of coverage not initiated by an enrollee

enrollment request (i.e. involuntary disenrollment) are not included in this mechanism. Guidance for

these situations is available in §50.1.5.

Additional information regarding employer/union sponsored group health plans can be found in

Chapter 9 of this manual.

20.3.2 - Passive Enrollment by CMS

42 CFR 422.60(g)

(Rev. 1, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

Passive enrollment is a process where CMS enrolls an individual into another plan under certain

circumstances specified below (note that CMS may also enroll individuals in plans under auto- and

facilitated enrollment per § 40.1.5 and reassignment per § 40.1.8). The beneficiary receives a notice of

this change and has the opportunity to accept or decline it. If the individual takes no action, the

individual has made a choice to accept the enrollment. Passive enrollments are permitted in specific,

limited circumstances associated with:

• Immediate plan terminations,

• Situations in which remaining enrolled in the plan would pose potential harm to members, and

• Situations where CMS determines passive enrollment is necessary to promote integrated care

and continuity of care for full-benefit dual eligible beneficiaries.

CMS will determine when passive enrollment is appropriate under 42 CFR 422.60(g) and will initiate

contact through the MA organization’s CMS account manager. CMS will consult with the state

Medicaid agency and may authorize passive enrollment for full-benefit dual eligible beneficiaries

enrolled in an integrated dual-eligible special needs plan (D-SNP) to continue access in integrated

care, including when:

• The organization’s Medicaid managed care plans non-renew because the state awards these

contracts to another organization, or

• An integrated D-SNP non-renews at the end of the contract year.

CMS will provide specific instructions directly to the affected organizations (both the plan losing the

member and the plan receiving the member) regarding processing the enrollments and specific

information relevant to the situation for inclusion in notices.

Notices:

Organizations receiving passive enrollments must send required notices. The chart below outlines the

requirements and timing:

Passive enrollment due to immediate plan

termination or potential harm to members

Passive enrollment to continue access to

integrated care

1 notice required

2 notices required

Notice language must:

• describe the costs and benefits of the

plan;

• outline the process for accessing care

in the plan; and

• explain the ability to decline the

enrollment or choose another plan,

how to take that action and by when

Each notice language must:

• describe the costs and benefits of the

plan;

• outline the process for accessing care

in the plan; and

• explain the ability to decline the

enrollment or choose another plan,

how to take that action and by when

Notice language must be approved by CMS

Notice must be sent:

• prior to the date coverage in the plan

begins; or

• as soon as possible after coverage in

the plan begins, if prior notice isn’t

practical

Notice must be sent:

• at least 60 calendar days prior to the

date coverage in the plan begins; and

• at least 30 calendar days prior to the

date coverage in the plan begins

Evaluation of Plans Receiving Passive Enrollments:

For passive enrollment, CMS evaluates the receiving plan as noted in the following chart.

Passive enrollment due to immediate plan

termination or potential harm to members

Passive enrollment to continue access to

integrated care

Key criteria CMS may use:

Requirements (all must be met):

Similar or lower out-of-pocket maximum

Currently operate as a fully integrated dual

eligible SNP (FIDE SNP) or qualify to meet

Medicare-Medicaid integration criteria as D-

SNP that meets a higher standard of

integration (see Chapter 16b)

Similar or lower hospital cost-sharing amount

Substantially similar provider and facility

networks

No additional network restrictions

Substantially similar Medicare and Medicaid

covered benefits

Premium isn’t significantly higher

Have limits on premiums and cost-sharing

that are appropriate for full-benefit dually

eligible beneficiaries (CMS interprets this

standard as having no premium or cost-

sharing ($0) (see Chapter 16b)

Equivalent or higher value Part D benefit and

formulary structure

Have overall MA star rating of at least 3 stars

(Exception: plan is low enrollment contract or

new plan without star ratings)

Similar Part B buy-down feature, if applicable

Not under sanction for new enrollments

Have capacity (and agree) to accept the

enrollments

Special Enrollment Period:

An SEP is available to all individuals who are passively enrolled in addition to the ability to opt-out of

a passive enrollment. This SEP allows the individual to make an election before the passive enrollment

is effective in the receiving plan or after the coverage in the receiving plan starts. The SEP lasts 3

months beginning from the later of notice of a CMS or State-initiated enrollment action or the

enrollment effective date. See §30.4.7 for more details about this SEP.

NOTE: Individuals in non-renewing or terminating plans also have the ability to use other existing

SEPs outlined in § 30. Dually-eligible individuals may also have the ability to use the duals SEP to

switch plans, provided he or she meets the criteria for that election period (see § 30.4.4 #5). When

more than one SEP is available, the individual may use the SEP that provides him or her with the

greatest flexibility to choose the plan that best meets his or her needs, but use of one SEP does not

negate the availability of other SEPs if the beneficiary chooses to make a subsequent election

(provided that the SEP hasn’t expired and the individual still meets the SEP qualifying conditions).

20.3.3 - Group Enrollment for Employer or Union Sponsored Plans

CMS is providing a process for group enrollment into an employer/union sponsored MA plan. CMS

will allow an employer or union to enroll its retirees using a group enrollment process in which the

beneficiaries participate through advance notification and that provides CMS with any information the

employer/union has on other insurance coverage for the purposes of coordination of benefits. MA

organizations must adhere to the guidelines outlined in §40.1.6, as well as all other program

requirements, in developing and implementing this process.

20.4 - Agreeing to Abide by MA Organization Rules

42 CFR 422.50(a)(6)

Rev. 1, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

To be eligible to elect an MA plan, a beneficiary must be fully informed of and agree to abide by the

rules of the MA organization that were provided during the enrollment process (refer to §§ 40.4,

40.4.1, and 40.4.2 regarding what information must be provided to the individual during the

enrollment process). “Fully informed” means that the individual must be provided with the applicable

rules of the MA organization, as described in §40.4.1 of this chapter, as well as in the Medicare

Communications and Marketing Guidelines. The MA organization must deny enrollment to any

individual who does not agree to abide by the rules of the MA organization. Agreement to abide by

the rules of the MA organization in this context is made through the completion of the enrollment

request.

20.5 - Grandfathering of Members on January 1, 1999

An individual who was enrolled on December 31, 1998, in an HMO with a risk contract under §1876

of the Social Security Act was deemed to be enrolled on January 1, 1999, in an MA plan offered by

the same organization if he/she did not choose to disenroll from the organization effective on the latter

date. This deemed enrollment applied even if the enrollee was not entitled to Medicare Part A or did

not live in an MA plan service area or continuation area. The MA organization was not permitted to

disenroll such individuals because they were not entitled to Part A, or did not live in the service or

continuation area. However, if these individuals elect to disenroll from the MA organization, they are

not eligible to enroll in any MA plan until or unless they meet all MA eligibility requirements.

If enrollment in Medicare Part B ends for an individual, the individual may not continue as a member

of the MA plan and must be disenrolled as described in §§50.2.2 and 50.6.

The MA organization must identify all Medicare Part B-only “grandfathered” individuals and inform

them of their status annually. This notification may be included as part of the Evidence of Coverage.

The notice must inform these individuals that if they disenroll from the MA organization, they cannot

elect another MA plan unless they become entitled to Medicare Part A (by enrolling in Medicare Part

A at SSA and by paying the appropriate premium to CMS) and remain enrolled in Medicare Part B.

MA organizations may continue to provide Part A-equivalent benefits to Medicare Part B-only

grandfathered members. In addition, if an MA organization offers Part A-equivalent coverage as a

supplemental benefit in an MA plan, then the MA organization may disenroll a Medicare Part B-only

grandfathered member who fails to pay the organization’s Part A-equivalent premium, just as any

member of the MA organization could be disenrolled for nonpayment of premiums (refer to §50.3.1).

Grandfathered members may enroll in other MA plans in the same MA organization (within the same

State). However, if grandfathered members disenroll from the MA organization (i.e., they switch to

Original Medicare), they will not be eligible to enroll in any MA plan in any MA organization until or

unless they meet all MA eligibility requirements. If the out-of-area grandfathered members disenroll

from the MA organization (i.e., they switch to Original Medicare or attempt to enroll in another MA

organization), they will only be able to enroll in other MA organizations if they meet all MA eligibility

requirements, including, but not limited to, that of living in the service area of the MA plan.

20.6 - Eligibility and the Hospice Benefit

An MA organization must not deny enrollment to any individual who has elected the hospice benefit

(except in the case of a Medicare MSA plan; see §20.10 for additional eligibility requirements for

Medicare MSA plans). Until the MA organization acknowledges that it has received the completed

enrollment request and gives a coverage effective date to the individual (refer to Exhibit 4, Exhibit 4a,

and §40), the MA organization must not ask any questions related to the existence of a terminal illness

or election of the hospice benefit. Such questions will be considered impermissible health screening.

The MA organization may not disenroll any member on the basis of the member electing the hospice

benefit either before or after becoming a member of the MA plan.

20.7 - Continuation of Enrollment Option for MA Local Plans

With CMS approval, an MA organization may establish continuation areas, separate and apart from an

MA local plan’s service area. Refer to Chapter 11 (Medicare Advantage Application Procedures and

Contract Requirements) regarding CMS approval of continuation areas. As defined in§10, the CMS-

approved continuation area is an additional area outside an MA local plan’s service area within which

the MA organization furnishes or arranges for furnishing of services to the MA plan’s members.

Members may only choose to continue enrollment with the MA local plan if they have permanently

moved from the service area into the continuation area.

As described in Chapter 11, if an MA organization wants to offer a continuation of enrollment option

under one or more of the MA local plans it offers, then it must obtain CMS’ approval of the

continuation area and the marketing materials that describe the continuation of enrollment option. The

MA organization must also describe the enrollment option(s) in member materials and make the

option available to all members of the MA local plan in question who make a permanent move to the

continuation area. An MA organization may require members to give advance notice of their intent to

use the continuation of enrollment option. If the MA organization has this requirement, then it must

fully describe the required notification process in the CMS-approved marketing materials. In addition,

the MA organization must fully explain any continuation option to all potential members of the MA

local plan, current members of any other health plan of the MA organization members who reside in

the MA local plan service area and/or MA organization continuation area.

If a member who permanently moves from the service area into the continuation area does not choose

the continuation of enrollment option when he/she is eligible for the option, then the individual is no

longer eligible to be a member of the MA local plan, and the MA organization must initiate the

individual’s disenrollment. Procedures for continued enrollment are in §60.8 and procedures

describing disenrollment for permanent change of residence are described in §50.2.1.

20.8 - Additional Eligibility Requirements for MA Religious Fraternal Benefit

(RFB) Plans

An MA RFB plan is a plan that an RFB society may offer only to members of the church, or

convention or group of churches with which the society is affiliated. The requirement for membership

can be met by any documentation establishing membership issued by the church, or by using the

church’s records of membership. An individual must also meet all the other requirements to elect an

MA plan.

20.9 - Eligibility Requirements for Medicare Medical Savings Account (MSA)

Plans

There are additional requirements and limitations for individuals who wish to elect a Medicare

Medical Savings Account (MSA) plan. An individual is not eligible to elect a Medicare MSA plan if

any one of the following applies:

• The individual will reside in the United States for fewer than 183 calendar days during the year

in which the enrollment request is effective;

• The individual is enrolled in a Federal Employees Health Benefits program, or is eligible for

health care benefits through the Department of Veterans Affairs or the Department of Defense;

• The individual is dual eligible and is entitled to coverage of Medicare premium and/or cost-

sharing under a Medicaid State plan;

• The individual is receiving hospice benefits under the Medicare benefit prior to completing the

enrollment request; or

• The individual receives health benefits that cover all or part of the annual Medicare MSA

deductible such as through insurance primary to Medicare, supplemental insurance policies not

specifically permitted under 42 CFR 422.104, or retirement health benefits.

20.10 - Additional Eligibility Requirements for Enrollment in MA Special Needs

Plans

MA Special Needs Plans (SNP) must limit enrollment to individuals who meet specified eligibility

requirements in addition to the eligibility requirements in §20 of this chapter. To be eligible for

enrollment in a SNP an individual must meet the eligibility requirements for the specific SNP. Refer to

Chapter 16-B of the Medicare Managed Care Manual for additional information regarding special

needs plan requirements.

Before processing an enrollment into a dual eligible SNP (D-SNP), the SNP must confirm eligibility,

including both MA eligibility and Medicaid eligibility. Acceptable proof of Medicaid eligibility can be

a current Medicaid card, a letter from the state agency that confirms entitlement to Medical Assistance,

or verification through a systems query to a State eligibility data system. The aforementioned

documents or State systems verifications are acceptable proof of Medicaid entitlement for

beneficiaries residing in the 50 states and the District of Columbia. Only where a state Medicaid

agency requires a Social Security number to verify Medicaid status may the SNP enrollment request

mechanism include a field for this element. An individual’s current eligibility for the Medicare Part D

Low Income Subsidy (LIS) or any other Medicaid status flag in CMS systems are not acceptable for

initial or ongoing Medicaid eligibility verification for the purposes of determining dual eligible SNP

eligibility. For current enrollees, the SNP must verify continuing eligibility (e.g. full or partial dual

status, as applicable) at least as often as the state Medicaid agency conducts re-determinations of

Medicaid eligibility.

Medicaid subset SNPs may enroll only those dual eligible individuals who meet all applicable MA

eligibility requirements and are eligible to enroll in the organization’s Medicaid managed care plan, as

described in the organization’s State contract.

For enrollments into an institutional SNP (I-SNP), the organization must confirm that the individual

requires an institutional (skilled nursing facility (SNF), nursing facility (NF), SNF/NF, intermediate

care facility for the mentally retarded (ICF/MR) or inpatient psychiatric facility) level-of-care, and that

the need for an institutional level-of-care has lasted 90 days or longer. When an institutional SNP opts

to enroll special needs individuals prior to a 90 day length-of-stay, the needs-assessment (pre-

approved by CMS) must show that the individual’s condition makes it likely that the length-of-stay (or

need for an institutional level-of-care) will be at least 90 days.

For enrollments into a chronic condition SNP (C-SNP), the organization must contact the provider or

provider’s office to confirm that the individual has the qualifying condition. The organization must

obtain this information in one of the following two ways:

1) Contact the provider or provider’s office and obtain verification of the condition prior to

enrollment, or

2) Utilize a CMS-approved pre-enrollment qualification assessment tool prior to enrollment and

obtain verification of the condition from the provider or provider’s office on a post-enrollment

basis.

For either method, verification from the provider can be in the form of a note from a provider or the

provider’s office, or documented telephone contact with the provider or provider’s office confirming

that the individual has the condition. The organization may need to obtain written permission

(separately from the enrollment form) permitting it to contact the beneficiary’s provider’s office to

obtain verification of the condition.

If the organization chooses to use a CMS-approved prequalification assessment tool, it has until the

end of the first month of enrollment to confirm that the enrollee has the qualifying condition necessary

for enrollment into the severe/chronic disabling condition SNP. If it cannot confirm that the enrollee

has the qualifying condition within that time, the organization has the first seven calendar days of the

following month (i.e., the second month of enrollment) in which to send the beneficiary notice of his/

her disenrollment at the end of that month for not having the qualifying condition. Disenrollment is

effective at the end of the second month of enrollment; however, the organization must retain the

member if confirmation of the qualifying condition is obtained at any point during the second month

of enrollment. In the event the organization submits a disenrollment request to CMS prior to

confirming the qualifying condition, a reinstatement request must be submitted to CMS (or its

designee). The beneficiary has an SEP that begins with the month of notification and continues

through the two following months to enroll in another MA organization for a prospective effective

date. This SEP allows a beneficiary time to find a new plan while reducing the potential for incurring a

late enrollment penalty.

EXAMPLE: A beneficiary submits a request to enroll in a SNP effective March 1st. The SNP

uses a CMS-approved prequalification assessment tool in February and attempts to confirm the

beneficiary’s special needs status but is unable to do so by March 31st. Between April 1st and

April 7

(inclusive), the SNP must send a notice of prospective disenrollment to the beneficiary

indicating April 30th as the disenrollment date. If the beneficiary fails to select a new plan by

April 30th, his/her SEP will continue through June 30

. S/he can enroll in a plan effective June

1st or July 1

30 - Election Periods and Effective Dates

42 CFR 422.62 & 422.68

(Rev. 1, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

In order for an MA organization to accept an election, a valid request must be made during an election

period (see §10 for the definition of “election”). It is the responsibility of the organization to determine

the election period of each enrollment or disenrollment request. To make this determination, the

organization may need to contact the individual directly. The plan may incorporate specific statements

regarding eligibility of an election period with the enrollment or disenrollment request (see Exhibit 1a

for optional use with enrollment mechanisms). However, if this information is not provided with the

request, the plan must attempt to contact the individual by phone or other communication mechanism,

and determine within the seven (7) day requirement if s/he is eligible to make an election at that time

(see Exhibits 5 & 11a). Use of Exhibit 5 for the sole purpose of requesting information regarding an

applicant’s eligibility for an election period must include a due date that is no later than seven calendar

days from the date the enrollment request was received.

Enrollment requests the plan is not denying must be submitted to CMS within seven (7) calendar days

of the plan’s receipt of the completed enrollment request. (Section 40.3)

Note: An organization’s determination about an individual’s eligibility for an election period is

separate from a determination regarding whether an enrollment/disenrollment request is complete. See

Section 40.2.2 for information pertaining to incomplete enrollment requests.

There are six types of election periods during which individuals may make enrollment requests. They

are:

• Annual Election Period (AEP);

• Initial Coverage Election Period (ICEP);

• Initial Enrollment Period for Part D (IEP for Part D)

• Open Enrollment Period for Institutionalized Individuals (OEPI)

• Special Election Periods (SEP); and

• Medicare Advantage Open Enrollment Period ( MA OEP)

Unless a CMS-approved capacity limit or a CMS-issued enrollment sanction applies, all MA

organizations must accept requests to enroll in their MA plans (with the exception of Medicare MSA

plans) during the AEP, an ICEP, an IEP for Part D (MA-PD plans only), the MA OEP and any SEP

that allows enrollment into the specific plan. (Refer to §30.7 for election periods for Medicare MSA

plans.) When an MA plan is closed due to a capacity limit, the MA plan must remain closed to all

For MA, allows enrollment requests for MA-PD plans only.

The employer/union establishes criteria for its retirees to

participate in the employer/union sponsored MA plan. These criteria are exclusive of and in addition to the eligibility

criteria for MA enrollment. 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.

prospective enrollees (with the exception of reserved vacancies) until the limit is lifted. Refer to §30.9

and §30.9.1 for more information on OEPI plan closures, capacity limits and reserved vacancies.

30.1 - Annual Election Period (AEP)

During the AEP, MA eligible individuals may enroll in or disenroll from an MA plan. The last

enrollment request made, determined by the application date, will be the enrollment request that takes

effect (refer to §60.1 for information on multiple transactions).

Beginning in 2011, the AEP is from October 15 through December 7 of every year. The AEP is also

referred to as the “Fall Open Enrollment” season and the “Open Enrollment Period for Medicare

Advantage AND Medicare prescription drug coverage” in Medicare beneficiary publications and other

tools. MA organizations may use these descriptions of the AEP in their member materials, as well as

in materials for prospective members.

Note: An employer/union sponsored MA plan may have an “open season” as determined by the

employer. This may or may not correspond with the AEP. Therefore, organizations are not required to

accept enrollment requests into employer/union plans during the AEP (unless the AEP and open

season occur simultaneously); however, organizations must accept valid requests for disenrollment.

30.2 - Initial Coverage Election Period (ICEP)

The ICEP is the period during which an individual newly eligible for MA may make an initial

enrollment request to enroll in an MA plan. This period begins three months immediately before the

individual’s first entitlement to both Medicare Part A and Part B and ends on the later of:

1. The last day of the month preceding entitlement to both Part A and Part B, or;

2. The last day of the individual’s Part B initial enrollment period.

The initial enrollment period for Part B is the seven (7) month period that begins 3 months before the

month an individual meets the eligibility requirements for Part B, and ends 3 months after the month

of eligibility. See 42 CFR 407.14 for additional information.

Once an ICEP enrollment request is made and enrollment takes effect, the ICEP election has been

used.

EXAMPLES

• Mrs. Donovan’s 65

birthday is June 20, 2009. She is eligible for Medicare Part A and Part B

beginning June 1, 2009 and has decided to enroll in Part B beginning on June 1. Her ICEP

begins on March 1, 2009 and ends on September 30, 2009.

•

Mrs. Smith’s 65

birthday is April 20, 2008. She is eligible for Medicare Part A and Part B

beginning April 1, 2008. Because she is still working and has health insurance provided by her

employer, she has decided not to enroll in Part B during her initial enrollment period for Part B.

Upon retiring, she will have the opportunity to enroll in Part B (through a Part B SEP). She has

enrolled in Part B effective May 1, 2009. Her ICEP would be February 1 through April 30,

2009.

Please note that the ICEP for an MA enrollment election will frequently relate to either the

individual’s 65th birthday or the 25th month of disability, but it must always relate to the individual’s

entitlement to both Medicare Part A and Part B. When an individual enrolls in an MA-PD plan, s/he

has used both the ICEP and the IEP for Part D (see §30.2.1).

30.2.1 - Initial Enrollment Period for Part D (IEP for Part D)

The Initial Enrollment Period for Part D (IEP for Part D) is the period during which an individual is

first eligible to enroll in a Part D plan. In general, an individual is eligible to enroll in a Part D plan

when he or she is entitled to Part A OR is enrolled in Part B, AND permanently resides in the service

area of a Part D plan. Ultimately, CMS provides a part D eligibility effective date and maintains it in

CMS systems.

At the beginning of the Medicare prescription drug coverage program, all current Part D eligible

individuals had an IEP for Part D that began on November 15, 2005, and ended on May 15, 2006.

During the IEP for Part D, individuals may make one Part D enrollment choice, including enrollment

in an MA-PD plan.

Generally, individuals will have an IEP for Part D that is the same period as the Initial Enrollment

Period for Medicare Part B. The initial enrollment period for Part B is the seven (7) month period that

begins 3 months before the month an individual meets the eligibility requirements for Part B, and ends

3 months after the month of eligibility. See 42 CFR 407.14 for additional information.

EXAMPLE: Mr. Hackerman’s 65th birthday is March 23, 2010. He is currently working, and

while he signed up for his Medicare Part A benefits, effective March 1, 2010, he declined his

enrollment in Part B, given his working status. He is eligible for Part D since he has Part A and

lives in the service area. Even though he did not enroll in Part B, his Part B IEP is still the 3

months before, the month of, and the 3 months following his 65th birthday – that is, December

2009 – June 2010. Hence, his IEP for Part D is also December 2009 – June 2010.

Individuals not eligible to enroll in a Part D plan at any time during their initial enrollment period for

Medicare Part B have an IEP for Part D that is the 3 months before becoming eligible for Part D, the

month of eligibility, and the three months following eligibility for Part D.

EXAMPLE: Mr. Duke lived in Italy at the time of his 65

birthday, which occurred on August

3, 2008. His Part B initial enrollment period began on May 1, 2008, and ended November 30,

2008. He plans to return to the U.S. to reside permanently in June 2010. Since he lived out of

the U.S. and was not eligible to enroll in a Part D plan during his IEP for Part B, his initial

enrollment period for Part D will occur when he meets all the eligibility requirements for Part D,

that is, when he has Part A or B and resides in a Part D plan service area. His IEP for Part D is

March 2010 – September 2010.

Individuals eligible for Medicare prior to age 65 (such as for disability) will have another Initial

Enrollment Period for Part D based upon attaining age 65.

The ICEP and the IEP for Part D occur together as one period when a newly Medicare eligible

individual has enrolled in BOTH Part A and B at first eligibility. Should an individual delay

enrollment in Part B to a later time, the ICEP and IEP for Part D become separate with the ICEP

changing to then occur as the 3 months immediately preceding entitlement to BOTH parts A and B.

If a Medicare entitlement determination is made retroactively eligibility for Part D begins with the

month in which the individual received notification of the retroactive entitlement decision. Therefore,

the Part D IEP begins the month the individual receives the notice of the Medicare entitlement

determination and continues for three additional months after the month the notice is provided. The

effective date is generally the first day of the month after the organization receives a completed

enrollment request.

In MA context, the IEP for Part D applies only to MA-PD enrollment requests. Accordingly, when an

applicant has both the ICEP and IEP for Part D available to him/her, the organization must submit the

transaction to CMS as an IEP for Part D election. Refer to Chapter 3 of the Medicare Prescription

Drug Benefit Manual for additional information regarding Part D election periods.

30.3 - Open Enrollment Period for Institutionalized Individuals (OEPI)

The OEPI is continuous for eligible individuals. For purposes of enrollment under the OEPI election

period, an institutionalized individual is defined as an individual who moves into, resides in, or moves

out of an institution, as defined in §10. The OEPI ends two months after the month the individual

moves out of the institution.

Special Note for SNP enrollment: In addition, the OEPI is available for individuals who meet

the definition of “institutionalized” to enroll in or disenroll from an MA SNP for institutionalized

individuals.

An MA eligible institutionalized individual can make an unlimited number of MA enrollment requests

during the OEPI. An MA organization is not required to accept requests to enroll into its plan during

the OEPI, but if it is open for these enrollment requests, it must accept all OEPI requests to enroll into

the plan.

Since the OEPI is continuous for eligible individuals, Original Medicare is also open continuously.

Therefore, MA organizations must accept requests for disenrollment from their MA plans during the

OEPI whether or not the MA plan is open to accept enrollment.

Please note the definition of “institution” here differs from that used in determining when an

institutionalized full-benefit dual eligible qualifies for the low-income subsidy copayment level of

zero.

30.4 - Special Election Period (SEP)

42 CFR 422.62(b)

(Rev. 1, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

Special election periods constitute periods outside of the usual IEP, AEP or MA OEP when an

individual may elect a plan or change his or her current plan election. As detailed below, there are

various types of SEPs, including SEPs for dual eligibles, and for individuals whose current plan

terminates, who change residence and who meet “exceptional conditions” as CMS may provide,

consistent with §1851(e)(4) of the Act and §422.62(b) of the MA regulations.

Depending on the nature of the particular special election period, an individual may:

• Discontinue an enrollment in an MA plan and enroll in Original Medicare

• Switch from Original Medicare to an MA plan

• Switch from one MA plan to another MA plan

Certain SEPs are limited to an enrollment or disenrollment request. If the individual disenrolls from

(or is disenrolled from) the MA plan and changes to Original Medicare, the individual may

subsequently elect a new MA plan within the SEP time period. Once the individual has elected the

new MA plan, the SEP ends for that individual even if the time frame for the SEP is still in effect. In

other words, the SEP for the individual ends when the individual elects a new MA plan or when

the SEP time frame ends, whichever comes first, unless specified otherwise within an SEP.

Note: An individual’s eligibility for an SEP provides an opportunity to make an election but does not

convey eligibility to enroll in the plan; an individual must also meet all applicable MA eligibility

criteria.

It is generally the responsibility of the organization to determine whether the individual is eligible for

an SEP. The exception to this determination requirement would be enrollment and disenrollment

requests completed or approved by CMS staff. To make this determination, the organization may need

to contact the individual directly. The plan may incorporate specific statements regarding eligibility of

an SEP with the enrollment or disenrollment request (see Exhibit 1a for optional use with enrollment

mechanisms and Exhibit 10a for optional use with disenrollment forms). However, if this information

is not provided with the request, the plan must contact the individual to determine if they are eligible

to make an election at that time. Unless stated otherwise in this guidance, the organization MUST

accept an individual’s verbal or written confirmation regarding the conditions that make him or her

eligible for the SEP. Determination of eligibility for some SEPs requires that the organization obtain

the date on which the individual’s circumstances changed (i.e. change in residence, loss of special

needs status, etc.). Organizations that obtain this information on the enrollment or disenrollment

request are not required to obtain an additional verbal or written confirmation of SEP eligibility.

For enrollment requests obtained during a face-to-face interview or telephone request, the

determination of SEP eligibility can be made at that time. For enrollment requests made using paper,

or via an electronic enrollment mechanism or the Medicare OEC (without accompanying CMS

approval), the organization is not required to contact the applicant to confirm SEP eligibility if the

enrollment request includes the applicant’s attestation of SEP eligibility.

If SEP eligibility is obtained orally (by phone or in person), the organization must document this

contact and retain this information with the enrollment or disenrollment record. If the organization

obtains this confirmation through a written notice, such notice must afford the beneficiary the option

of calling the organization and confirming this information verbally. If the organization is not able to

obtain SEP eligibility information from the applicant, the organization must deny the enrollment or

disenrollment request and provide the individual a denial notice (see Exhibit 7).

The following are examples of questions that might be used to determine eligibility for an SEP:

Type of SEP?

Examples of Questions

Change in Residence

Have you recently moved? If so, when? Where did

you move from?

Employer/Union Group Health

Plan (EGHP)

Do you currently have (or are leaving) coverage

offered by an employer or union? Have you recently

lost such coverage?

Disenroll from Part D to Enroll

in Creditable Coverage

Are you a member of TriCare? Do you have or want

to obtain VA benefits?

Full Dual Eligible or Other Low

Income Subsidy

Do you currently have Medicaid coverage? Does

your state pay for your Medicare premiums?

Do you receive SSI cash benefits without Medicaid?

Did you receive a letter from Medicare letting you

know that you automatically qualify for extra help?

How much do you pay for your prescriptions?

Retroactive notice of Medicare

entitlement

Have you recently received a notice telling you that

you have been approved for Medicare for a

“retroactive” date? If so, when did you receive this

notice?

PACE

For enrollment – are you currently enrolled in a

special plan called “PACE”?

CMS/State Assignment

Have you recently received a blue letter (i.e.,

Reassignment notice) from Medicare?

Did your state/plan send you a letter to let you know

they are moving you to a different plan?

Did you recently receive a yellow letter (i.e., Auto-

enrollment notice) from Medicare?

Have you recently received a green letter (i.e.,

Facilitated Enrollment notice) from Medicare?

Change in Dual/LIS Status

Have you recently gained/lost coverage under

Medicaid?

Did you recently receive a grey letter (i.e., Loss of

Deemed Status notice) from Medicare?

Did you recently receive an orange letter (i.e.,

Change in Extra Help Co-Payment notice) from

Medicare?

Did you recently receive a purple letter (i.e., Deemed

Status notice) from Medicare?

Please note that the time frame of an SEP denotes the time frame during which an individual may

make an enrollment or disenrollment request. It does not necessarily correspond to the effective date

of coverage. For example, if an SEP exists for an individual from May - July, then an MA organization

must receive an enrollment request from that individual sometime between May 1 and July 31 in order

to consider the enrollment request an SEP enrollment request. However, the type of SEP will dictate

what the effective date of coverage may be.

Individuals who disenroll from an MA plan to Original Medicare during an SEP may be provided

Medigap guaranteed issue rights. These rights are not afforded to those individuals who enroll into an

MA plan during an SEP. MA organizations are required to notify members of these guaranteed issue

rights when members disenroll to Original Medicare during a SEP. See §§50.1.7 and 50.2 for the

additional information regarding these notification requirements

The time frames and effective dates for SEPs are discussed in the following sections. SEPs apply to

local and regional MA plans unless otherwise specifically stated. Corresponding Part D SEPs are

provided in separate PDP Enrollment guidance.

30.4.1 - SEPs for Changes in Residence

An SEP for a change in residence exists for these scenarios:

1) individuals who are no longer eligible to be enrolled in an MA plan due to a change in

permanent residence outside of the MA plan service area;

2) individuals who were not eligible for MA because they were incarcerated and have now

been released, or;

3) individuals who will have new Medicare health or Part D plans available to them as a result

of a permanent move.

The SEP permits enrollment elections only; it begins on either the date of the permanent move or on

the date the individual provides notification of such move. Since individuals who do not permanently

reside in the plan service area are ineligible for the plan and must be disenrolled, a SEP is not needed

to effectuate an involuntary disenrollment for that reason (see §50.2.1). Individuals who move and

have new Medicare health or Part D plans available to them as a result of the move, but continue to

reside in the current plan service area, may use this SEP to enroll in any MA or Part D plan for which

they are eligible in their new place of residence. It is the individual’s responsibility to notify the MA

organization that he/she is permanently moving.

When the individual notifies the organization of a permanent move out of the plan service area, the

SEP begins either the month before the individual’s permanent move, if the individual notifies the

organization in advance, or the month the individual provides the notice of the move, if the individual

has already moved. The SEP continues for two months following the month it begins or the two

months following the month of the move, whichever is later.

If the organization learns from CMS or another source (as described in §50.2.1.3) that the individual

has been out of the service area for over six months and the organization has not been able to confirm

otherwise with the individual, the SEP starts at the beginning of the sixth month and continues through

to the end of the eighth month.

The enrollment effective date is determined by the date the MA organization receives the enrollment

request. The individual may choose an effective date of up to three months after the month in which

the MA organization receives the enrollment request. However, the effective date may not be earlier

than the date the individual moves to the new service area and the MA organization receives the

enrollment request.

EXAMPLE 1

A beneficiary is a member of an MA plan in Florida and intends to move to Arizona on June 18.

A SEP exists for this beneficiary from May 1 - August 31.

A. If an MA organization in Arizona receives an enrollment request from the beneficiary in

May, the beneficiary can choose an effective date of July 1, August 1, or September 1.

B. If the MA organization receives the enrollment request from the beneficiary in June (the

month of the move), the beneficiary can choose an effective date of July 1, August 1, or

September 1.

C. If the MA organization receives the enrollment request in July, the beneficiary could choose

an effective date of August 1, September 1, or October 1.

EXAMPLE 2

A beneficiary resides in Florida and is currently in Original Medicare and not enrolled in an MA

plan. The individual intends to move to Maryland on August 3. An SEP exists for this

beneficiary from July 1 through October 31.

At the time the individual makes the enrollment request into an MA plan, the individual must provide

the specific address where the individual will permanently reside upon moving into the service area, so

that the MA organization can determine that the individual meets the residency requirements for

enrollment in the plan.

Disenrollment from Previous MA Plan

Please keep in mind that a member of an MA plan who moves permanently out of the service area

must be involuntarily disenrolled from the plan, unless continuation of enrollment applies. A member

of an MA plan who is out of the service area for more than six months must be involuntarily

disenrolled from the plan.

CMS has established an SEP that allows an individual adequate time to choose a new MA plan, given

the fact that the individual will no longer be enrolled in the original MA plan after the month of the

move or after the sixth month (whichever is appropriate). Unless an individual enrolls in a new MA

plan with an effective date of the month after the move or the beginning of the seventh month (e.g., the

individual moves on June 18 and enrolls in a new plan effective July 1), he/she will be enrolled in

Original Medicare until he/she elects the new MA plan during a valid enrollment period. If the

individual had Part D coverage and lost it due to the involuntary disenrollment, s/he may be subject to

a Part D late enrollment penalty (LEP). See Chapter 4 of the Medicare Prescription Drug Manual for

more information.

30.4.2 - SEPs for Contract Violation

In the event an individual is able to demonstrate to CMS that the MA organization offering the MA

plan of which he/she is a member substantially violated a material provision of its contract under MA

in relation to the individual, or the MA organization (or its agent) materially misrepresented the plan

when marketing the plan, the individual may disenroll from the MA plan and elect Original Medicare

or another MA plan. The SEP will begin once CMS determines that a violation has occurred. Its length

will depend on whether the individual immediately elects a new MA plan upon disenrollment from the

original MA plan or whether the individual initially elects Original Medicare before choosing a new

MA plan.

We note that in some case-specific situations, CMS may process a retroactive disenrollment for these

types of disenrollments. If the disenrollment is not retroactive:

• A SEP exists such that an individual may elect another MA plan or Original Medicare during

the last month of enrollment in the MA organization, for an effective date of the month after

the month the new MA organization receives the enrollment request.

EXAMPLE

On January 16, CMS determines, based on a member’s allegations, that the MA organization

substantially violated a material provision of its contract. As a result, the member will be

disenrolled from the MA plan on January 31. A SEP exists for this beneficiary beginning

January 16 and lasting until the end of January. The beneficiary promptly applies for a new

MA plan, and the new MA organization receives the enrollment form on January 28 for a

February 1 effective date.

• If the individual in the above example elected Original Medicare during the last month of

enrollment in the MA organization (either by choosing Original Medicare or by not choosing

an MA plan and therefore defaulting to Original Medicare), the individual will be given an

additional 90 calendar days from the effective date of the disenrollment from the MA

organization to elect another MA plan. During this 90-day period, and until the individual

elects a new MA plan, the individual will be enrolled in Original Medicare. The individual may

choose an effective date into a new MA plan beginning any of the three months after the month

in which the MA organization receives the enrollment request. However, the effective date

may not be earlier than the date the MA organization receives the enrollment request.

EXAMPLE

On January 16, CMS determines, based on a member’s allegations that the MA organization

substantially violated a material provision of its contract. The member decides to return to

Original Medicare. As a result, the member is disenrolled from the MA plan on January 31 and

enrolled in Original Medicare with a February 1 effective date. A 90-day SEP continues to

exist for the beneficiary from February 1 through April 30. In this example, a new MA

organization then receives an enrollment request from the individual on April 15. The

beneficiary can choose an effective date of May 1, June 1, or July 1.

If the disenrollment is retroactive, CMS will provide the beneficiary with the time frame for his/her

SEP to elect another plan on a case-by-case basis. Depending on the circumstances surrounding the

contract violation, CMS may determine a retroactive enrollment into another MA plan is warranted.

30.4.3 - SEPs for Non-renewals or Terminations

In general, SEPs are established to allow members affected by non-renewals or terminations ample

time to elect a new plan. Effective dates during these SEPs are described below. CMS has the

discretion to modify this SEP as necessary for any non-renewals or terminations when the

circumstances are unique and warrant a modified SEP.

• Non-renewals - A SEP exists for members of MA plans that will be affected by plan or contract

non-renewals and plan service area reductions that are effective January 1 of the contract year. In

order to provide sufficient time for members to evaluate their options, the SEP begins December

8 and ends on the last day in February of the following year.

Enrollment requests received from December 8 through December 31 will have an effective date

of January 1. Enrollment requests received in January will have an effective date of February 1.

Enrollment requests received in February will have an effective date of March 1.

• MA organization Termination of Contract and Terminations/Contract Modifications by

Mutual Consent - A SEP exists for members of plans who will be affected by a termination of

contract by the MA organization or a modification or termination of the contract by mutual

consent (42 CFR §§422.512 and 422.508(a)(1)). The SEP begins two months before the

proposed termination effective date, and ends one month after the month in which the

termination occurs.

Please note that if an individual does not elect an MA plan before the termination effective date,

he/she will be defaulted to Original Medicare on the effective date of the termination. However,

the SEP will still be in effect for one month after the effective date of the termination should the

individual wish to subsequently elect an MA plan (for a current, not retroactive, effective date).

Beneficiaries affected by these types of terminations may request an effective date of the month

after notice is given, or up to two months after the effective date of the termination. However, the

effective date may not be earlier than the date the new MA organization receives the enrollment

request.

EXAMPLE

If an MA organization contract terminates for cause on April 30, an SEP lasts from March 1

through May 31. In this scenario, a beneficiary could choose an effective date of April 1, May 1,

or June 1; however, the effective date may not be earlier than the date the new MA organization

receives the enrollment request.

• CMS Termination of MA organization Contract - A SEP exists for members of plans that will

be affected by MA organization contract terminations by CMS (42 CFR 422.510). The SEP

begins 1 month before the termination effective date and ends 2 months after the effective date of

the termination.

Please note that if an individual does not elect an MA plan before the termination effective date,

he/she will be defaulted to Original Medicare on the effective date of the termination. However,

the SEP will still be in effect for two months after the effective date of the termination should the

individual wish to subsequently elect an MA plan (for a current, not retroactive, effective date).

Beneficiaries affected by these types of terminations may select an effective date of up to three

months after the month of termination. However, the effective date may not be earlier than the

date the new MA organization receives the enrollment request.

EXAMPLE

If CMS terminates an MA organization contract effective June 30, an SEP lasts from June 1

through August 31. In this scenario, a beneficiary could choose an effective date of July 1,

August 1, or September 1; however, the effective date may not be earlier than the date the new

MA organization receives the enrollment request.

• Immediate Terminations By CMS - CMS will establish the SEP during the termination process

for immediate terminations by CMS (42 CFR 422.510(b)(2)), where CMS provides notice of

termination to an MA plan’s members and the termination may be mid-month.

Note: Approved plan consolidations are neither terminations nor non-renewals. Thus individuals

affected by plan consolidations are not eligible for the SEP for non-renewals or terminations. Please

see the annual CMS Call Letter and other CMS end-of-year guidance for more information about

approved plan consolidations.

30.4.4 - SEPs for Exceptional Conditions

42 CFR 422.62(b)(4)

(Rev. 2, Issued: August 12, 2020; Effective/Implementation: 01-01-2021)

CMS has the legal authority to establish SEPs when an individual or group of individuals meets

exceptional conditions specified by CMS, including on a case-by-case basis. The SEPs CMS has

established include:

1. SEP EGHP (Employer/Union Group Health Plan)

42 CFR 422.62(b)(4)

An SEP exists for individuals making MA enrollment requests into or out of employer sponsored MA

plans, for individuals to disenroll from an MA plan to take employer sponsored coverage of any kind,

and for individuals disenrolling from employer sponsored coverage (including COBRA coverage) to

elect an MA plan. The SEP EGHP may be used when the EGHP allows the individual to make

changes in their health coverage choices, such as during the employer’s or union’s “open season,” or

at other times the employer or union allows. This SEP is available to individuals who have (or are

enrolling in) an employer or union sponsored plan and ends 2 months after the month the employer or

union coverage ends.

The individual may choose an effective date of up to three months after the month in which the

individual completed an enrollment or disenrollment request; however, the effective date may not be

earlier than the first of the month following the month in which the request was made. The effective

date also may not be earlier than the first day of the individual’s entitlement to both Medicare Part A

and Part B.

NOTE: If necessary due to the employer’s or union’s delay in forwarding the completed

enrollment request to the MA organization, the MA organization may process the enrollment

request with a retroactive effective date, as outlined in §60.6. Keep in mind that all MA eligible

individuals, including those in EGHPs, may elect MA plans during the AEP and ICEP and during

any other SEP. The SEP EGHP does not eliminate the right of these individuals to make

enrollment requests during these election periods.

Refer to §30.6 for additional information for situations in which an individual is determined eligible

for more than one election period, one of which includes the SEP EGHP.

2. SEP for Individuals Who Disenroll in Connection with a CMS Sanction

42 CFR 422.62(b)(5)

On a case by case basis, CMS will establish an SEP for individuals enrolled in an MA plan offered by

an MA organization that has been sanctioned by CMS who elect to disenroll in connection with the

matter that gave rise to that sanction. The start/length of the SEP, as well as the effective date, is

dependent upon the situation. The SEP starts with the imposition of the sanction and ends when the

sanction ends or when the individual makes an election, whichever occurs first.

CMS may require the MA organization to notify current enrollees that if the enrollees believe they are

affected by the matter(s) that gave rise to the sanction, the enrollees are eligible for a SEP to elect

another MA plan or disenroll to original Medicare and enroll in a PDP.

3. SEP for Individuals Enrolled in Cost Plans that are Non-renewing their Contracts

42 CFR 422.62(b)(6)

An SEP will be available to Medicare beneficiaries who are enrolled in an HMO or CMP under a

§1876 cost contract that will no longer be offered in the area in which the beneficiary resides.

Beneficiaries electing to enroll in an MA plan via this SEP must meet MA eligibility requirements.

This SEP begins December 8 of the current contract year and ends on the last day of February of the

following year.

Enrollment requests received from December 8 through December 31 will have an effective date of

January 1. Enrollment requests received in January will have an effective date of February 1.

Enrollment requests received in February will have an effective date of March 1.

4. SEP for Individuals in the Program of All-inclusive Care for the Elderly (PACE)

42 CFR 422.62(b)(7)

Individuals may disenroll from an MA plan at any time in order to enroll in PACE. In addition,

individuals who disenroll from PACE have an SEP to elect an MA plan. The SEP ends 2 months after

the effective date of PACE disenrollment.

5. SEP for Dual-eligible Individuals and Other LIS-Eligible Individuals–

42 CFR 423.38(c)(4)

(Rev. 1, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

There is an SEP for individuals who have Medicare Part A and Part B and receive any type of

assistance from the Title XIX (Medicaid) program. This includes both “full benefit” dual eligible

individuals as well as individuals often referred to as “partial duals” who receive cost sharing

assistance under Medicaid (e.g. QMB-only, SLMB-only, etc.) and individuals who qualify for LIS

(but who do not receive Medicaid benefits).

This SEP begins the month the individual becomes dually-eligible and exists as long as he or she

receives Medicaid benefits; however there are limits in how often it can be used. This SEP allows an

individual to enroll in, or disenroll from, an MA plan once per calendar quarter during the first nine

months of the year. This SEP can be used once during each of the following time periods:

• January – March,

• April – June, and

• July – September.

It may not be used in the 4

quarter of the year (October – December).

The SEP is considered “used” based on the month in which the individual makes the election (i.e.,

application date of the enrollment request). If the plan receives an election in March (which would be

effective April 1

), this counts as “using” the SEP for the 1

quarter, not the 2

quarter.

The effective date of an enrollment request made using this SEP is the first of the month following

receipt of an enrollment request.

NOTES:

• As described in § 40.1.5, the effective date for auto-enrollments of full-benefit dual-eligible

individuals may be retroactive.

• Organizations need to check for prior uses of the SEP via the BEQ or MARx UI to determine

eligibility.

• CMS will reject enrollment transactions for individuals who have already used this SEP in the

calendar quarter.

Use of this SEP is separate from, and in addition to, the SEPs outlined in #12 in this section (SEP for

Individuals who Lose or Have a Change in their Dual or LIS-Eligible Status) and § 30.4.7 (SEP for

Individuals Who Have Been Enrolled into a Plan by CMS or the State). If a dual or other-LIS eligible

beneficiary is making an election and is also eligible for another SEP, the organization should use the

other SEP instead of this SEP.

Limitation for “At-Risk” and “Potential At-Risk” Beneficiaries:

Once an individual is identified by the MA-PD organization as a “potential at-risk” or “at-risk”

beneficiary and the plan sponsor has sent written notice to the individual, he or she cannot use this

SEP to change plans while this designation is in place. The notice to the individual explains that this

SEP is no longer available. Additional information on drug management programs is available at

www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/RxUtilization.html

Duration of Limitation – This limitation starts as of the date on the initial notice provided to the

“potential at-risk” beneficiary. The chart below outlines when the limitation ends:

Situation

SEP limitation ends

Plan decides not to identify the “potential at-

risk” beneficiary as an “at-risk” beneficiary

60 days from the date on the initial notice, or the

date the beneficiary receives notice of the plan’s

decision, if earlier.

The “potential at-risk” or “at-risk” beneficiary

identification is subsequently removed by the

The date that the designation is removed by the

plan or upon effectuation of a favorable appeal

Situation

SEP limitation ends

plan or through beneficiary’s favorable appeal of

an “at-risk” determination

The plan determines the beneficiary is “at-risk”

12 months from the date the individual is

determined to be “at-risk”

The plan extends the “at-risk” designation

beyond the initial 12 months

24 months from the date the individual is

determined to be “at-risk”

NOTE: This is the maximum consecutive time

the SEP limitation can be imposed for each “at-

risk” limitation a sponsor implements.

The limitation ends based on whichever situation occurs first. If a plan sponsor removes the

individual’s status as an “at-risk” beneficiary or the designation expires, the plan may subsequently

determine that the individual is “potentially at-risk” again, in accordance with the requirements for

drug management programs in 42 CFR 423.153(f)(1). Consequently, the SEP would, once again, not

be available to the individual based on the date the plan sends the new notification. For more

information on “potentially at-risk” or “at-risk” designations, see

www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/RxUtilization.html

NOTE: Organizations need to check for this designation via the BEQ or MARx UI to determine

eligibility. The enrollment limitation for a “potential at-risk” or an “at-risk” individual will not apply

to other Part D enrollment periods, including the AEP or other SEPs.

6. SEP for Individuals Who Terminated a Medigap Policy When They Enrolled For the First

Time in an MA Plan, and Who Are Still in a “Trial Period”

42 CFR 422.62(b)(8)

For Medicare beneficiaries who terminated a Medigap policy when they enrolled for the first time in

an MA plan, §1882(s)(3)(B)(v) of the Act provides a guaranteed right to purchase another Medigap

policy if they disenroll from the MA plan while they are still in a “trial period.” In most cases, a trial

period lasts for 12 months after a person enrolls in an MA plan for the first time.

This SEP is for individuals who are eligible for “guaranteed issue” of a Medigap policy under

§1882(s)(3)(B)(v) of the Act upon disenrollment from the MA plan in which they are enrolled. This

SEP allows a qualified individual to make a one-time election to disenroll from their first MA plan to

join Original Medicare at any time of the year. The SEP begins upon enrollment in the MA plan and

ends after 12 months of enrollment or when the beneficiary disenrolls from the MA plan, whichever is

earlier.

7. SEP for Individuals with ESRD Whose Entitlement Determination Made Retroactively

42 CFR 422.62(b)(9)

If a Medicare entitlement determination is made for a retroactive effective date, an individual has not

been provided the opportunity to elect an MA plan during his/her ICEP. Therefore, these individuals

will be allowed to elect an MA plan for a prospective effective date.

This would also be allowed in cases when there is an administrative delay and the entitlement

determination is not made timely. For example, an individual who performs self-dialysis will have

his/her entitlement date adjusted to begin at the time of dialysis, rather than the customary 3-month

period AFTER dialysis begins.

The SEP begins the month the individual receives the notice of the retroactive Medicare entitlement

determination and continues for 2 additional calendar months after the month the notice is received.

The enrollment effective date is the first day of the month after the MA plan receives the enrollment

request. This SEP is not available after December 31, 2020.

8. SEP for Individuals Whose Medicare Entitlement Determination Made Retroactively

42 CFR 422.62(b)(10)

If a Medicare entitlement determination is made for a retroactive effective date, an individual has not

been provided the opportunity to elect an MA plan during his/her ICEP. Therefore, these individuals

will be allowed to elect an MA plan for a prospective effective date. This would also be allowed in

cases when there is an administrative delay and the entitlement determination is not made timely by

SSA and/or received by the individual in a timely manner.

The SEP begins the month the individual receives the notice of the retroactive Medicare entitlement

determination and continues for two additional calendar months after the month the notice is received.

The effective date is the first day of the month after the MA plan receives the enrollment request.

9. MA SEPs to Coordinate With Part D Enrollment Periods – Individuals eligible for an

enrollment period under the guidance for Part D enrollment and disenrollment may use that SEP to

make an election into or out of an MA-PD plan (as applicable). Most Part D SEPs are duplicated in the

MA program as described above; however, those that are not described elsewhere are provided here:

A. Involuntary loss of creditable coverage, including a reduction in the level of coverage so that it

is no longer creditable, not including any such loss or reduction due to a failure to pay

premiums. The SEP permits enrollment into an MA-PD and begins when the individual is

advised of the loss of (or reduction in) creditable coverage. The SEP ends two calendar

months after either the loss (or reduction) occurs or the individual received notice, whichever is

later. The effective date of this SEP is the first of the month after the election is made or, at the

beneficiary’s request, may be up to 3 months prospective. (42 CFR 422.62(b)(19))

B. Individuals who are not adequately informed of a loss of creditable coverage, or that they never

had creditable coverage, have an SEP that permits one enrollment in, or disenrollment from, an

MA-PD plan. CMS determines eligibility for this on a case-by-case basis, based on its

determination that an entity offering prescription drug coverage failed to provide accurate and

timely disclosure of the loss of creditable prescription drug coverage or whether the

prescription drug coverage offered is creditable. This SEP begins the month of CMS approval

of this SEP and continues for two additional calendar months following this approval. (42 CFR

422.62(b)(20))

C. Individuals whose enrollment or non-enrollment in a Part D plan is erroneous due to an action,

inaction or error by a Federal Employee. The SEP permits disenrollment and/or enrollment in a

Part D plan on a case-by-case basis. Requests for this SEP must be developed and presented to

the CMS Regional Office serving the MA-PD plan for which the SEP will apply. This SEP

begins the month of CMS approval of this SEP and continues for two additional months

following this approval. (42 CFR 422.62(b)(21))

D. An individual eligible for an additional Part D IEP, such as an individual currently entitled to

Medicare due to a disability and who is attaining age 65, has an MA SEP to coordinate with the

additional Part D IEP. The SEP may be used to disenroll from an MA-only or MA-PD plan to

Original Medicare, or to enroll in an MA-only plan (regardless of whether the individual uses

the Part D IEP to enroll in a PDP). The SEP begins and ends concurrently with the

additional Part D IEP. (42 CFR 422.62(b)(22))

For more information about PDP enrollment and disenrollment, please refer to the CMS guidance for

PDPs.

10. SEP for Individuals Who Lose Special Needs Status

42 CFR 422.62(b)(11)

CMS will provide an SEP for individuals enrolled in a SNP who are no longer eligible for the SNP

because they no longer meet the specific special needs status. This SEP begins the month the

individual’s special needs status changes and ends when he or she makes an enrollment request or

three calendar months after the effective date of involuntary disenrollment from the SNP, whichever is

earlier.

11. SEP for Individuals Who Belong to a Qualified SPAP or Who Lose SPAP Eligibility

42 CFR 422.62(b)(12)

Individuals who belong to a qualified State Pharmaceutical Assistance Program (SPAP) are eligible

for an SEP to request enrollment in an MA-PD plan at any time through the end of each calendar year

(i.e. once per year). SPAP members may use this SEP to enroll in a Part D plan outside of existing

enrollment opportunities, allowing them, for example, to join an MA-PD plan upon becoming a

member of an SPAP or to switch to another MA-PD plan. In summary, a beneficiary may use this SEP

to switch from an MA-PD plan to another MA-PD plan, from Original Medicare without a PDP to an

MA-PD plan, from a PDP to another PDP or MA-PD plan or from an MA-only plan (no prescription

drug coverage) to an MA-PD plan. This SEP is available while the individual is enrolled in the SPAP

and, upon loss of eligibility for SPAP benefits, for an additional 2 calendar months after either the

month of the loss of eligibility or notification of the loss, whichever is later.

12. SEP for Individuals who Gain, Lose, or Have a Change in their Dual or LIS-Eligible Status–

42 CFR 423.38(c)(9)

(Rev. 1, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

An SEP is provided for individuals who receive “Extra Help.” It includes those who:

• Become eligible for any type of assistance from the Title XIX program (including “partial

duals” who receive cost sharing assistance under Medicaid) and individuals who qualify for

LIS (but who do not receive Medicaid benefits);

• Lose eligibility for any type of assistance; and

• Have a change in the level of assistance they receive (e.g., stop receiving Medicaid benefits,

but still qualify for LIS, those who have a change in cost sharing, or become eligible for

additional Medicaid benefits [e.g., when an individual newly qualifies as needing nursing

home level of care and thus becomes eligible for certain Medicaid long term supports and

services, or becomes eligible for full Medicaid after having previously been eligible for

Medicaid coverage of Medicare premiums or cost-sharing]).

The SEP allows the individual one opportunity to make an election within three months of any of the

changes noted above, or notification of such a change, whichever is later. The effective date for

enrollments under this SEP is the first day of the month following receipt of the enrollment request by

the plan.

NOTE: Use of this SEP does not count towards the once per calendar quarter limitation outlined in

SEP #5 in this section.

13. SEP for Enrollment Into a Chronic Care SNP and for Individuals Found Ineligible for a

Chronic Care SNP

42 CFR 422.62(b)(13)

CMS will provide an SEP for those individuals with severe or disabling chronic conditions to enroll in

a SNP designed to serve individuals with those conditions. This SEP is available while the individual

has the qualifying condition(s); it ends upon enrollment in the chronic care SNP. Once the SEP ends,

that individual may make enrollment changes only during applicable MA election periods. In addition,

individuals enrolled in a Chronic Care SNP who have a severe/disabling chronic condition which is

not a focus of their current SNP are eligible for this SEP. Such individuals have an opportunity to

enroll in a Chronic Care SNP that focuses on this other condition. Eligibility for this SEP ends at the

time the individual enrolls in the new SNP.

Individuals who are found after enrollment not to have the qualifying condition necessary to enroll in a

Chronic Care SNP will have an SEP to enroll in a different MA-PD plan or an MA-only plan with

accompanying Part D coverage. This would normally occur when the required post enrollment

verification with a provider did not confirm the information provided on the pre-enrollment

assessment tool. This SEP begins when the plan notifies the individual of the lack of eligibility and

extends through the end of that month as well as the following two calendar months. The SEP ends

when the individual makes an enrollment election or on the last day of the second of the two calendar

months following notification. Any enrollments made during this election period are for prospective

effective dates.

14. SEP for Disenrollment from Part D to Enroll in or Maintain Other Creditable Coverage

42 CFR 422.62(b)(14)

Individuals may disenroll from an MA-PD plan) to enroll in or maintain other creditable drug

coverage (such as TriCare or VA coverage). The effective date of disenrollment is the first day of the

month following the month a disenrollment request is received by the MA organization. Additionally,

individuals enrolled in an MA-PD plan who have or are enrolling in other creditable coverage may use

this SEP to disenroll from the MA-PD plan by enrolling in an MA-only plan.

15. SEP to Enroll in an MA Plan, PDP or Cost Plan With a Plan Performance Rating of Five (5)

Stars

42 CFR 422.62(b)(15)

An eligible individual may enroll in an MA plan offered by an MA organization with a Star Rating of

5 Stars during the year in which that plan has the 5-star overall performance rating, provided the

enrollee meets the other requirements to enroll in that plan (e.g., living within the service area).

Individuals may use the 5-Star SEP to disenroll from a Medicare Advantage plan by enrolling in a 5-

Star cost plan that is open for enrollment.

As overall ratings are assigned for the plan contract year (January through December), possible

enrollment effective dates are the first of the month from January 1 to December 1 during the year for

which the plan has been assigned an overall performance rating of 5 stars. An individual may use this

SEP only one time from December 8 through November 30 of the following year in which the

organization has been granted a 5-star overall rating. The enrollment effective date is the first of the

month following the month in which the plan receives the enrollment request.

EXAMPLE: Plan X has an overall rating of 4.5 stars in 2020 and 5 stars for 2021. An

individual could use this SEP to request enrollment in Plan X beginning December 8, 2020 for

an effective date of January 1, 2021. An individual could not use the SEP to enroll in Plan X for

an effective date on or before December 1, 2020, as the enrollment effective dates available

during that period are prior to the calendar year for which Plan X has been assigned a 5-star

overall rating.

EXAMPLE: Plan Y has an overall rating of 5 stars for 2020 but has lost that 5-star rating for

2021. A beneficiary could use this SEP to request enrollment in Plan Y for the first of the

following month until November 30, 2020, with the last possible effective date available being

December 1, 2020. The beneficiary could not use the SEP to enroll in Plan Y on or after

December 1, 2020, as the enrollment effective dates available during that period are after the

calendar year for which Plan Y has been assigned a 5-star overall rating.

An individual using this SEP can enroll in an MA-only or an MA-PD plan, even if coming from

Original Medicare (with or without concurrent enrollment in a PDP). Individuals enrolled in a plan

with a 5-star overall rating may also switch to a different plan with a 5-star overall rating. An

individual in an MA-only or MA-PD coordinated care plan who switches to a PDP with a 5-star

overall rating will lose MA coverage and will revert to Original Medicare for basic medical coverage.

Regardless of whether the individual has Part D coverage prior to use of this SEP, any individual who

enrolls in a 5-star MA Private Fee-for-Service plan without prescription drug coverage or a 5-star cost

plan is eligible for a coordinating Part D SEP to enroll in a PDP. (See Chapter 3, Section 30.3.8 #8,

letter H, of the Medicare Prescription Drug Benefit Manual for more information.)

Note that use of this SEP does not guarantee Part D coverage. If an individual in either an MA-PD

plan or a PDP chooses to enroll in an MA-only coordinated care plan with a 5-star overall rating, that

individual would lose Part D coverage and must wait for a subsequent enrollment period to obtain Part

D coverage under the normal enrollment rules. Late enrollment penalties might also apply.

Individuals may use the 5-Star SEP to disenroll from an MA plan by enrolling in a 5-Star cost plan

that is open for enrollment.

EXAMPLE: A cost plan has an overall rating of 5 stars for 2020 and is open for enrollment. An

individual enrolled in a MA plan uses this SEP to enroll in the cost plan. The cost plan submits the

enrollment transaction to MARx using the “R” election type code, and the MA plan accepts and

processes the subsequent disenrollment per the Daily Transaction Reply Report (DTRR).

16. SEP for Non-U.S. Citizens who become Lawfully Present

42 CFR 422.62(b)(16)

CMS will provide an SEP for non-U.S. citizens who become lawfully present in the United States.

The individual may use this SEP to request enrollment in any MA plan for which he or she is eligible,

including an MA-PD. This SEP begins the month the individual attains lawful presence starts and

ends the earlier of when the individual makes an enrollment request or two (2) full calendar months

after the month it begins.

17. SEP for Providing Individuals who Requested Materials in Accessible Formats Equal Time

to Make Enrollment Decisions

42 CFR 422.62(b)(17)

(Rev. 2, Issued: August , 2020; Effective/Implementation: 01-01-2021)

As outlined in Section 504 of the Rehabilitation Act of 1973 (Section 504), organizations are required

to comply with its requirements, and provide materials in accessible formats to its members. This

generally includes formats such as Braille, Data, and Audio files, or other formats accepted by the

member in place of, or in addition to, the original print material.

A SEP is available to an individual who was adversely affected by having requested, but not received,

required notices or information in an accessible format within the same timeframe that the MA

organization or CMS provided the same information to individuals who did not request an accessible

format. This limited SEP ensures that beneficiaries who have requested information in accessible

formats are not disadvantaged by any additional time necessary to fulfill their request, including

missing an election period deadline.

The SEP begins at the end of the election period during which the beneficiary was seeking to make an

election. The length of the SEP is at least as long as the time it took for the information to be provided

to the individual in an accessible format. Organizations may determine eligibility for this SEP when

the criterion is met, ensuring adequate documentation of the situation, including records indicating the

amount of time taken to provide accessible versions of the requested materials and the amount of time

it takes for the same information to be provided to an individual who does not request an accessible

format. Individuals seeking assistance for this SEP may also contact 1-800-MEDICARE.

18. SEP for Government Entity-Declared Disaster or Other Emergency

42 CFR 422.62(b)(18)

(Rev. 2, Issued: August 12, 2020; Effective/Implementation: 01-01-2021)

A SEP exists for individuals affected by a disaster or other emergency declared by a Federal, state or

local government entity who were unable to, and did not make an election during another valid

election period. This includes both enrollment and disenrollment elections. Individuals are eligible for

this SEP if they:

• Reside, or resided at the start of the SEP eligibility period described in this guidance, in an area

for which a federal, state or local government entity has declared a disaster or other

emergency or they do not reside in an affected area but rely on help making healthcare

decisions from one or more individuals who reside in an affected area; and

• Were eligible for another election period at the time of the SEP eligibility period; and

• Did not make an election during that other valid election period due to the disaster or other

emergency.

The SEP starts as of the date the declaration is made, the incident start date or, if different, the start

date identified in the declaration, whichever is earlier. The SEP ends 2 full calendar months following

the end date identified in the declaration or, if different, the date the end of the incident is announced,

whichever is later.

19. SEP for Individuals Enrolled in a Plan Placed in Receivership

42 CFR 422.62(b)(24)

A SEP exists for individuals enrolled in a plan offered by an MA organization that has been placed

into receivership by a state or territorial regulatory authority.

The SEP begins the month the receivership is effective and continues until it is no longer in effect or

until the enrollee makes an election, whichever occurs first. When instructed by CMS, the MA plan

that has been placed under receivership must notify its enrollees, in the form and manner directed by

CMS,

of the enrollees’ eligibility for this SEP and how to use the SEP.

20. SEP for Individuals Enrolled in a Plan That Has Been Identified by CMS as a Consistent Poor

Performer

42 CFR 422.62(b)(25)

A SEP exists for individuals enrolled in a plan that has been identified with the low performing icon in

accordance with 42 CFR 422.166(h)(1)(ii). This SEP exists while the individual is enrolled in the low

performing MA plan.

21. SEP for Other Exceptional Circumstances

422.62(b)(26)

CMS will establish a SEP, on a case by case basis, for individuals whom CMS determines have

experienced exceptional circumstances related to enrollments into or disenrollments from an MA plan

that are not otherwise captured in regulation. Consistent with current practice, CMS will consider

granting an enrollment or disenrollment opportunity in situations such as the following:

• Circumstances beyond the beneficiary’s control that prevented him or her from submitting a

timely request to enroll or disenroll from a plan during a valid election period. This is

inclusive of, but not limited to, a serious medical emergency of the beneficiary or his or her

authorized representative during an entire election period, a change in hospice status, or

mailed enrollment or disenrollment requests returned as undeliverable on or after the last day

of an enrollment period.

• Situations in which a beneficiary provides a verbal or written allegation that his or her

enrollment in a MA or Part D plan was based upon misleading or incorrect information

provided by a plan representative or State Health Insurance Assistance Program (SHIP)

counselor, including situations where a beneficiary states that he or she was enrolled into a

plan without his or her knowledge or consent, and requests cancellation of the enrollment or

disenrollment from the plan.

• A SEP may be warranted to ensure beneficiary access to services and where without the

approval of an enrollment exception, there could be adverse health consequences for the

beneficiary. This is inclusive of, but not limited to, maintaining continuity of care for a chronic

condition and preventing an interruption in treatment.

CMS will review supporting details and documentation to determine eligibility for the SEP for

exceptional circumstances. CMS’s review can be in response to an individual beneficiary’s request for

an exception to the current enrollment rules, as well as CMS’ determination that an exception is

warranted for a group of beneficiaries.

The SEP would take effect once CMS makes its determination and the enrollee has been notified. The

effective date for an enrollment or disenrollment election using an approved enrollment exception

would be based on the beneficiary’s circumstances and may be either prospective or retroactive.

30.4.5 - SEPs for Beneficiaries Age 65 (SEP65)

MA eligible individuals who elect an MA plan (other than an MSA plan) during the initial enrollment

period (IEP) for Part B surrounding their 65th birthday have an SEP. This “SEP65” allows the

individual to disenroll from this MA plan and elect the Original Medicare plan any time during the 12-

month period that begins on the effective date of coverage in the MA plan.

The IEP for Part B is established by Medicare and begins 3 months before and ends 3 months after the

month of the individual’s 65th birthday. Individuals entitled to Medicare prior to age 65 are not

eligible for the SEP65.

30.4.6 – SEP for Significant Change in Provider Network

42 CFR 422.62(b)(23)

(Rev. 1, Issued: August 12, 2020; Effective/Implementation: 01-01-2021)

CMS will establish a SEP, on a case by case basis, for situations in which CMS determines that

changes to an MA plan’s provider network are significant based on the affect, or potential to affect,

current plan enrollees who are assigned to, are currently receiving care from, or who have received

care within the past 3 months from a provider or facility being terminated from the provider network.

The SEP can be used only once per significant change in provider network. It begins the month

enrollees are notified of eligibility for the SEP and continues for an additional two calendar months

thereafter.

30.4.7 – SEP for CMS and State-Initiated Enrollments

42 CFR 422.60(g)(5) and 423.38(c)(10)

(Rev. 1, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

Individuals who are enrolled into a plan by CMS or a State (i.e., through passive enrollment, auto-

enrollment, facilitated enrollment, and reassignment) have an SEP to disenroll from their new plan or

enroll into a different plan. The SEP permits a onetime election within three months of the effective

date of the assignment, or notification of the assignment, whichever is later. It allows the individual to

make an election before the enrollment is effective in the receiving plan or after the coverage in the

receiving plan starts. This SEP must be used within three months of the start of coverage in the

receiving plan. In the case where the notice is sent after the coverage in the receiving plan starts, the

SEP ends three months after the date of the notice. This SEP is provided so that an individual may

exercise any mandatory “opt-out” right provided to the enrollee as part of the CMS or State-initiated

enrollment.

The effective date for enrollments under this SEP is the first day of the month following receipt of the

enrollment request by the plan.

Individuals passively enrolled due to a plan’s non-renewal or termination (outlined in § 20.4.2) may

also be eligible for an SEP as outlined in § 30.4.3 of this Chapter.

30.5 – Medicare Advantage Open Enrollment Period (MA OEP)

42 CFR 422.62(a)(3)

(Rev. 2, Issued: August 12, 2020; Effective/Implementation: 01-01-2021)

During the MA OEP, MA plan enrollees may enroll in another MA plan or disenroll from their MA

plan and return to Original Medicare. Individuals may make only one election during the MA OEP.

This chart outlines who can use the MA OEP and when:

Who can use the MA OEP:

MA OEP occurs:

Individuals enrolled in an MA plan

January 1 – March 31

New Medicare beneficiaries who are enrolled in

an MA plan during their ICEP

The month of entitlement to Part A

and Part B – the last day of the 3rd

month of entitlement

Individuals enrolled in an MA plan may add or drop Part D coverage during the MA OEP. Individuals

enrolled in either MA-PD or MA-only plans can switch to:

• MA-PD

• MA-only

• Original Medicare (with or without a stand-alone Part D plan)

The effective date for an MA OEP election is the first of the month following receipt of the enrollment

request.

NOTE: The MA OEP does not provide an opportunity for an individual enrolled in Original Medicare

to join a MA plan. It also does not allow for Part D changes for individuals enrolled in Original

Medicare, including those enrolled in stand-alone Part D plans. The MA OEP is not available for those

enrolled in Medicare Savings Accounts or other Medicare health plan types (such as cost plans or

PACE).

30.6 - Effective Date of Coverage

42 CFR 422.68(c)

(Rev. 2, Issued: August 12, 2021; Effective/Implementation: 01-01-2021)

With the exception of some SEPs and when election periods overlap, generally beneficiaries may not

request their enrollment effective date. Furthermore, except for EGHP enrollment requests, the

effective date is generally not prior to the receipt of an enrollment request by the MA organization. An

enrollment cannot be effective prior to the date the beneficiary or his/her legal representative

completed the enrollment request. The effective date may not be earlier than the first day of the

individual’s entitlement to both Medicare Part A and Part B. §40.2 includes procedures for handling

situations when a beneficiary chooses an unallowable enrollment effective date.

To determine the proper effective date, the MA organization must determine which election period

applies to each individual before the enrollment may be transmitted to CMS. The election period may

be determined by reviewing information such as the individual’s date of birth, Medicare card, a letter

from SSA, or by the date the enrollment request is received by the MA organization.

Once the election period is identified by the MA organization, the MA organization must determine

the effective date. Refer to §60.8 to determine the effective date for a continuation of enrollment. In

certain circumstances, EGHP enrollments may be retroactive (refer to §60.6 for more information on

EGHP retroactive effective dates).

Effective dates are as follows:

Election Period

Effective Date of

Coverage

Do MA organizations have to

accept enrollment requests in

this election period?

Initial Coverage

Election Period

and Initial

Enrollment Period

for Part D

First day of the month of

entitlement to Medicare Part

A and Part B – or-

The first of the month

following the month the

enrollment request was made

if after entitlement has

occurred.

Yes – unless capacity limit applies

(see §30.9 for capacity limit

information). IEP for Part D is

applicable only to MA-PD enrollment

requests.

Open Enrollment

Period for

Institutionalized

Individuals (OEPI)

First day of the month after

the month the MA

organization receives an

enrollment request

No - the MA organization can choose

to be “open” or “closed” for

enrollments during this period.

Annual Election

Period

January 1 of the following

year

Yes – unless capacity limit applies

Special Election

Period

First day of the month after

the month the MA

organization receives an

enrollment request, unless

otherwise noted.

Yes – unless capacity limit applies

Medicare

Advantage Open

Enrollment Period

(MA OEP)

First day of the month after

the month the MA

organization receives an

enrollment request

No - the MA organization can choose

to be “open” or “closed” for

enrollments during this period.

It is possible for an individual to make an enrollment request when s/he is eligible for more than one

election period, resulting in more than one possible effective date. Therefore, if an organization

receives an enrollment request and determines the applicant is eligible for more than one election

period, the organization must allow the individual to choose the enrollment effective date (see

exception in the next paragraph regarding the ICEP). To accomplish this, the organization must

attempt to contact the individual, and must document its attempt(s), to determine the individual’s

preferred effective date. Note: This requirement does not apply to beneficiary requests for enrollment

into an employer/union sponsored plan using the group enrollment mechanism, as these may be

submitted to CMS with the EGHP SEP election type code.

If one of the election periods for which the individual is eligible is the ICEP, the individual may not

choose an effective date any earlier than the month of entitlement to Medicare Part A and Part B.

EXAMPLE

If an individual will be entitled to Medicare Part A and Part B in February his ICEP is November

through May. If an MA organization receives an enrollment request from that individual during

the AEP, the individual may NOT choose a January 1 effective date and must be given a February

1 effective date for the ICEP because January 1st is earlier than the month of entitlement to

Medicare Part A and Part B.

If an individual is eligible for more than one election period but does not indicate a preferred effective

date or the organization is unable to contact the individual, the organization must assign an effective

date using the following ranking of election periods. The election period with the highest rank

generally determines the effective date of enrollment (refer to §30.7 for procedures to determine the

effective date of voluntary disenrollment).

Individuals eligible for the SEP EGHP and one or more other election periods who make an election

via the employer or union election process will be assigned an effective date according to the SEP

EGHP, unless the individual requests a different effective date that is allowed by one of the other

elections periods for which s/he is eligible.

Ranking of Election Periods: (1 = Highest, 5 = Lowest)

1. ICEP/IEP-D

2. MA OEP

3. SEP

4. AEP

5. OEPI

30.6.1 - Effective Date of Auto- and Facilitated Enrollments

The effective dates for auto-enrollment and facilitated enrollment are described in §40.1.5 of this

chapter.

30.7 - Effective Date of Voluntary Disenrollment

42 CFR 422.68

(Rev. 1, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

With the exception of some SEPs and when election periods overlap, generally beneficiaries may not

select their effective date of disenrollment. §50.1 includes procedures for handling situations when a

beneficiary chooses a disenrollment effective date that is not allowable based on the requirements

outlined in this section.

When a member disenrolls through the MA organization or 1-800-MEDICARE, the disenrollment will

return the member to Original Medicare. If a member elects a new MA plan while still a member of a

different plan, he/she will automatically be disenrolled from the old plan and enrolled in the new plan

by CMS systems with no duplication or delay in coverage.

As with enrollments, it is possible for a member to make a disenrollment request when more than one

election period applies. Therefore, in order to determine the proper effective date, the MA organization

must determine which election period applies to each member before the disenrollment may be

transmitted to CMS.

If an MA organization receives a disenrollment request when more than one election period applies,

the MA organization must allow the member to choose the effective date of disenrollment. If the

member does not make a choice of effective date, then the MA organization must give the effective

date that results in the earliest disenrollment.

Effective dates for voluntary disenrollment are as follows (refer to §§50.2 and 50.3 for effective dates

for involuntary disenrollment).

Election

Period

Effective Date of

Disenrollment*

Do MA organizations have

to accept disenrollment

requests in this election

period?

Medicare

Advantage Open

Enrollment Period

First day of the month after the

month the MA organization

receives the disenrollment

request.

Yes

Annual Election

Period

January 1 of the following year. Yes

Special Election

Period

Varies, as outlined in §30.4 Yes

Open Enrollment

Period for

Institutionalized

Individuals

First day of the month after the

month the MA organization

receives the disenrollment

request.

Yes

*NOTE: CMS may allow up to 90 days retroactive payment adjustments for EGHP disenrollments.

Refer to §60.6 for more information.

30.8 - Election Periods and Effective Dates for Medicare MSA Plans

42 CFR 422.56, 422.62(d)

(Rev. 1, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

Individuals may enroll in Medicare MSA plans (should one be offered in their area) only during the

ICEP or the AEP; they may not enroll in Medicare MSA plans during a SEP (see exception below).

The effective date of coverage is determined by the election period in which an enrollment request is

made. Effective dates are provided in §30.6 of this chapter.

Individuals may disenroll from Medicare MSA plans only during the AEP or an SEP. The effective

date of disenrollment during an SEP depends on the type of SEP. Additionally, MSA enrollees may

not use the MA OEP to disenroll from the MSA.

Exception: To facilitate the offering of employer/union sponsored MSA plans, CMS will permit

individuals to request enrollment into an employer/union sponsored MSA plan using the

Employer Group Health Plan Special Enrollment Period (EGHP SEP).

30.9 - Closed Plans, Capacity Limits, and Reserved Vacancies

42 CFR 422.60(a)(2), 422.60(b) and 422.66(d)(2)

(Rev. 1, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

An MA organization may specify a capacity limit for one or all of the MA plans it offers and reserve

spaces for individual and employer or union group commercial members who are converting from a

commercial product to an MA product at the time the member becomes eligible (i.e., conversion

enrollments). When an MA plan is closed due to a capacity limit, the MA plan must remain closed to

all prospective enrollees (with the exception of reserved vacancies) until space becomes available. All

requests from MA organizations for a capacity limit should be submitted to the CMS Regional Office

account manager.

All MA plans (with the exception of Medicare MSA plans; see §30.8) must accept enrollment requests

made during the AEP, ICEP and SEP unless an approved capacity limit applies. Only with an

approved number of reserved vacancies may an MA organization set aside openings for the enrollment

of conversions (i.e., ICEP enrollment requests).

Unlike the mandatory election periods (AEP, ICEP and SEP), an MA organization has the option to

voluntarily close one or more of its MA plans to OEP and OEPI enrollment requests. If an MA plan is

closed for OEP and OEPI enrollments, then it is closed to all individuals who are making OEP or

OEPI enrollment requests for that plan. All MA plans must accept OEP and OEPI disenrollment

requests, regardless of whether or not it is open for enrollment.

NOTE: For purposes of auto-enrollment and facilitated enrollment, MA organizations must

ensure that the MA-PD plans into which beneficiaries are deemed to have enrolled have the

capacity to accept them. Should a capacity limit be proposed for an MA-PD plan, it must be set

high enough to ensure all beneficiaries may be transitioned.

30.9.1 - MA Plan Closures

The decision to be open or closed for OEP and OEPI enrollment requests rests with the MA

organization and does not require CMS approval. However, if an MA organization has an MA plan

that is open for OEP and OEPI enrollment requests, and decides to change this process, it must notify

CMS and the general public 30 calendar days in advance of the new limitations on the open enrollment

process.

If an MA organization has more than one MA plan, those plans may be open or closed to OEP and

OEPI enrollment requests independent of one another, as the MA organization determines. Further,

each MA plan may be open for OEP and OEPI enrollment requests:

1. Only certain months of the year;

2. Some portion of certain months; and/or

3. During the first 25 days (or any part) of each month.

When an MA plan is voluntarily closed for OEP and OEPI enrollments, it is closed to ALL OEP and

OEPI enrollment requests, but it must accept enrollment requests made during the ICEP and SEP as

well as be open for the AEP, unless an approved capacity limit applies and has been reached

(excluding reserved vacancies). CMS may approve a partial service area closure for capacity reasons.

If a plan is closed in a portion of its service area for capacity reasons, that plan may be open for OEP

and OEPI enrollments in the remaining portion of the service area.

When an MA plan is closed due to an approved capacity limit that has been reached, it may continue

to accept ICEP (i.e., conversion) enrollments only if there are reserved vacancies set aside. If there are

no reserved vacancies, or once all of these vacancies have been filled, the MA organization cannot

accept any new enrollees into the MA plan until space becomes available. Refer to §40.5.1 for more

information on enrollment processing after reaching capacity.

Refer to §40.5 of this chapter for additional information on enrollment processing during closed

periods.

If an MA organization has an MA plan that is approved by CMS for a capacity limit, it should estimate

when a capacity limit will be reached and notify CMS and the general public 30 calendar days in

advance of the closing of the open enrollment process. If CMS approves the capacity limit for

immediate closing of enrollment, the MA organization must notify the general public within 15

calendar days of CMS approval that it has closed for enrollment.

Exhibit 23 contains three model notices that MA organizations can use to notify the public when they

are closing for enrollment. NOTE: Public notices must receive CMS approval under the usual

marketing review process.

When an MA organization has a plan that re-opens after being closed to OEP and OEPI enrollment

requests or as a result of a capacity limit, there is no requirement for the MA organization to notify the

general public. However, the MA organization should notify CMS when this occurs.

40 - Enrollment Procedures

42 CFR 422.66

(Rev. 1, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

An MA organization must accept enrollment requests it receives, regardless of whether they are

received in a face-to-face interview, by mail, by facsimile, or through other mechanisms defined by

CMS.

An individual (or his/her legal representative) must complete an enrollment request mechanism to

enroll in an MA plan and submit the enrollment request to the MA plan during a valid enrollment

period. If an individual wishes to elect another MA plan in the same parent organization, he/she must

complete a new enrollment request to enroll in the new MA plan. Enrollment may also be made via

Auto- and Facilitated enrollment processes as described in §40.1.5 of this chapter and via the group

enrollment process for employer or union sponsored plans as described in §40.1.6.

Upon receiving an enrollment request, an MA organization must provide within 10 calendar days, one

of the following:

• Acknowledgement notice (as described in section 40.4.1);

• Request for additional information (as described in 40.2.2); or

• Notice of denial (as described in 40.2.3).

If a plan uses the combined acknowledgment/confirmation notice, the plan may send the notice of

rejection within 7 calendar days of receiving the DTRR indicating a rejection instead of sending the

above items (as described in 40.4.2).

Unless otherwise directed in this guidance, the organization must provide required notices in response

to information received from CMS on the DTRR that contains the earliest notification.

MA organizations may not delay the processing of enrollment requests unless the beneficiary’s

enrollment request is being placed on a waiting list, as allowed under §40.5.

Refer to §40.2.5 for MA-PD enrollments in which an individual has other qualified prescription drug

coverage through an employer or union group.

Special Rule for the Annual Election Period (AEP):

Medicare Advantage (MA) organizations may not solicit submission of paper enrollment forms or

accept telephone or on-line enrollment requests prior to the beginning of the AEP. Brokers and agents

under contract to MA organizations may not accept or solicit submission of paper enrollment forms

prior to the start of the AEP. MA organizations and their brokers and agents also should remind

beneficiaries that they cannot submit enrollment requests prior to the start of the AEP.

Despite these efforts, CMS recognizes that MA organizations may receive unsolicited paper

enrollment forms prior to the start of the AEP, given that marketing activities may begin prior to this

date. To be considered unsolicited, the MA organization must have received the paper AEP

enrollment request directly from the applicant and not through a sales agent or broker. Other

enrollment request mechanisms may not be accepted prior to the actual start of the AEP. Paper AEP

enrollment requests received prior to the start of the AEP for which there is indication of sales agent or

broker involvement in the submission of the request (i.e., the name or contact information of a sales

agent or broker) must be investigated by the organization for compliance with the requirements in the

Medicare Communications and Marketing Guidelines. If an MA organization receives unsolicited

paper enrollment forms on or after October 1

but prior to the start of the AEP, it must retain and

process them as follows:

• Within 7 calendar days of the receipt of a paper enrollment request, the MA organization must

provide the beneficiary with a written notice that acknowledges receipt of the complete

enrollment request, and indicates that the enrollment will take effect on January 1 of the

following year (refer to Exhibits 4, 4a, 4b and 4c for model notices).

• For AEP enrollment requests received prior to the start of the AEP, the MA organization must

submit all transactions to CMS systems (MARx) on the first day of the AEP with an “application

date” of the same date. For example, unsolicited AEP paper enrollment requests received

October 1 through October 14 must be submitted on October 15

with an “application date” of

October 15

of the current year in the appropriate data field on the enrollment transaction. If a

beneficiary has submitted more than one AEP paper enrollment request prior to the start of the

AEP, the beneficiary will be enrolled in a plan based on the first application that is processed.

• Once the MA organization receives a MARx DTRR from CMS indicating whether the

individual’s enrollment has been accepted or rejected, it must meet the remainder of the

requirements (e.g., sending a notice of the acceptance or rejection of the enrollment within 10

calendar days following receipt of the DTRR from CMS) provided in §40.4.2.

Note: If organizations receive incomplete unsolicited AEP paper enrollment requests prior to the start

of the AEP, they must follow existing guidance for working with beneficiaries to complete the

applications (refer to §40.2.2).

Again, this policy applies only to the receipt of unsolicited paper enrollment forms prior to the

beginning of the AEP. To help ensure a successful AEP season, it is imperative that organizations

follow these steps and submit valid enrollment transactions promptly as directed.

40.1 - Format of Enrollment Requests

42 CFR 422.60(c)

Rev. 2, Issued: August 12, 2020; Effective/Implementation: 01-01-2021)

MA organizations must have, at minimum, a paper enrollment form process available for potential

enrollees to request enrollment in an MA plan.

In addition to the paper enrollment form, MA organizations have the option to accept enrollment

requests through other approved mechanisms as described in §§ 40.1.2, 40.1.3, 40.1.4 and 40.1.5

below.

40.1.1 - Enrollment Request Mechanisms

Rev. 1, Issued: August 12, 2020; Effective/Implementation: 01-01-2021)

The MA organization must use an enrollment mechanism that complies with CMS’ guidelines in

format and content.

Specific model enrollment forms have been developed for each plan type as follows:

Exhibit 1 - MA coordinated care plans

Exhibit 1b - MSA plans

Exhibit 1c - PFFS plans

Organizations should utilize the model appropriate to the plan type for all enrollment request

mechanisms to ensure all required elements are included. CMS has also developed a model EGHP

enrollment (Exhibit 2) for EGHP members, a model short enrollment form (“short form”) (Exhibit 3)

and a model plan selection form (Exhibit 3a) to allow for enrollment requests into another plan (PBP)

offered by the same parent organization. For determining the appropriate use of the short form or

model plan selection form, CMS defines parent organization as the contract numbers (H#) and legal

entities that are owned and operated by a single organization in a single State. As a result, a short

form or a model plan selection form may be used only for enrollment requests into another plan of the

same type (i.e., HMO to HMO, PPO to PPO, or PFFS to PFFS).

Organizations can utilize model enrollment forms included in Exhibits 1-3a, or choose to develop their

own materials using these models as a guide. Materials are subject to the CMS review and approval of

plan marketing materials.

In addition to the information collected on the request, the enrollment mechanism must include

information indicating that the applicant acknowledges--

• The requirement to keep Part A and B;

• That they will abide by the rules of the MA plan;

• The release of information to Medicare and other plans. Information may be used to track

enrollment and for other purposes, as allowed under federal law;

• That enrollment in the MA plan automatically disenrolls him or her from any other Medicare

health plan and prescription drug plan. Note: The model PFFS and MSA enrollment

mechanisms provide language as appropriate; and

• The right to appeal service and payment denials made by the organization.

Please refer to Appendix 2 for a complete listing of required elements that must be included on

enrollment mechanisms and Exhibits 1 – 3a for complete information on these statements.

The plan premium is not required to be displayed or disclosed on the enrollment mechanism unless it

is part of the plan name. Organizations may include the premium amount on the enrollment

mechanism if they choose to do so, but they must do so consistently for all PBPs listed on the

enrollment mechanism.

Special Needs Plans (SNPs) must include elements on the enrollment mechanism that correspond to

the special needs focus of the particular SNP.

Medical Savings Plans (MSA) must include elements on the enrollment form as provided in

Exhibit 1b.

No enrollment form or other enrollment request mechanism may include a question regarding binding

arbitration, whether the individual receives hospice coverage (except MSA plans) or any other health

screening information, with the exception of questions regarding nursing home status (some additional

exceptions apply for SNPs; please refer to §40.2, item “D” of this chapter).

Refer to §60.9 for requirements regarding retention of enrollment request mechanisms.

40.1.2 – Electronic Enrollment

42 CFR 422.60(c)

Rev. 1, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

MA organizations may develop and offer electronic enrollment mechanisms made available via an

electronic device or secure internet website.

The following standards, in addition to all other program requirements, apply to electronic enrollment

mechanisms:

• Submit all materials, web pages, and images (e.g. screen shots) related to the electronic enrollment

process for CMS approval following the established process for the review and approval of

marketing materials and other enrollment request mechanisms.

• Provide individuals with all the information required by Medicare regulations and communication

and marketing guidelines for the MA program.

• At a minimum, comply with CMS’ data security policies.

• Advise each individual at the beginning of the electronic enrollment process that he or she is

completing an actual enrollment request to the MA organization.

• Capture the same data as required on the model enrollment form (see Exhibit 1 and Appendix 2).

o For enrollment requests from one plan to another plan within the same parent organization,

the data required on the model short enrollment form are sufficient, provided the plan can

verify that the individual is currently enrolled in the parent organization at the time the

individual submits the enrollment request.

o Electronic ICEP enrollment requests from individuals enrolled in a non-Medicare plan

under the same organization (or parent organization) and transitioning to the MA plan

without a break in coverage may be based on the simplified opt-in enrollment mechanism

as described in § 40.1.9.

• As part of any electronic enrollment process, obtain an electronic signature from the applicant or

include a clear and distinct step that requires the applicant to activate an “Enroll Now,” or “I

Agree,” type of button or tool. By taking this affirmative step, the individual indicates his or her

intent to enroll. It must also be made clear to the applicant that, by taking this action, he or she

agrees to the release of information as provided on the model enrollment form (see Exhibit 1), and

attests to the truthfulness of the data provided. The process must also remind the individual of the

penalty for providing false information. See §40.2 for information about legally binding electronic

signatures.

• The electronic enrollment mechanism must capture an accurate time and date stamp at the time the

applicant executes the electronic signature or activates the step in the previous bullet (i.e. “Enroll

Now or I Agree” button or tool). The organization will use this data to establish the application

date for the enrollment request. This time stamp also marks the start of the seven day

timeframe for processing the enrollment request, as it is at this time that the enrollment

request is considered by CMS to be received by the MA organization.

• If a legal representative is completing this enrollment request, he or she must attest that he or she

has such authority to make the enrollment request and that proof of this authority is available upon

request by the MA organization or CMS.

• Inform the individual of the effects of completing the electronic enrollment, including that the

individual will be enrolled (if approved by CMS), and that he or she will receive notice (of

acceptance or denial) following submission of the enrollment to CMS.

• Include a tracking mechanism (e.g., a confirmation number) to provide the individual with

evidence that the MA organization has received the electronic enrollment request.

• Optionally, may request or collect premium payment or other payment information, such as a bank

account number or credit card numbers.

• Maintain electronic records that are securely stored and readily reproducible for the period

required in §60.9 of this chapter. The MA organization’s record of the enrollment request must

exist in a format that can be easily, accurately and quickly reproduced for later reference by each

individual member and/or CMS. A data extract file alone is not acceptable.

• Plans have the option of obtaining technical and related services from outside entities in support of

the MA organization’s electronic enrollment mechanism, (e.g. licensed software). MA

organizations may use downstream entities, such as a broker or third party website, as a means of

facilitating and capturing the electronic enrollment request. However, organizations retain

complete responsibility for ensuring enrollment policies in this guidance are followed, and for

ensuring the appropriate handling of any sensitive beneficiary information provided as part of the

online enrollment, including those facilitated by downstream entities.

• From the point at which an individual selects the plan of his or her choice on the third-party

website and begins the online enrollment process, CMS holds the organization responsible for the

security and privacy of the information provided by the applicant and for the timely disclosure of

any breaches.

Medicare Online Enrollment Center

In addition to the process described above, CMS offers an online enrollment center (OEC) through the

Medicare.gov

website and the 1-800-MEDICARE Call Center for enrollment into Medicare

Advantage plans (except for MSA) and Medicare prescription drug plans. The date and time

“stamped” by the Medicare OEC will serve as the application date for purposes of determining the

election period and enrollment effective date. MA organizations must promptly retrieve enrollment

requests from the OEC and should check for requests at least daily.

40.1.3 - Enrollment via Telephone

(Rev. 2, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

MA organizations may accept requests for enrollment into their MA plans via an incoming (in-bound)

telephone call to a plan representative or agent. MAOs may also accept enrollment requests during

communications initiated by the organization when, during the course of outreach to provide

information about their Medicare plan offerings to individuals with whom they have an existing

business relationship, the individual expresses a desire to enroll in one of the organization’s MA plans.

The following standards apply, in addition to all other applicable program requirements:

• Enrollment requests from individuals with whom the organization does not have an existing

business relationship may be accepted only during an incoming (or in-bound) telephone call

from a beneficiary. This includes inbound calls to an incorrect department or extension

transferred internally.

• For all telephonic enrollment requests, the MA organization must ensure that the telephonic

enrollment request is effectuated entirely by the beneficiary or his or her authorized

representative.

• Individuals must be advised that they are completing an enrollment request.

• Each telephonic enrollment request must be recorded (audio) and include a statement of the

individual’s agreement to be recorded, all required elements necessary to complete the

enrollment (as described in Appendix 2), and a verbal attestation of the intent to enroll. If the

request is made by someone other than the beneficiary, the recording must include the attestation

regarding the individual’s authority under State law to complete the request, in addition to the

required contact information. All telephonic enrollment recordings must be reproducible and

maintained as provided in section §60.9.

• Include a tracking mechanism to provide the individual with evidence that the telephonic

enrollment request was received (e.g. a confirmation number).

• Optionally, organizations may request or collect premium payment or other payment information

needed, such as a bank account number or credit card numbers, to process the form of premium

payment requested by the individual.

• A notice of acknowledgement and other required information must be provided to the individual

as described in §40.4.1.

• Telephonic enrollment requests into a plan offered by the same parent organization may be based

on the model short enrollment form (Exhibit 3) or the model plan selection form (Exhibit 3a)

instead of the comprehensive individual enrollment form.

• Telephonic ICEP enrollment requests from individuals enrolled in a non-Medicare plan under

the same organization (or parent organization) and transitioning from the non-Medicare plan to

the MA plan without a break in coverage may be based on the simplified opt-in enrollment

mechanism as described in § 40.1.9.

The MA organization must ensure that all MA eligibility and enrollment requirements provided in this

chapter are met. Scripts for completing an enrollment request in this manner must be developed by the

MA organization and submitted to CMS for review and approval. The scripts must contain the

required elements for completing an enrollment request as described in Appendix 2, and must receive

CMS approval in accordance with applicable Medicare regulations before use.

40.1.4 - Default Enrollment Option for Medicaid Managed Care Plan Enrollees

who are Newly Eligible for Medicare Advantage

42 CFR 422.66(c) and 422.68(a)

(Rev. 1, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

Subject to prior CMS approval, MA organizations may automatically enroll newly eligible Medicare

beneficiaries into a dual eligible MA special needs plan (D-SNP). 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 MA organization (or by

an entity under the same parent organization as the MA organization); and

• will remain in the Medicaid managed care plan upon their conversion to Medicare.

CMS approval of default enrollment

To qualify for default enrollment, an MA organization must have an affiliated Medicaid managed care

plan. An affiliated Medicaid managed care plan is one that is offered by the MA organization that also

offers the D-SNP (or is offered by an entity under the same parent organization as the MA

organization). The MA organization must be able to demonstrate:

• State approval for the use of a default enrollment process in its contract with the state Medicaid

agency; and

• State agreement to provide the information that is necessary for the MA organization to

identify individuals in their Medicaid managed care plan who are in their MA initial coverage

election period.

NOTE: Data provided by the State must include all information necessary to submit the enrollment

transaction to CMS (i.e., Medicare number, date of birth, etc.).

MA organizations 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 § 422.252) and must not

have any prohibition on new enrollment imposed by CMS. MA organizations must submit proposals

to their CMS Account Manager via HPMS and receive CMS approval before beginning any default

enrollments under this authority.

Proposals for default enrollment must include a description of the MA organization’s process to

identify individuals eligible for default enrollment, including:

• Those currently enrolled in a Medicaid managed care plan offered by the organization and who

are about to convert to Medicare;

• How the process ensures the organization will identify eligible individuals in time to provide

the required written notice to these individuals no fewer than 60 days prior to the date of their

initial Medicare eligibility (the conversion date); and

• How the process ensures identification of individuals whose upcoming Medicare eligibility is

based on disability as well as age.

Notice to individuals about automatic (default) enrollment

Proposals must include a copy of the required written notice and copies of any written, telephonic or

electronic outreach materials for CMS prior approval, as well as a description of the organization’s

outreach activity for its default enrollment process. The required written notice must include the

following:

• Information and materials required under § 422.111 for initial enrollments (e.g., Evidence of

Coverage and Summary of Benefits);

• Information on how to opt-out of (decline) the enrollment prior to the enrollment effective

date, and either enroll in Original Medicare or choose another MA plan. This must include the

opportunity to contact the MA organization either in writing or by telephone to a toll-free

number. The MA organization is prohibited from discouraging declination. The organization

will submit opt-out requests to CMS as enrollment cancellations;

• Information on the differences in premium, benefits, and cost sharing between the individual’s

current Medicaid managed care plan and the D-SNP;

• Information on the process for accessing care under the D-SNP; and

• A general description of alternative Medicare health and drug coverage options available to an

individual in his or her Initial Coverage Election Period.

Default enrollment process

The MA organization will send the enrollment transaction to CMS at the same time that it sends the

written notice (i.e., no fewer than 60 days prior to the conversion date). Default enrollment

transactions must be submitted with

election code type ‘J’ and must always use the first day of an

individual’s ICEP as the application date. The enrollment effective date must always be the date of the

individual’s first entitlement to both Medicare Part A and Part B. Opt-out requests received after

coverage begins are to be processed as disenrollment requests; once enrolled in the MA plan, these

individuals may use the MA OEP to either enroll in Original Medicare or choose another MA plan

(see § 30.4 for more information).

Approval Period

CMS may approve an MAO using the default enrollment for a period of up to five years. Such

approval shall continue after contract consolidations or other CMS-approved changes to the Plan

Benefit Package if the D-SNP continues to be offered by the same parent organization and continues

to meet all qualifying criteria for default enrollment. CMS may suspend or rescind approval prior to

the expiration of this period if CMS determines the MA organization is not in compliance with the

requirements of this section. An MA organization that wants to continue default enrollment after the

expiration of an approval period must re-apply and CMS must approve the request to use default

enrollment before the MA organization begins default enrollments again. MA organizations may not

continue to use default enrollment if they are pending a response from CMS at the time their approval

period expires.

40.1.5 - Auto- and Facilitated Enrollment

42 CFR 423.34

(Rev. 1, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

CMS requires that MA organizations offering both MA-PD and MA-only plans have a process for

auto- and facilitated enrollment. All LIS eligible individuals who elect an MA plan without Medicare

prescription drug benefits (“MA-only plan”) will be auto- or facilitated enrolled into an MA-PD plan

in the same organization or into a PDP offered by the same organization, unless the individual declines

the enrollment. The MA organization’s auto- and facilitated enrollment processes will occur monthly.

As noted in the preamble to the final regulation for Part D (Federal Register/Vol. 70, No. 18, January

28, 2005), the legal authority for both auto- and facilitated enrollment processes is technically termed

"facilitated" enrollment, since auto-enrollment is limited to PDPs. However, the term "auto-

enrollment" is used here to denote the process that applies to full-benefit dual eligible individuals, and

“facilitated enrollment” to others with LIS

CMS has safeguards in place to prevent existing MA and cost plan enrollees from being auto- or

facilitated enrolled by CMS into a PDP. However, there may be instances in which a beneficiary’s

request to enroll into an MA plan will not yet be reflected in CMS systems at the point in time when

CMS processes auto- or facilitated PDP enrollments. In these cases, the beneficiary will receive a

notice from CMS informing him/her that s/he has been enrolled into a PDP. However, once the

beneficiary’s request to enroll into the MA plan is processed by CMS, it will prevail over the

previously processed auto- or facilitated PDP enrollment submitted by CMS.

Please note this section does not apply to MA organizations that offer only MA-PD plans, as all their

enrollees already have Part D coverage. Nor does it apply to PFFS plans offered by organizations that

do not offer any MA-PD plans (these beneficiaries are included in the standard CMS auto/facilitated

enrollment process into PDPs), nor to MA organizations in the U.S. territories, including Puerto Rico,

or to employer sponsored MA plans.

Starting January 1, 2010, CMS implemented the Limited Income Newly Eligible Transition (Limited

Income NET) demonstration, which modified its procedures for auto/facilitating enrollment of LIS

beneficiaries into PDPs for those who have retroactive enrollment effective dates. That demonstration

does not impact the auto/facilitated requirements for MA organizations as specified in this section,

except for MA-PFFS plans that autoenroll new full benefit dual eligible enrollees into a PDP owned

by the same organization (see §40.1.5, item B as well as Exhibit 27A).

A. Populations

1. Auto-Enrollment

Full-benefit dual eligibles in MA-only plans will be auto-enrolled by the MA organization into an

MA-PD plan. Full-benefit dual eligible individuals are defined as those eligible for comprehensive

Title XIX Medicaid benefits as well as eligible for Medicare Part D. This includes those who are

eligible for comprehensive Medicaid benefits plus Medicaid payment of Medicare cost-sharing

(sometimes known as QMB-plus or SLMB-plus). Please note that full-benefit dual eligible

individuals do not include those eligible only for Medicaid payment of Medicare cost-sharing (i.e.

QMB-only, SLMB-only, or QI). In Part D, these distinctions are key to distinguishing full-benefit dual

eligibles, who need to be auto-enrolled, from other types of dual eligibles, who need to be facilitated

enrolled.

Full-benefit dual eligible individuals to be auto-enrolled include those who are full-benefit dual

eligible upon initial enrollment into an MA-only plan, as well as existing Medicare enrollees of an

MA-only plan who become newly Medicaid eligible. This includes full-benefit dual eligible MA-only

enrollees who reside in the 50 states or the District of Columbia.

This excludes full-benefit dual eligibles who:

• Live in any of the five U.S. territories;

• Live in another country;

• Are individuals for whom an employer or union is claiming the retiree drug subsidy, or are

enrolled in an employer-sponsored MA-only plan, including MA-only “800 series” plans.

• Are incarcerated, as defined in §10;

• Are not lawfully present in the U.S.; or

• Have opted out of auto-enrollment into the Part D benefit.

• [For MA-PFFS only] Are already enrolled in a stand-alone Prescription Drug Plan

2. Facilitated enrollment

Other LIS eligibles are defined as those deemed automatically eligible for LIS because they are QMB-

only, SLMB-only, QI (i.e. only eligible for Medicaid payment of Medicare premiums and/or cost-

sharing); SSI-only (Medicare and Supplemental Security Income [SSI], but no Medicaid); or those

who apply for LIS at the Social Security Administration (SSA) or a State Medicaid Agency and are

determined eligible for LIS. This includes those who apply and are determined eligible for either the

full or partial level of the LIS.

Other LIS eligible individuals to be facilitated enrolled include those who are Other LIS eligible upon

initial enrollment into an MA-only plan, as well as existing Medicare enrollees of an MA-only plan

who become newly Other LIS eligible. This includes Other LIS eligible MA-only enrollees who reside

in the 50 states or the District of Columbia.

This excludes Other LIS eligible individuals who:

• Live in any of the five U.S. territories,

• Live in another country,

• Are individuals for whom the employer or union is claiming the retiree drug subsidy, or are

enrolled in an employer-sponsored MA-only plan, including MA-only “800 series” plans,

• Are incarcerated, as defined in §10;

• Are not lawfully present in the U.S.; or

• Have opted out of facilitated enrollment into the Part D benefit.

• [For MA-PFFS only] Are already enrolled in a stand-alone Prescription Drug Plan

B. Auto/Facilitated Enrollment Process

The procedure for auto/facilitated enrollment is as follows:

1. The MA organization will identify full-benefit dual eligibles to be auto-enrolled, and Other LIS

eligibles to be facilitated enrolled. Please see subsection C for details on how to distinguish the

two populations.

a. Auto/facilitated enrollment specifically excludes individuals in employer-sponsored MA-

only plans, including “800 series” plans, and individuals with Retiree Drug Subsidy

(RDS).

b. For PFFS plans, the organization must exclude individuals who are already enrolled in a

stand-alone PDP. The organization may submit a Batch Eligibility Query (BEQ)

transaction or access the MARx online query (M232 screen) to determine whether

individuals are enrolled in a stand-alone PDP.

2. The MA organization will then identify MA-PD plans in the same service area, and in the same

MA organization, with the lowest combined Part C and Part D premium amount. If more than

one MA-PD plan have the same lowest premium amount, auto-enrollment must be random

among the available MA-PD plans. The selection of MA-PD plan is without regard to the Part

C cost-sharing. The only exception to this is when the MA-PD plan is a high-deductible plan,

unless the high-deductible plan is the only MA-PD plan offered in the area. Please note that

the Part D premium is the dollar amount equaling the premium charged to a beneficiary with a

100 percent premium subsidy.

If an MA Special Needs Plan (SNP) meets these criteria, the MA organization must ensure that

the individual meets the eligibility criteria for the SNP (e.g. type of dual eligible, type of

chronic condition, or institutionalized). Please note the “MA full dual file” uses LIS deemed

reason code to identify full duals, meaning they were full dual in at least one month in the past

year; it cannot be used by MA organizations to confirm dual status in the current month. If the

MA SNP does not meet the criteria of lowest combined Part C and D premium (with the Part D

premium equaling the premium charged to a beneficiary with a 100 percent premium subsidy),

the MA organization may not auto-enroll full benefit dual eligibles into it, even if it is a dual

eligible SNP.

Organizations offering both an MA-PD PFFS plan and a stand-alone PDP in the same region

with a basic benefit and a premium at or below the low-income premium subsidy amount for

that region may auto/facilitate enrollment into either the MA-PD PFFS plan or the PDP, but

must apply this policy consistently for all PFFS plans offered by the organization. CMS will

conduct auto/facilitated enrollment of LIS individuals enrolled in MA-only PFFS plans where

the organization does not offer an MA-PD PFFS plan, even if they also offer a stand-alone

PDP.

3. Within 10 calendar days of identifying an individual as needing auto/facilitated enrollment, the

MA organization sends an auto/facilitated enrollment notice to the beneficiary (see Exhibits 27,

27A, 28 and 28a).

4. If the person does not respond or opt-out by the deadline below, submit a Code 61 transaction

(PBP change) for the auto/facilitated enrollment into the MA-PD plan and include the

appropriate effective date within the timelines specified below (see subsection C). The new

MA-PD plan will be notified of the auto/facilitated enrollment via a transaction reply.

• Auto-enrollment – within 10 calendar days of sending notice

• Facilitated enrollment – by last day before effective date of facilitated enrollment

C. Effective Date of Auto/Facilitated Enrollments

1. Auto-Enrollment

The effective date of auto-enrollment is retroactive to the first day of the month the individual first

became a full-benefit dual eligible, or January 1, 2006, whichever is later. For individuals who are

full-benefit dual eligible upon enrollment into an MA-only plan, the effective date would be

retroactive to the effective date of enrollment in the MA-only plan. For existing MA-only Medicare

enrollees who subsequently become Medicaid eligible, the effective date is retroactive to the first day

of the month the person became Medicaid eligible. In no case will the effective date of auto-

enrollment precede the date that the individual became an enrollee of the MA organization.

For MA-PFFS plans that elect to auto-enroll a full-benefit dual eligible beneficiary into a PDP offered

by the same organization, the effective date will be prospective, i.e., the first day of the second month

after the enrollee is identified as a new full benefit dual eligible. This is because CMS implemented

the Limited Income NET demonstration in January, 2010, in which a single contractor addresses all

retroactive periods of PDP auto-enrollment. The MA-PFFS may not submit an election on behalf of a

beneficiary into the Limited Income NET demonstration contractor. To ensure the beneficiary is

aware s/he can request retroactive coverage from the demonstration contractor, Exhibit 27a includes

instructions on how to do so.

There is nothing that prohibits a full-benefit dual eligible from initially electing an MA-only plan. To

ensure they understand the consequences of doing so, marketing material and the acknowledgement

letter emphasize that prescription drugs are not covered.

2. Facilitated Enrollment

The effective date of facilitated enrollment for all Other LIS eligible members is the first day of the

second month after the person is identified as qualifying for facilitated enrollment. For example, if the

plan is notified in August 2010 that an existing member of an MA-only plan has become LIS eligible,

the effective date is October 1, 2010.

The MA organization may move up the effective date of a facilitated enrollment by a month if an

Other LIS beneficiary requests this in a timely fashion, i.e. before start of earlier month. The SEP

under §30.4.4 #12 should be used.

Example: The MA organization facilitates enrollment of an Other LIS eligible in May, 2010,

effective July 1, 2010. The beneficiary receives the facilitated enrollment by the last day in May,

and requests the MA organization makes the facilitated enrollment effective June 1. The MA

organization submits an enrollment transaction to do so.

3. Distinguishing Between Full-Benefit Dual Eligible and Other LIS Individuals

MA organizations need to distinguish full benefit dual eligibles from others with LIS for purposes of

setting the effective date. The first step is to identify all LIS eligibles in the MA-only plan. In the

past, CMS did not transmit a data element to plans that could be used to distinguish full-benefit dual

eligibles from other LIS. As a result, CMS sends a monthly “Auto Assignment Full Dual Notification

File” (for file format and technical specifications, please see section 8.1 of the Plan Communications

User Guide, on the CMS website at http://www.cms.hhs.gov/mmahelp/. This file identifies full-benefit

dual eligibles.

However, starting December, 2010, the monthly membership report (MMR) will include a new field

(Medicaid dual status code) that will provide the dual status code of the enrollee, if that enrollee has

Medicaid status. The new field will be aligned with the already-existing Field 40 (Current Medicaid

Status). If Field 40 indicates that the enrollee has Medicaid status, Field 85 will provide the dual status

code for that enrollee. Field 40 indicates that an enrollee is Medicaid when that enrollee has a

Medicaid period reported to CMS for either the month prior to payment or two months prior to

payment. Please note that Field 40 and, thus the new field, are not related to payment, but are provided

for purposes of benefits coordination and bidding. The new field will be coded as follows:

The valid values when Field 40 = 1 are:

01 = Eligible is entitled to Medicare- QMB only

02 = Eligible is entitled to Medicare- QMB AND Medicaid coverage

03 = Eligible is entitled to Medicare- SLMB only

04 = Eligible is entitled to Medicare- SLMB AND Medicaid coverage

05 = Eligible is entitled to Medicare- QDWI

06 = Eligible is entitled to Medicare- Qualifying individuals

08 = Eligible is entitled to Medicare- Other Dual Eligibles (Non QMB, SLMB,QDWI or QI) with

Medicaid coverage

09 = Eligible is entitled to Medicare- Other Dual Eligibles but without Medicaid coverage

99=Unknown

The valid value when Field 40 = 0 is:

00 = No Medicaid Status

The valid value when Field 40 is blank is: Blank

Full-benefit dual eligible beneficiaries are represented by dual status codes 02, 04, and 08.

To ensure a sufficient period of transition, CMS will continue to send the Auto Assignment Full Dual

Notification File to identify the subset of the LIS enrollees in the MA-only plan who are full-benefit

dual eligibles. Plans may begin using the MMR instead, but starting August, 2011, plans will be

required to use the MMR as CMS will discontinue transmission of the Auto Assignment Full Dual

Notification File.

To determine the auto-enrollment effective date, identify the LIS copay start date data provided on

other files (i.e., Transaction Reply Report or monthly LIS history report). MA-PFFS plans that elect

to auto/facilitate enroll new LIS beneficiaries into a PDP offered by the same organization do not need

to distinguish between full-benefit dual eligible enrollees and others with LIS because the effective

date will always be prospective.

The remaining LIS eligibles in the MA-only plan qualify for facilitated enrollment, and the effective

date should be set as noted in item 2 above.

D. Notice

The MA organization will notify the beneficiary in writing that she/he will be enrolled in the given

MA-PD plan on the specified effective date. The notice must be sent within 10 calendar days of

identifying the individual as qualifying for auto/facilitated enrollment. The notice will inform the

beneficiary that they may choose another Part D plan (either another MA-PD plan or Original

Medicare with a PDP) or opt out of auto/facilitated enrollment into the Part D benefit. If the

beneficiary does not opt out, or choose another Part D plan within the specified deadline, the person’s

silence will be deemed to be an election of the auto/facilitated enrollment and it will take effect on the

effective date. These individuals will also be informed they have a Special Enrollment Period (SEP)

that permits them to change Part D plans, even after the auto/facilitated enrollment takes effect.

1. Auto-Enrollment

Please use the model notice language in Exhibit 27. For MA-PFFS auto-enrolling into a PDP, please

use Exhibit 27a. The deadline for responding is 10 calendar days from when the notice is sent.

2. Facilitated enrollment

Please use the model notice language in Exhibit 28. For MA-PFFS auto-enrolling into a PDP, please

use Exhibit 28a. The deadline for responding is the last day before the facilitated enrollment effective

date.

E. Opt-Out

Full-benefit dual eligible and Other LIS individuals may opt-out, or affirmatively decline, the Part D

benefit. Beneficiaries may opt-out verbally or in writing. For an MA-only plan enrollee, this

primarily means declining auto/facilitated enrollment into an MA-PD plan in the same organization

and maintaining enrollment in the MA-only plan. MA organization may check the common User

Interface to see if the individual has previously opted out; if so, the person should not be

auto/facilitated enrolled. Once a beneficiary has opted out, the MA organization should document this

and not include him/her in future auto/facilitated enrollment processing.

The MA plan should counsel the individual to ensure they understand the implications of their request

to decline, and should confirm this in writing (see Exhibit 29) within 10 calendar days of the

individual’s request to opt-out. If a beneficiary opts out of auto/facilitated enrollment by the deadline

in the auto/facilitated notice, do not submit an enrollment transaction that would move them to an MA-

PD plan. This will have the effect of leaving him/her in the MA-only plan.

If the individual opts-out after the Code 61 transaction has been submitted, the effective date of

returning to the MA-only plan is normally prospective, i.e. first day of the following month. However,

through the 15

of the month after the month in which the notice was sent, at a full-dual eligible

beneficiary’s request, the MA organization may restore the person to the MA-only plan retroactive to

the auto-enrollment effective date. This is accomplished by submitting a Code 61 transaction with the

same effective date, and setting the opt-out flag as noted below.

Individuals who want to opt-out of auto/facilitated enrollment into an MA-PD plan must do so with

their MA organization, not through 1-800-MEDICARE. This differs from the procedure for

individuals who want to opt-out of auto/facilitated enrollment into a stand-alone PDP. If a 61

transaction has already been submitted to move the person to the MA-PD plan, the MA organization

sends another 61 transaction (to move the person back to the MA-only plan), setting the Part D Opt-

Out Flag (field 38) to Y (opt-out of auto-enrollment) . If it has not, submit just the opt out indicator on

a 79 transaction.

An individual who opts out does not permanently surrender his or her eligibility for, or right to enroll

in, a Part D plan; rather, this step ensures the person is not included in future monthly auto/facilitated

enrollment processes. To obtain Part D benefits, the beneficiary simply makes a voluntary request to

enroll into a plan that offers Part D benefits.

F. Special Procedures for Individuals With Employer Coverage

When the individual’s employer or union-sponsored enrollment, including in “800 series” plans, or

Retirement Drug Subsidy (RDS) status is known, the MA organization shall exclude the individual

from auto/facilitated enrollment. It is possible the MA organization will not be aware an individual has

RDS until they submit a Code 61 transaction to auto/facilitate his/her enrollment. As with all

enrollment transactions for individuals with RDS, MARx will enforce a two-step process, initially

rejecting the transaction. The MA organization must follow normal procedures of confirming with the

beneficiary that she/he wants to be enrolled in the Part D benefit and, if confirmed, resubmit the

transaction with the employer subsidy override.

G. Information Provided to Auto/Facilitated Enrolled Beneficiaries

The MA-PD plan into which the beneficiary has been auto/facilitated enrolled must send a modified

version of the pre- and post-enrollment materials required to be provided to new enrollees. If the

effective date is retroactive into the previous calendar year, only send the current year’s version of the

documents below.

Prior to effective date, the MA-PD plan must send:

• The information required in §40.4.1, and

• A Summary of Benefits (those who are auto/facilitated enrolled still need to make a decision

whether to stay with the plan into which they have been auto/facilitated enrolled or change to

another one that better meets their needs). Providing the Summary of Benefits, which is

considered marketing material normally provided prior to making an enrollment request,

ensures that those auto/facilitated enrolled have a similar scope of information as those who

voluntarily enroll.

After the effective date of coverage:

• The guidance in §40.4.2 applies, including guidance on what to do if the MA-PD plan is not

notified early enough of an auto/facilitated enrollment to meet the timelines in §40.4.1 on

materials required to be provided prior to the effective date.

H. Summary of Differences between Auto- and Facilitated Enrollment Processes

Auto-Enrollment of Full Duals

Facilitated Enrollment of

Other LIS

Steps

• Identify full dual eligibles in

MA-only plan who need to

be enrolled into MA-PD plan

• Send notice to beneficiary

within 10 calendar days of

identifying need for person

to be auto-enrolled

• If no answer or person does

not opt out within 10

calendar days, submit 61

transaction to move to MA-

DPD plan

• Identify non-full dual LIS

beneficiaries in MA-only plan

who need to be enrolled into

MA-PD plan

• Send notice to beneficiary

within 10 calendar days of

identifying need for person to

be facilitated enrolled

• If no answer or person does

not opt out by last day before

effective date of facilitated

enrollment, submit 61

transaction to move to MA-PD

plan

Who needs to be

moved

• Full dual who newly enrolls

in MA-only plan

• Beneficiary in MA-only plan

who recently became

Medicaid eligible and is thus

newly full dual

• Non-full dual with LIS who

newly enrolls in MA-only plan

• Beneficiary in MA-only plan

who recently became LIS-

eligible

Who does not need

to be moved

• Those who have already

opted out

• Those with RDS

• Those in “800 series”

employer sponsored plans

• Those in employer sponsored

plans (other than “800

series” plans)

• Those who have already opted

out

• Those with RDS

• Those in “800 series”

employer sponsored group

plans

• Those in employer sponsored

plans (other than “800 series”

plans)

Data to identify

those in MA-only

plan who need to be

moved to MA-PD

plan

Monthly MA full dual file or on

MMR with dual status code 02,

04, or 08

LIS data (DTRR or monthly LIS

history report):

• Premium subsidy = 25%, 50%,

75%

•

Premium subsidy = 100 and

LIS copay = 4 (15%)

• Premium subsidy = 100 and

LIS copay = 1, 2, or 3, and

person is not on MA full dual

file or on MMR with dual

status code 02, 04, or 08

Auto-Enrollment of Full Duals

Facilitated Enrollment of

Other LIS

Plan Into Which

Beneficiary Should

be Enrolled

MA-PD plan with the lowest

combined Part C and D premium

MA-PD plan with the lowest

combined Part C and D premium

Notice to send

Exhibit 27 (27a if applicable)

Exhibit 28 (28a if applicable)

Effective date

• First day of month person

qualified for LIS (will be

retroactive)

• Cannot be prior to start of

enrollment in the MA-only

plan

• First day of second month

after person identified as

needing enrollment

• Cannot be prior to start of

enrollment in the MA-only

plan

Opt out

• Document and do not enroll

again in future.

• Confirm with beneficiary (see

Exhibit 29)

• If submitting 61 transaction

to move beneficiary back to

MA-only, set Opt-Out flag to

Y (field 38)

• Document and do not enroll

again in future.

• Confirm with beneficiary (see

Exhibit 29)

• If submitting 61 transaction

to move beneficiary back to

MA-only, set Opt-Out flag to

Y (field 38)

Data on

Transaction

Auto-Enrollment of Full Duals

Facilitated Enrollment of

Other LIS

Application date

First day of month prior to

enrollment effective date OR day

after current application date on

MA-only plan enrollment,

whichever is later.

First day of month prior to

effective date of the enrollment

Election type Code

Z = MA auto-enrollment period*

U = Dual/LIS Special

Enrollment Period

Enrollment Source

Code

E (MA-submitted auto-

enrollment)*

F (MA-submitted facilitated

enrollment)

* Use of the enrollment period of “Z” and enrollment source code of “E” permits these 61 transactions

for retroactive auto-enrollments to bypass normal MARx suspension of processing for retroactive

effective dates (i.e. they will process immediately).

40.1.6 – Additional Enrollment Request Mechanisms for Employer/Union

Sponsored Coverage

MA organizations may choose to accept voluntary enrollment requests directly from the employer or

unions who sponsor MA coverage for its members in any of the enrollment mechanisms described in

this guidance (except auto or facilitated enrollment). In addition, the MA organization may also

accept enrollment requests using either the optional enrollment request mechanism or group

enrollment process described in this section.

It is the MA organization’s responsibility to ensure that all applicable MA enrollment requirements are

met, regardless of the process utilized, as required by CMS. In any case, the enrollment requests

provided to the MA organization by the employer or union will reflect the choice of retiree coverage

individuals made using their employer’s or union’s process for selecting a health plan.

For enrollments processed using the SEP EGHP, the application date on the enrollment transaction

submitted to CMS is the first day of the month prior to the effective date of enrollment into the

employer or union group-sponsored plan. For the purposes of providing notices and meeting other

timeframe requirements provided in this guidance, use the date the organization receives the request.

40.1.6.1 - Group Enrollment Mechanism

CMS will allow an MA organization to accept enrollment requests into an employer or union

sponsored MA plan using a group enrollment process in which beneficiaries enroll in an employer or

union sponsored MA plan. Beneficiaries participate in this process through advance notification that

provides each individual with all the information necessary to make an informed choice. Furthermore,

the process must provide CMS with any information the employer/union has on other insurance

coverage for the purposes of coordination of benefits. It is the MA organization’s responsibility to

ensure the group enrollment process meets all applicable MA enrollment requirements. MA

organizations must ensure that any contracts and other arrangements and agreements with employers

and unions intending to use the group enrollment process make these requirements clear.

The group enrollment process must include providing the following information to each beneficiary as

follows:

• Beneficiaries participate in the group enrollment mechanism by receiving an advance notice that

the employer/union intends to enroll them for a prospective coverage effective date in an MA

plan that the employer/union is sponsoring; and

• Clear instruction that the beneficiary may affirmatively opt out of such enrollment; explaining

the process to opt-out; and any consequences to employer or union benefits opting out would

bring; and

• This notice must be provided by the MA organization, or the employer or union acting on its

behalf, not less than 21 calendar days prior to the effective date of the beneficiary’s enrollment in

the employer/union sponsored MA plan; and

• Additionally, the information provided to each beneficiary must include a Summary of Benefits

offered under the employer/union sponsored MA plan, as well as an explanation of how to get

more information about the MA plan, and an explanation on how to contact Medicare for

information on other Medicare health plan options that might be available to the beneficiary; and

• Each individual must also receive in the group enrollment notice materials the information

contained in Exhibit 2 under the heading “Please Read & Sign Below.”

The organization must ensure all of the above requirements are met prior to submission of the

enrollment transactions to CMS. For enrollments processed using the SEP EGHP, the application date

on the enrollment transaction submitted to CMS is the first day of the month prior to the effective date

of the group enrollment. This will ensure that any subsequent beneficiary-generated enrollment request

will supersede the group enrollment in CMS systems.

The employer or union must provide in the group enrollment file(s) all the information required for the

MA organization to submit a complete enrollment request transaction to CMS, including permanent

residence information (refer to Appendix 2 of this chapter for a complete list of the required data

elements and any other relevant CMS systems guidance). Records must be maintained as outlined in

§60.9 of this chapter.

40.1.6.2 - Optional Mechanism For MA Group-sponsored plan Enrollment

This enrollment request mechanism is optional for MA organizations and may not be required.

Therefore, MA organizations may specify the employers or unions, if any, from which they will accept

this enrollment request format. It is the MA organization’s responsibility to ensure that the process it

uses, as well as the process used by the employer or union, meets the following requirements:

The MA organization must inform its Regional Office Account Manager of its intent to use this

mechanism and identify the employer group(s) or union(s) for which it will be accepting enrollments

made in this manner.

The enrollment information (i.e., the electronic file) submitted to the MA organization by an employer

or union (or TPA) must accurately reflect the employer’s or union’s record of the election of coverage

made by each individual according to the processes the employer or union has in place, and may be

accepted without a paper MA enrollment request form.

Sales package minimum information requirements are not changed by using this option. These

include, but are not limited to, providing the applicable rules of the MA organization. Each

individual’s enrollment request must clearly denote his/her agreement to abide by the MA organization

rules, certify his/her receipt of required disclosure information and include authorization by the

beneficiary for the disclosure and exchange of necessary information between the U.S. Department of

Health and Human Services (and its designees) and the MA organization. The requirements for all

other information provided to enrollees, both pre- and post-enrollment, are unchanged by this option

and must be satisfied.

The enrollment request transaction must include all the data necessary for the MA organization to

determine each individual’s eligibility to make an enrollment request as described in §20 of this

chapter of the MMCM. Agreements with employer groups or unions should identify required data

elements. A detailed list of these elements is provided in Appendix 2.

This alternate enrollment request mechanism is used in place of paper MA enrollment request forms

and does not require a signature. For purposes of compatibility with existing instructions in this

chapter, the application date of enrollments processed using the SEP EGHP will be the first day of the

month prior to the effective date of enrollment into the employer/union sponsored plan. This will

ensure that any subsequent beneficiary-generated enrollment request will supersede the enrollment

submitted by the employer or union.

Effective date calculation of voluntary enrollment requests and the collection and submission of

enrollment requests to CMS will follow existing procedures.

To accept electronic records of employer or union enrollment requests, the MA organization must, at

minimum, comply with the CMS security policies regarding the acceptable method of encryption

utilized to provide for data security, confidentiality and integrity, and authentication and identification

procedures to ensure both the sender and recipient of the data are known to each other and are

authorized to receive and decrypt the information. (See the CMS web site at:

http://www.cms.hhs.gov/informationsecurity for additional information.)

The employer’s or union’s record of the request to enroll must exist in a format that can be easily,

accurately and quickly reproduced for later reference by each individual member, the MA organization

and/or CMS, as necessary, and be maintained (by the employer/union or the MA organization, as they

agree) following the guidelines for MA enrollment request forms (see §60.9). Included in this

requirement is the MA organization’s record of information received from the employer or union.

40.1.7 - Enrollment for Beneficiaries in Qualified State Pharmaceutical Assistance

Programs (SPAPs)

CMS will allow MA organizations to accept enrollment requests in an agreed-upon electronic file

format from qualified SPAPs, provided the SPAP has met the following requirements:

• The SPAP must attest, as required by §40.2.1 of this guidance, that it has the authority under

state law to enroll on behalf of its members.

• The SPAP must coordinate with the MA Organization to provide the required data elements for

the organization to process and submit an enrollment request to CMS.

• The SPAP must provide a notice to its members in advance of submitting the requests that

explains that it is enrolling on their behalf, how the enrollment works with the SPAP and how

individuals can decline such enrollment.

In return, MA organizations that agree to accept mass enrollment requests from SPAPs are required to

process them like any other enrollment and in accordance with notification timeframes. Additionally,

the organization must ensure the SPAP has met the above requirements prior to submission of the

enrollment transaction to CMS. It is important for the MA organization to work with the SPAP in the

event that the organization encounters any problems processing the enrollment request in the format

provided. Because the SPAP is the authorized representative of the beneficiary, the organization is

responsible for following up with the SPAP if the enrollment is incomplete in any way (to obtain

missing information) or if the enrollment is conditionally rejected due to the existence of employer or

union sponsored drug coverage (to confirm that the individual understands the implications of

enrolling in a Part D plan).

Special note for SPAP enrollment requests during the AEP - For enrollment processing purposes,

the application date on the enrollment transaction submitted to CMS for the AEP must be set to

October 15

. This will ensure that subsequent beneficiary-generated enrollment requests made during

the AEP will supersede the SPAP enrollment in CMS systems.

40.1.8 – Re-Assignment of Certain LIS Beneficiaries

CMS has the discretion to re-assign LIS beneficiaries, including situations in which their current MA

plan will terminate. CMS will announce its intent to conduct reassignment in the Call Letter. CMS will

conduct the reassignment in the fall of each year, and ensure all affected LIS beneficiaries are notified.

Affected MA organizations are not responsible for initiating any disenrollment transactions for

reassigned beneficiaries. Gaining PDP sponsors are only responsible for responding to the CMS

enrollment transaction promptly when they receive it and for providing appropriate beneficiary notices

and materials, as described below.

A. Population to be Re-Assigned

CMS will reassign all current LIS enrollees in terminating MA plans. This includes non-renewing

MA only plans, as well as MA-PD plans and MA PFFS plans. CMS will perform this reassignment

when plan benefit packages are being non-renewed in their entirety, as well as MA plans that will

continue but have service area reductions (SARs). In the case of an MA-only or MA-PD plan with a

SAR, reassignment will only be performed for counties that will no longer be served by the plan in the

following year).

Beneficiaries who have LIS this year and will continue to do so next year will be included in this

reassignment process, regardless of whether the individual was assigned to or voluntarily enrolled in a

plan. The only exception is when an LIS beneficiary in an MA-PFFS plan that does not offer drugs is

concomitantly enrolled in a stand-alone PDP. In these cases the beneficiary will not be reassigned.

Reassignment is not performed for LIS beneficiaries in a non-renewing MA-only or MA-PD plan in

the U.S. Territories, or in an employer-sponsored MA-only or MA-PD plan.

The actual reassignment process is typically run on a single day in mid-October. CMS will only

reassign beneficiaries who meet the above criteria as of the day of the reassignment run. CMS does

not subsequently “sweep” for individuals who may meet the criteria at later points in time.

B. Re-assignment Process

CMS will reassign LIS beneficiaries from a non-renewing MA plan or MA plan with a SAR to a

stand-alone prescription drug plan (PDP). Beneficiaries retain the option to elect another MA plan.

CMS will attempt to reassign beneficiaries to a PDP offered by the same organization that offers the

MA plan in which they are currently enrolled, wherever possible. CMS will identify PDPs that qualify

to receive reassignment and are sponsored by the same parent organization (see §40.1.5 in Chapter 3

of the Medicare Prescription Drug Benefit Manual for details on PDPs to which beneficiaries will be

reassigned as well as for the responsibilities of those “gaining” PDPs). If the organization has more

than one such plan in that region, CMS will randomly reassign beneficiaries among those plans.

If the organization does NOT offer a qualifying PDP, CMS will randomly reassign affected

beneficiaries to PDP sponsors that have at least one qualifying PDP in that region. CMS will follow

the two-step process used under auto/facilitated enrollment (i.e. random distribution first at the sponsor

level, then randomly among qualifying plans within the sponsor).

C. CMS Notification to Beneficiaries

CMS will ensure that all beneficiaries being re-assigned are notified. These notices will be on blue

paper, and will instruct beneficiaries who are being reassigned because of a premium increase to

contact their current plan if they wish to remain with the plan for the following year. Per section 1860

D–14 (c) of the Social Security Act, CMS will also provide reassigned beneficiaries with information

on formulary differences between the individual’s former plan and new plan (with respect to the

individual’s drug regimen), and a description of the right to coverage determination, exception,

reconsideration, appeal or grievance.

D. Plan Communication to Affected Beneficiaries

Non-renewing MA plans or MA plans with a SAR are not required to send any beneficiary notices

specific to the reassignment process. Please refer to the Call Letter for details on general notification

requirements related to non-renewals and SARs.

“Gaining” PDPs are responsible for providing enrollment confirmation (See Exhibit 29 of Chapter 3 of

the Prescription Drug Manual) and enrollment materials to beneficiaries within 10 calendar days of

receiving confirmation of reassignment on a DTRR.

40.1.9 – Simplified (Opt-In) Enrollment Mechanism

42 CFR 422.66(d)(5)

(Rev. 1, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

This mechanism permits an MA organization to use data it has from its non-Medicare lines of business

(commercial, Marketplace, Medicaid, etc.) to obtain some of the information it would normally need

to receive from the beneficiary in the enrollment request. The organization is required to obtain any

data necessary from the individual that it doesn’t have from its data sharing.

Use of this mechanism is not required. It is up to the MA organization whether it has the capability

and wants to share data between its Medicare and non-Medicare lines of business.

MA organizations may only offer simplified enrollment to individuals who:

• Are in their ICEP based on their initial enrollment in Medicare;

• Are enrolled in any type of non-Medicare plan under the same organization (or an entity under

the same parent organization as the MA organization); and

• Do not have a break in coverage between the non-Medicare plan and the MA plan.

The MA organization identifies individuals who are enrolled in its non-Medicare coverage, nearing

Medicare eligibility (or recently enrolled), and in their ICEP. It may conduct outreach to these current

members and offer them the opportunity to enroll in their plan. Outreach efforts are considered

marketing, and should clearly articulate the various plan offerings, plan structure, premium, costs,

network, etc.

MA organizations may offer simplified enrollment via paper, telephone or electronically, as outlined

in §§ 40.1, 40.1.1 through 40.1.3. For telephonic or electronic requests, the plan may limit the data to

be collected from the applicant to those items it does not already have.

The MA organization must collect the following data for the simplified enrollment:

• Minimal personal data sufficient for the MA organization to correctly identify the current

member and his or her information within its systems;

• Medicare number;

• Name of the MA plan selected for enrollment;

• Statement of a language or alternate format preference (beneficiary response is optional; does

not effect enrollment if not completed);

• Applicant’s acknowledgement of the following items:

o The plan has a contract with the federal government;

o Sales agents/brokers may be compensated if they are helping the individual to enroll;

o Release of information to Medicare and other plans, as necessary. Information may be

used for research and other purposes, as allowed under federal law and regulations;

o Obtaining benefits and services from the plan in order to be covered;

o Maintain enrollment in both Part A and B;

o Information provided in the enrollment request is correct; intentionally falsifying

information will result in disenrollment; and

o Understanding that completion/signature indicates an understanding of the enrollment

application, and that authorized representatives have legal authority to complete the

enrollment request.

• Signature or attestation of intent to enroll and, as applicable, from an authorized representative

acting on the beneficiary’s behalf, contact information; and

• Any other data the MA organization doesn’t already have in its records that is necessary to

meet the requirements in Appendix 2.

Organizations are encouraged, but are not required, to request premium payment method information

in the simplified enrollment request. In the absence of a stated preference, individuals are to be placed

in direct billing status, as outlined in §40.2.M. Additionally, the parameters outlined in

§§ 40.1.1 through 40.1.3 must be met based on the method of the simplified enrollment request

(telephonic, electronic, or paper).

Enrollments requested using this mechanism are the same as any other new ICEP enrollment the plan

receives and should be processed similarly.

Example:

Mr. Smith is turning 65 in June 2018 and is enrolled in commercial coverage with an organization

named Good Insurance. Good Insurance identifies in its records that Mr. Smith’s Medicare Part A and

B Initial Enrollment Period begins March 2018. Based on its data from Mr. Smith’s commercial

enrollment, Good Insurance knows that Mr. Smith lives in the service area of MA plans that Good

Insurance offers.

A representative of Good Insurance calls Mr. Smith in May 2018 and identifies herself as his

commercial health insurance plan. Using the plan’s internal protocols, she confirm his identity on the

call. In this call, she informs Mr. Smith that because he’s soon to be eligible for Medicare, he can

enroll in a plan that Good Insurance offers just for people with Medicare. She provides information on

Good Insurance MA plans available in Mr. Smith’s area and asks if he is interested in enrolling in one

of these or learning more. Mr. Smith expresses his interest in enrolling in Good Insurance’s MA plan

with prescription drugs.

Good Insurance already has Mr. Smith’s personal information via its internal systems and, while on

the call, the representative obtains what is needed for the MA enrollment that Good Insurance doesn’t

already have. The representative uses this information to complete the telephonic enrollment request

in Good Insurance’s internal MA enrollment system. Good Insurance confirms the MA plan Mr. Smith

wants to enroll in and asks for his Medicare number. Good Insurance explains the legal requirements

for enrollment, release of information, and confirms Mr. Smith’s understanding and

acknowledgement/approval to process the request. Good Insurance also provides information to Mr.

Smith to process his disenrollment from the commercial coverage to be effective as of May 31, 2018.

Good Insurance processes the telephonic enrollment the same as other received requests and submits

the enrollment transaction to CMS. Mr. Smith’s MA plan coverage will begin on June 1, 2018, when

his Medicare coverage begins.

40.2 - Processing the Enrollment Request

42 CFR 422.60

(Rev. 2, Issued: August 12, 2020; Effective/Implementation: 01-01-2021)

If an individual completes an enrollment request during a face-to-face interview, the MA organization

may ask to see the individual’s Medicare card to verify the spelling of the name, and to confirm the

correct recording of Medicare Number, and entitlement dates for Medicare Part A and Part B. The

individual does not have to show or provide the Medicare card or other evidence when submitting the

request. The other forms of evidence as listed in item “B” are only requested when the enrollment

request doesn’t include the Medicare Number and the plan is unable to locate the individual in CMS

systems. For processing all enrollment requests, the MA organization must verify Medicare

entitlement as described in item “B” below in this section.

Appendix 2 lists all the elements that must be provided in order to consider an enrollment request

“complete.” If the MA organization receives an enrollment request that contains the required

elements, the MA organization must consider the enrollment complete even if the optional data

elements on the enrollment request are not provided. If an MA organization has received CMS

approval for an enrollment request that contains data elements in addition to those included in

Appendix 2, then the enrollment request is considered complete even if those additional elements are

not provided.

If an MA organization receives an enrollment request that does not have all necessary elements

required in order to consider it complete, it must not immediately deny the enrollment. The MA

organization must always check available systems (i.e. BEQ, MARx online query) for information to

complete an enrollment before requiring the beneficiary to provide the missing information. For

example, if a beneficiary failed to fill out the “sex” field on the enrollment request and the MA

organization has access to this information via available systems, the organization must use that source

to complete the application instead of requesting the information from the beneficiary. If the required

but missing information is not available via CMS systems, the enrollment request is considered

incomplete and the MA organization must follow the procedures outlined in §40.2.2 in order to

complete the enrollment request.

For EGHP enrollees, the MA Organization may choose to accept enrollment requests as described in

§40.1.2 or §40.1.6. All required elements as listed in Appendix 2 must be included in the record of the

enrollment request provided by the group for the enrollment request to be considered complete (except

signature). Follow the procedures outlined in §40.2.2 to address incomplete enrollment requests.

For paper, telephone and electronic enrollment requests, all required elements as listed in Appendix 2

must be included. The “Beneficiary Signature and/or Authorized Representative Signature” element

for a paper request is satisfied with a pen-and-ink signature, for a telephone request it is satisfied with

a verbal attestation of intent to enroll, and for an electronic request it is satisfied with an electronic

signature or a clear and distinct step that requires the applicant to activate an “Enroll Now,” or “I

Agree,” type of button or tool. Follow the procedures outlined in §40.2.2 to address incomplete

enrollment requests.

Electronic signatures have the same legal effect and validity as pen-and-ink signatures. An MA

organization utilizing electronic signatures in electronic enrollment must, at a minimum, comply with

the CMS security policies. For more information on the requirements for legally binding electronic

signatures, see the Electronic Signatures in Global and National Commerce Act, 15 U.S.C. §7001, and

“Use of Electronic Signatures in Federal Organization Transactions” published by the CIO Council.

The following should also be considered when completing an enrollment:

A. Permanent Residence Information - The MA organization must determine whether or not the

enrollee resides within the MA plan’s service area. If an individual puts a Post Office Box as

his or her place of residence on the enrollment request, the MA organization must consider the

enrollment request incomplete and must contact the individual to determine place of permanent

residence. If the applicant claims permanent residency in two or more states or if there is a

dispute over where the individual permanently resides, the MA organization should consult the

State law in which the MA organization operates and determine whether the enrollee is

considered a resident of the State.

Refer to §10 for a definition of “evidence of permanent residence,” and §20.3 for more

information on determining residence for homeless individuals.

Individuals for whom the Batch Eligibility Query (BEQ) or MARx online query (M232 screen)

reflects an incarcerated status, that beneficiary is considered to reside outside of the service

area and are, therefore, not eligible to enroll.

B. Entitlement Information and Medicare Number –

42 CFR 422.50(a)(1)

(Rev. 2, Issued: August 12, 2020; Effective/Implementation: 01-01-2021)

Following the procedures outlined in the CMS Plan Communications User Guide, MA

organizations must verify Medicare entitlement using the Batch Eligibility Query (BEQ)

process or MARx online query (M232 screen) for all enrollment requests, except enrollment

requests from a current enrollee of an MA plan who is requesting enrollment into another MA

plan offered by the same parent organization with no break in coverage (i.e. “switching

plans”).

Individuals are not required to provide evidence of entitlement to Medicare Part A and

enrollment in Part B with the enrollment request. If the systems (BEQ or MARx online query)

indicate that the individual is entitled to Medicare Part A and is enrolled in Part B, no further

documentation of Medicare entitlement is needed from the individual.

CMS systems are updated within two business days of SSA processing new or changed Part A

or Part B entitlement for a Medicare beneficiary. The CMS systems are the most up-to-date

data regarding Medicare entitlement for the beneficiary.

The Medicare Number will be assigned at the time CMS first receives entitlement information

for a new beneficiary. In the event that the enrollment request doesn’t include the Medicare

Number and the plan is unable to locate the individual in the BEQ or MARx online query, the

organization should consider the enrollment request incomplete and follow § 40.2.2.

The individual may provide the Medicare Number to the organization verbally or in writing.

Examples of documents the beneficiary may send to the plan which display the Medicare

Number (and entitlement information) include:

• Medicare card;

• Medicare Award notice from SSA (shows Medicare entitlement dates only);

• Benefit Verification notice from SSA (includes Medicare Number and entitlement start

dates);

• Medicare card information from the individual’s MyMedicare.gov account; and

• A notice from CMS regarding change in Medicare Number.

NOTE: If the beneficiary provides any of the notices listed above, the date on the letter should

be no more than two months before the enrollment request was received by the organization. If

there is a discrepancy between the entitlement information in a document and the information

in CMS’ systems, use the data in CMS systems to determine eligibility for enrollment.

For auto- and facilitated enrollments, as described in §40.1.5 of this chapter, entitlement

verification is deemed complete, as the individual is already an MA enrollee.

C. Effective Date of Coverage - The MA organization must determine the effective date of

coverage as described in §30.5 for all enrollment requests. If the individual fills out an

enrollment form in a face-to-face interview, then the MA organization representative may

advise the individual of the proposed effective date, but must also stress to the individual that it

is only a proposed effective date and that the individual will hear directly from the MA

organization to confirm the actual effective date. The MA organization must notify the member

of the effective date of coverage prior to the effective date (refer to §40.4 for more information

and a description of exceptions to this rule).

With the exception of some SEPs and when election periods overlap, beneficiaries may not

choose their effective date (effective dates are described in §30.5). Instead, the MA

organization is responsible for assigning the appropriate effective date based on the election

period. During face-to-face enrollments, the MA organization staff are responsible for ensuring

that a beneficiary does not choose an effective date that is not allowed under the requirements

outlined in §30.5.

If a beneficiary completes an enrollment request with an unallowable effective date, or if the

MA organization allowed the beneficiary to choose an unallowable effective date, the MA

organization must notify the beneficiary in a timely manner and explain that the enrollment

must be processed with a different effective date. The organization should resolve the issue

with the beneficiary as to the correct effective date, and the notification must be documented. If

the beneficiary refuses to have the enrollment processed with the correct effective date, the

beneficiary can cancel the enrollment request according to the procedures outlined in §60.2.1.

MA organizations must ensure enrollees have access to plan benefits as of the effective date of

enrollment the MA organization has determined and may not delay provision of plan benefits

in anticipation of the submission to or reply from CMS systems.

For auto- and facilitated enrollments, refer to §40.1.5 of this chapter for more information.

D. Health Related Information - MA organizations may not ask health screening questions

during completion of the enrollment request. MA organizations are only permitted to send

health assessment forms after enrollment. However, MA organizations may ask very limited

health status questions related to a beneficiary’s eligibility to join an MA plan, such as whether

the individual is enrolled in Medicaid, or is currently admitted to a certified

Medicare/Medicaid institution. Queries for this information are included on the model EGHP

form in Exhibit 2. These queries are not considered to be health screening questions. The

responses to these questions must not have an effect on eligibility to enroll in an MA plan.

Exception for certain MA-SNPs - An SNP that is being offered to individuals with certain

medical conditions (i.e. an SNP for chronic and disabling conditions), as permitted by CMS,

will need to establish that the individual has such a condition to determine eligibility for

enrollment in that specific SNP. Refer to §20.11 for more information.

E. Statements of Understanding - As outlined in §20.5, a beneficiary must understand and agree

to abide by the rules of the MA plan in order to be eligible to enroll. If the MA organization

lists such statements in an itemized format, it is at the MA organization’s discretion to decide

whether it will:

• Consider the beneficiary signature on the form (or completion of the enrollment request

process) to signify that the individual has read and understands the statements (as shown

on Exhibits 1, 1b, 2 and 3); or

• Have fields next to the statements and require the applicant’s initials next to each

statement.

The MA organization must apply the policy consistently. If the MA organization requires the

initials and the applicant fails to initial his/her understanding of each item listed on the

enrollment form, the MA organization may contact the applicant to clarify the MA

organization rules in order to complete the enrollment form. The MA organization must

document the contact and annotate the outcome of the contact. If the MA organization is

unable to contact the applicant to ensure their understanding, the enrollment form would be

considered incomplete.

F. Applicant Signature and Date - The individual must sign the enrollment form or complete the

enrollment request mechanism. If the individual is unable to do so, a legal representative must

sign the enrollment form (refer to §40.2.1 for more detail) or complete the enrollment request

mechanism. If a legal representative enrolls an individual, the legal representative must attest

to having the authority under State law to do so, and confirm that a copy of the proof of court-

appointed legal guardian, durable power of attorney, or proof of other authorization required by

State law that empowers the individual to effect an enrollment request on behalf of the

applicant is available and can be presented upon request by the MA organization or CMS.

The individual and/or legal representative must indicate his/her relationship to the individual

and date he/she signed the enrollment form or completed the enrollment request; however, if

he/she inadvertently fails to include the date on the enrollment request, then the date the MA

organization receives the enrollment request may serve as the signature date of the form.

If a paper enrollment form is submitted and the signature is not included, the MA organization

may verify with the individual with a phone call and document the contact, rather than return

the paper enrollment form as incomplete. The documentation of this contact will complete the

enrollment request (assuming all other required elements are complete).

Certain enrollment request mechanisms do not include a pen-and-ink, or “wet,” signature. The

signature element listed in Appendix 2 is satisfied by specific procedures provided for the other

enrollment request mechanisms in this chapter; for example, see §40.1.2 for information about

enrollment.

For auto and facilitated enrollment as described in §40.1.5, an enrollee signature is not

required.

G. Other Signatures - If the MA organization representative helps the individual fill out the

enrollment form, then the MA organization representative must clearly indicate his/her name

on the enrollment form. However, the MA organization representative does not have to include

his/her name on the form when:

• He/she pre-fills the individual’s name and mailing address when the individual has

requested that an enrollment form be mailed to him/her,

• He/she fills in the “office use only” block, and/or

• He/she corrects information on the enrollment form after verifying information (see “final

verification of information” below).

The MA organization representative does have to include his/her name on the form if he/she

pre-fills any other information, including the individual’s phone number.

H. Old Enrollment Requests - If the MA organization receives an enrollment request that was

executed more than 30 calendar days prior to the MA organization’s receipt of the request, the

MA organization is encouraged to contact the individual to re-affirm intent to enroll prior to

processing the enrollment and to advise the beneficiary of the upcoming effective date.

I. Determining the Application Date - The MA organization must date all enrollment requests as

soon as they are initially received. Except for enrollment requests submitted via the CMS

Online Enrollment Center, requests made by the group enrollment mechanism and auto or

facilitated enrollments, the date the enrollment request is initially received is equivalent to the

“application date” (refer to §10 for definitions of “receipt of enrollment request,” “completed

enrollment request” and “application date”). If the enrollment request is not complete at the

time it is received, then the additional documentation required for the enrollment request to be

complete must be dated as soon as it is received. Appendix 3 describes the appropriate

application date to include in the enrollment transaction submitted to CMS under various

conditions.

J. Final Verification of Information - Some MA organizations verify information before

enrollment information has been transmitted to CMS. In these cases the MA organization may

find that it must make corrections to an individual’s paper enrollment form. The MA

organization should make those corrections, and the individual making those corrections must

place his/her initials and the date next to the corrections. A separate “correction” sheet, signed

and dated by the individual making the correction, may be used by the MA organization (in

place of the initialing procedure described in the prior sentence), and should become a part of

the enrollment file. These types of corrections will not result in the MA organization having to

co-sign the enrollment form.

K. Premiums Owed to the MAO - For individuals enrolling in an MA-only plan, an MA

organization may choose to wait for an enrolling individual’s payment of the MA-only plan

premium before considering the enrollment request complete. An MA organization cannot

consider an enrollment request incomplete if the individual enrolling has indicated that he or

she wants the plan premium withheld from an SSA benefit check.

For enrollment into either an MA-only or MA-PD plan, an MA organization may consider an

enrollment request incomplete if there are premium amounts due to the organization from a

prior enrollment, whether or not premium withhold from an SSA benefit check is selected.

The option chosen by the MA plan to consider the application complete or incomplete must be

applied consistently to all potential enrollees of the plan.

Optional Exception for Dual-Eligible Individuals and Individuals who Qualify for the

Low Income Subsidy

For enrollment requests submitted by dually eligible individuals and individuals who qualify

for the low income subsidy (LIS), an MA organization may consider an enrollment request

complete if there are premium amounts due to the organization from a prior enrollment, even if

the MA organization has a policy to consider such enrollment requests incomplete.

The MA organization has the discretion to implement this exception to dually eligible

individuals and individuals who qualify for LIS within each of its MA plans. If the MA

organization offers this exception in one of its plans, it must apply the policy to all such

individuals who request enrollment in that MA plan.

L. Completed Enrollment Requests - Once the enrollment request is complete, the MA

organization must transmit the enrollment to CMS within the time frames prescribed in §40.3,

and must send the individual the information described in §40.4 within the prescribed time

frames. There are instances when a complete enrollment can turn out to be legally invalid.

These instances are outlined in §40.6.

M. Plan Premium Payment and Premium Withhold Options –

42 CFR 422.60(c)(1)

(Rev. 2, Issued: August 12, 2020; Effective/Implementation: 01-01-2021)

MA organizations may include on all enrollment request mechanisms (except the simplified

enrollment mechanism) the option for individuals to: 1) pay plan premiums by being billed

directly by the plan or 2) have the premiums withheld from their SSA benefit check. The plan

may also choose to offer other payment methods, such as automatic deduction from the

individual’s bank or other financial institution or from the individual’s credit card. The

enrollment mechanism can also advise that if the individual does not select a premium

payment option, the default action will be direct bill.

MA-only plans that do not have a premium may omit the “Paying your Plan Premium” section

from their enrollment request mechanism. MA-PD plans that do not have a plan premium may

include, at minimum, the direct bill and SSA withhold options for those individuals subject to

the LEP to select how they will pay this penalty (premium); however, such plans may also

include introductory language to indicate that the premium payment section applies only to

individuals subject to the LEP.

Railroad Retirement Board (RRB) enrollees may also submit requests to have their premiums

withheld from their RRB retirement payments. Organizations may choose to offer this option

on all enrollment mechanisms as well.

MA-PD plans can also include on the enrollment request a statement in the premium payment

section advising those individuals who qualify for extra help that, if the extra help does not

cover the entire plan premium, the individual is responsible for the amount that Medicare does

not cover.

Model language has been provided on Exhibits 1, 1c, 3 and 3a to reflect these options. In

addition, suggested optional language for MA-PD plans without premiums has also been

provided.

N. Additional Information for MA-PD Enrollment Requests – Individuals enrolling in a Part

D plan must disclose any other existing coverage for prescription drugs.

O. U.S. Citizenship or Lawful Presence Information – MA organizations must use the CMS

Batch Eligibility Query (BEQ) (individual or batch submission) or, via online access, the

MARx M232 screen, to verify eligibility on the basis of incarceration status or unlawful

presence status. An exception to this are enrollment requests from a current enrollee of an MA

plan who is requesting enrollment into another MA plan offered by the same parent

organization with no break in coverage (i.e., “switching plans”).

Individuals are not required to provide evidence of U.S. citizenship or lawful presence status

with the enrollment request, nor are MA organizations permitted to request such information or

documentation. The systems (BEQ or MARx online query) will indicate the lawful presence

status of a non-U.S. citizen, including the start and, if applicable, the end date of the unlawful

presence status of the individual.

CMS eligibility queries will only reflect data for the existence of an unlawful presence status.

When neither the BEQ nor the MARx online query shows any indication of unlawful presence

in the U.S., the MA organization must treat the lack of information as confirmation of evidence

of U.S. citizenship or lawful presence status.

When either the BEQ or the MARx online query shows an indication of unlawful presence in

the U.S. and the organization receives documentation of lawful presence from the applicant,

the plan cannot use this documentation to establish eligibility. If the MA organization is

provided evidence of lawful presence by the applicant in the form of a document from the

Department of Homeland Security or SSA and neither the BEQ nor the MARx online query

reflects this lawful presence status, the organization should refer the applicant to SSA to

request that SSA update its records.

40.2.1 - Who May Complete an Enrollment or Disenrollment Request

42 CFR 422.60(c)

A Medicare beneficiary is generally the only individual who may execute a valid request for

enrollment in or disenrollment from an MA plan. However, another individual could be the legal

representative or appropriate party to execute an enrollment or disenrollment request as the law of the

State in which the beneficiary resides may allow. CMS will recognize State laws that authorize

persons to make such requests for Medicare beneficiaries. For example, persons authorized under State

law may be court-appointed legal guardians, persons having durable power of attorney for health care

decisions or individuals authorized to make health care decisions under State surrogate consent laws,

provided they have authority to act for the beneficiary in this capacity.

If a Medicare beneficiary is unable to sign an enrollment form or disenrollment request or complete an

enrollment request mechanism due to reasons such as physical limitations or illiteracy, State law

would again govern whether another individual may execute the enrollment request on behalf of the

beneficiary. Usually, a court-appointed guardian is authorized to act on the beneficiary’s behalf. If

there is uncertainty regarding whether another person may sign for a beneficiary, MA organizations

should check State laws regarding the authority of persons to sign for and make health care treatment

decisions for other persons.

Where MA organizations are aware that an individual has a representative payee designated by SSA to

handle the individual’s finances, MA organizations should contact the representative payee to

determine his/her legal relationship to the individual, and to ascertain whether he/she is the appropriate

person, under State law, to execute the enrollment or disenrollment request. Representative payee

status alone is not sufficient to enroll a Medicare beneficiary.

When someone other than the Medicare beneficiary completes an enrollment or disenrollment request,

he or she must:

1) Attest to having the authority under State law to do so;

2) Confirm that proof of authorization, if any, required by State law that empowers the individual

to make an enrollment or disenrollment request on behalf of the individual is available and can

be provided upon request by CMS. MA organizations cannot require such documentation as a

condition of enrollment or disenrollment; and

3) Provide contact information.

The MA organization must retain the record of this attestation as part of the record of the enrollment

or disenrollment request. CMS provides a sample attestation as part of the model MA enrollment form

(Exhibit 1).

If anyone has reason to believe that an individual making an election on behalf of a beneficiary may

not be authorized under State law to do so, the organization should contact its CMS account manager

with all applicable documentation regarding State Law and the case in question. The account manager

may request supporting documentation from the individual making the election.

When an authorized representative completes an enrollment request on behalf of a beneficiary, the MA

organization should inquire regarding the preference for the delivery of required notifications and

other plan materials (i.e. sending mail to the beneficiary directly or to the representative, or both) and

make reasonable accommodations to satisfy these wishes.

40.2.2 - When the Enrollment Request Is Incomplete

42 CFR 422.50(a)(5)

(Rev. 1, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

When the enrollment request is incomplete, the MA organization must document all efforts to obtain

additional documentation to complete the enrollment request and have an audit trail to document why

the enrollment request needed additional documentation before it could be considered complete. The

organization must make this determination and, within 10 calendar days of receipt of the enrollment

request, must notify the individual that additional information is needed, unless the required but

missing information can be obtained via CMS systems. This notification is not required for SNP

enrollment requests for which the only missing information is confirmation of the applicant’s special

needs status.

Note: An enrollment request is considered complete even if the only information missing is the

eligibility for the election period. In such circumstances, the plan must contact the individual to assure

they have a valid election period before processing the enrollment. (See Section 30 for more

information regarding eligibility for election periods and Section 40 for enrollment processing

requirements.)

If the request is missing the Medicare Number, see §40.2.B for more information.

If a paper enrollment form is missing a signature, see §40.2 F for more information.

For incomplete ICEP enrollment requests received prior to the month of entitlement to Part A and

enrollment in Part B, additional documentation to make the request complete must be received during

the first three months of the ICEP, or within 21 calendar days of the request for additional information

(whichever is later). For incomplete ICEP enrollment requests received during the month of

entitlement to Part A and enrollment in Part B or later, additional documentation to make the request

complete must be received by the end of the month in which the enrollment request was initially

received, or within 21 calendar days of the request for additional information (whichever is later).

For incomplete AEP enrollment requests, additional documentation to make the request complete must

be received by December 7, or within 21 calendar days of the request for additional information

(whichever is later). For all other enrollment periods, additional documentation to make the request

complete must be received by the end of the month in which the enrollment request was initially

received, or within 21 calendar days of the request for additional information (whichever is later).

EXAMPLES:

• Ms. Stears’ 65

birthday is April 20, 2011. She is eligible for Medicare Part A and Part B

beginning April 1, 2011 and has decided to enroll in Part B beginning on April 1. Her ICEP

begins on January 1, 2011 and ends on July 31, 2011. She submits an incomplete ICEP

enrollment request on January 15, 2011, and the MAO requests the required but missing

information on January 20, 2011. The enrollment request must be denied if the required

information is not received by March 31, 2011.

• Ms. Mohan’s 65

birthday is June 10, 2011. She is eligible for Medicare Part A and Part B

beginning June 1, 2011 and has decided to enroll in Part B beginning on June 1. Her ICEP

begins on March 1, 2011 and ends on September 30, 2011. She submits an incomplete ICEP

enrollment request on July 5, 2011, and the MAO requests the required but missing

information on July 7, 2011. The enrollment request must be denied if the required information

is not received by July 31, 2011.

When the MA organization receives an incomplete enrollment request near the end of either a month

or an enrollment period, the use of the full 21 calendar day period to complete the request may extend

beyond CMS systems plan submission “cut-off” date (these dates are provided in the CMS Plan

Communications User Guide). MA organizations may utilize a code 61 enrollment transaction to

directly submit the request to CMS as provided in the CMS Plan Communications User Guide.

If additional documentation needed to make the enrollment request “complete” is not received within

allowable time frames, the organization must deny the enrollment using the procedures outlined in

§40.2.3.

Requesting Information from the Beneficiary - To obtain information to complete the enrollment

request, the MA organization must contact the individual to request the information within ten

calendar days of receipt of the enrollment request. The organization may contact the beneficiary either

in writing (see Exhibit 5 for a model letter) or orally. If the contact is made orally, the MA

organization must document the contact and retain the documentation in its records. The MA

organization must explain to the individual that s/he has 21 calendar days in which to submit the

additional information or the enrollment will be denied. Since an incomplete enrollment request is an

invalid enrollment (as explained in §40.6), if the additional documentation is not received within

allowable time frames, the MA organization must send a denial of enrollment letter (see Exhibit 7).

If all documentation is received within allowable time frames and the enrollment request is complete,

the MA organization must transmit the enrollment to CMS within the time frames prescribed in §40.3,

and must send the individual the information described in §40.4.

40.2.3 - MA Organization Denial of Enrollment

MA organization denials occur before the organization has transmitted the enrollment to CMS. For

enrollment requests that do not require additional information from the applicant, an MA organization

must deny an enrollment within 10 calendar days of receiving the enrollment request based on its own

determination of the ineligibility of the individual to elect the MA plan. For an incomplete enrollment

request that requires information from the applicant and for which the applicant fails to provide the

information within the required time frame, an MA organization must deny the enrollment within 10

calendar days of the expiration of the time frames described in §40.2.2.

Notice Requirement - The organization must send notice of the denial to the individual that includes

an explanation of the reason for denial (refer to Exhibit 7 for a model notice). This notice must be sent

within ten calendar days of either 1) receipt of the enrollment request or 2) expiration of the time

frame for receipt of requested additional information, as described in the following examples:

• An MA organization receives an enrollment request from an individual on November 7 and

determines on that same day that the individual is ineligible due to place of residence. The

organization should send notice of denial within ten calendar days from November 7.

• An MA organization receives an enrollment request from an individual on January 7 and is

unable to determine, through direct contact with the beneficiary or the beneficiary’s authorized

representative, that the beneficiary has a valid enrollment period available. The organization

should send notice of denial within ten calendar days from January 7.

• An MA organization receives an enrollment form on November 7 from an individual, identifies

the enrollment form as incomplete, and notifies the individual of the need for additional

information, on November10. The beneficiary does not submit the information by December (as

required under §40.2.2), which means the organization must deny the enrollment. The

organization should send notice of denial within ten calendar days from December 1.

40.2.4 - MA-PD Enrollment When an Individual has Other Qualified Prescription

Drug Coverage through an Employer or Union Retiree Drug Subsidy (RDS) Plan

Sponsor

CMS systems will compare MA-PD enrollment transactions to information CMS has regarding the

existence of employer or union sponsored qualified prescription drug coverage for which the

beneficiary is also being claimed for the Retiree Drug Subsidy (RDS). If there is a match indicating

that the individual may have such other coverage, the enrollment will be conditionally rejected by

CMS systems as incomplete.

Within 10 calendar days of receipt of the Code 127 conditional rejection, the MA organization must

contact the individual to confirm the individual’s intent to enroll, and that the individual has discussed

and understands the implications of enrollment in a Part D plan on his or her employer or union

coverage. Individuals will have 30 calendar days from the date they are contacted to respond. The

organization must ensure that plan benefits are available to the individual as of the effective date of the

initial enrollment request and must not delay the provision of plan benefits in anticipation of the

applicant’s confirmation of intent to enroll. The organization may contact the individual in writing

(See Exhibit 6b) or by phone and must document this contact and retain it with the record of the

individual’s enrollment request. If the individual indicates that s/he is fully aware of any consequence

to his/her employer or union coverage brought about by enrolling in the Part D Plan, and confirms s/he

still wants to enroll, the MA organization must update the transaction with the appropriate “flag”

(detailed instructions for this activity are included with CMS systems guidance) and re-submit it for

enrollment. The effective date of enrollment will be based upon the individual's initial enrollment

request. This effective date may be retroactive in the event that the confirmation step occurs after the

effective date. MA organizations may use the Code 61 enrollment transaction code to submit the

enrollment transaction directly to CMS, as described in the Plan Communication Users Guide

(PCUG).

MA organizations are strongly encouraged to closely monitor their outreach efforts and to follow up

with applicants prior to expiration of the 30 day timeframe. If the individual does not respond in 30

days, or responds and declines the enrollment, the enrollment must be denied. A denial notice must be

provided (see Exhibit 7).

When an employer or union sponsored MA-PD plan is replacing an existing RDS plan offered by that

employer or union group, the MA organization may receive the Code 127 conditional rejection. In

these cases, it is not necessary to contact each individual, as described above. The MA organization

must resubmit the transactions updated with the appropriate flag.

MA organizations should work in close collaboration with employer/union sponsors who are replacing

RDS coverage with Part D coverage to ensure that all individuals are aware of the change and have the

information they need.

40.3 - Transmission of Enrollments to CMS

For all enrollment requests effective January 1, 2008, or later that the organization is not denying per

the requirements in §40.2.3, the MA organization must submit the information necessary for CMS to

add the beneficiary to its records as an enrollee of the MA organization within 7 calendar days of

receipt of the completed enrollment request. CMS system “down” days are included in the calculation

of the 7 calendar days (refer to Appendix C of the Plan Communications User Guide). For the purpose

of assessing compliance with this requirement, CMS will count the enrollment request receipt date as

“day zero” and the following day as “day one.” In the case of enrollment requests that are accepted

after the MA organization is enrolled to capacity, but as a vacancy occurs, the MA organization must

submit the information within 7 calendar days after a vacancy has become available.

All enrollment elections must be processed in chronological order by date of receipt of completed

enrollment elections (refer to §40.5 for procedures when the MA plan is closed for enrollment).

MA organizations are encouraged to submit transactions by the earliest possible MA organization

processing cutoff date (refer to the Plan Communications Users Guide (PCUG)). However, if the

organization misses the cutoff date, it must still submit the transactions within the required 7 calendar

day time frame.

NOTE: The requirement to submit the transaction within 7 calendar days does not affect the

effective date of the individual’s coverage under the plan, i.e., the effective date must be

established according to the procedures outlined in §§30.5 and 30.7

More detail on how MA organizations must submit transmissions to CMS are contained in the

Medicare Advantage and Prescription Drug Plans Plan Communications User Guide.

40.4 - Information Provided to Member

Much of the enrollment information that an MA organization must provide to the member must be

sent prior to the effective date of coverage. However, some information will be sent after the effective

date of coverage. A member’s coverage begins on the effective date regardless of when the member

receives all the information the plan sends.

As discussed previously (§40), the organization must provide required notices in response to

information received from CMS on the DTRR that provides the earliest notification. Organizations

may choose to send notifications based on the availability of each Batch Completion Summary Status

(BCSS) file if they desire. However, in no case may use of the BCSS for this purpose extend any

timeframe established in this guidance. Organizations choosing to utilize the BCSS for certain

required beneficiary notifications must do so consistently.

The organization may provide the required notices described in §§40.4.1 and 40.4.2 or may utilize a

single (“combination”) notice (see Exhibits 4b and 4e). The combination notice takes the place of

separate acknowledgement and confirmation notices and, as such, requires expedited issuance. To use

the combination notice, the organization must be able to provide this notice within 7 calendar days of

the availability of the DTRR. Additionally, when following this option to use the combination notice,

if the organization is unable to ensure that the beneficiary will receive this combination notice prior to

the enrollment effective date (or within timeframes for incomplete enrollment requests or enrollments

received at the end of the month), the organization still must ensure that the beneficiary has the

information required in §40.4.1 within the timeframes described therein.

If an individual’s enrollment includes a request for SSA or RRB premium withhold and was processed

after the monthly cut-off for payment, the organization must submit the request for premium withhold

separate from the enrollment request. Plans should resubmit the request for premium withhold timely

to assure the individual can have premium withholding at the next possible effective date.

Additionally, the organization must inform the individual that:

• If his/her request for premium withholding is approved, it will start in 1-2 months;

• The effective date for premium withholding will not be retroactive;

• S/he will be responsible for paying the organization directly for all premiums due from the

enrollment effective date until the month in which premium withholding begins; and

• For plans implementing §50.3.1, failure to pay premiums for months in which premium

withholding is not in effect will result in disenrollment from the plan.

40.4.1 - Prior to the Effective Date of Coverage

42 CFR 422.60(e)

(Rev. 2, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

Prior to the effective date of coverage, the MA organization must provide the member with all the

necessary information about being a Medicare member of the MA organization, the MA organization

rules, and the member’s rights and responsibilities (an exception to this requirement is described in

§40.4.2). The MA organization must also provide the following to the individual:

• For enrollment requests submitted via electronic enrollment or telephonic enrollment

mechanisms (including the simplified enrollment mechanism), evidence that the enrollment

request was received (e.g., a confirmation number). For paper enrollment requests, organizations

are not required to provide evidence of receipt outside of the acknowledgement or combination

notice outlined below. Organizations may choose to provide a confirmation number or other

tracking mechanism indicating receipt of the paper enrollment request. However, organizations

are expected to keep a copy of the paper enrollment form and provide a copy upon request by the

beneficiary.

• A notice acknowledging receipt of the completed enrollment request (refer to Exhibits 4, 4a, and

4c for model letters) and showing the effective date of coverage. This notice must be provided no

later than 10 calendar days after receipt of the completed enrollment request (organizations

choosing to use the combination notice, refer to 40.4 above).

• Proof of health insurance coverage so that he/she may begin using plan services as of the

effective date. This proof must include the 4Rx data necessary to access benefits.

NOTE: This proof of coverage is not the same as the Evidence of Coverage document described

in the Medicare Communications and Marketing Guidelines. The proof of coverage may be in

the form of member ID cards, the enrollment form, and/or a notice to the member (refer to

Exhibits 4, 4a, 4b and 4c, which are model letters with optional language that would allow the

member to use the letter as evidence of health insurance coverage until he/she receives a member

card). As of the effective date of enrollment, plan systems should indicate active membership.

Regardless of whether an enrollment request is made in a face-to-face interview, by fax, by mail, or by

other mechanisms defined by CMS, the MA organization must explain:

• The charges for which the prospective member will be liable, e.g., any premiums (this includes

any Part D late enrollment penalty), coinsurance, fees or other amounts; and any amount that is

attributable to the Medicare deductible and coinsurance, if this information is available at the

time the acknowledgement notice is issued (confirmation notices and combination

acknowledgement/confirmation notices must contain this information).

• The prospective member’s authorization for the disclosure and exchange of necessary

information between the MA organization and CMS.

• The lock-in requirement. The MA organization must also obtain an acknowledgment by the

individual that he/she understands that care will be received through designated providers except

for emergency services and urgently needed care.

• The potential for financial liability if it is found that the individual is not entitled to Medicare

Part A and Part B at the time coverage begins and he/she has used MA plan services after the

effective date.

• The effective date of coverage and how to obtain services prior to the receipt of an ID card (if the

MA organization has not yet provided the ID card).

40.4.2 - After the Effective Date of Coverage

42 CFR 422.62(e)

(Rev. 2, Issued: August 12, 2020; Effective/Implementation: 01-01-2021)

The CMS recognizes that in some instances the MA organization will be unable to provide the

materials and required notifications to new enrollees prior to the effective date, as required in §40.4.1.

These cases will generally occur when an enrollment request is received late in a month with an

effective date of the first of the next month. In these cases, the MA organization still must provide the

member all materials described in §40.4.1 no later than 10 calendar days after receipt of the completed

enrollment request. Additionally, the MA organization is also strongly encouraged to call these new

members as soon as possible (such as within 1-3 calendar days) to provide the effective date, the

information necessary to access benefits and to explain the MA organization rules. The member’s

coverage will be active on the effective date regardless of whether or not the member has received all

the information by the effective date.

Acceptance/Rejection of Enrollment

Once the MA organization receives a DTRR from CMS indicating whether the individual’s enrollment

has been accepted or rejected, the MA organization must notify the individual in writing of CMS’

acceptance or rejection of the enrollment within ten calendar days of the DTRR that contains the

earliest notification of the acceptance or rejection (see Exhibits 4d, 6, 6a, 6c, 6d and 8 for model

letters). The enrollment confirmation notice must explain the charges for which the prospective

member will be liable, e.g., any premiums, coinsurance, fees or other amounts; and any amount that is

attributable to the Medicare deductible and coinsurance. For those eligible for the low-income subsidy,

the enrollment confirmation notice must specify the limits applicable to the level of subsidy to which

the person is entitled.

There are exceptions to this notice requirement for certain types of transaction rejections. These

exceptions exist so as not to penalize the individual for a systems issue or delay, such as a plan

transmission or keying error. In this case, the MA organization should not send a rejection notice and

must request a retroactive enrollment from CMS (or its designee) within the timeframes provided in

the Standard Operating Procedures for the CMS Retroactive Processing Contractor. If CMS (or its

designee) is unable to process the retroactive enrollment due to its determination that the individual is

not eligible, the MA organization must notify the individual of the rejection in writing within ten

calendar days after CMS’ (or its designee’s) determination. Retroactive enrollments are covered in

more detail in §60.4.

If an MA organization rejects an enrollment and later receives additional information from the

individual substantiating his/her eligibility, the MA organization must obtain a new enrollment request

from the individual in order to enroll the individual and must process the enrollment with a current

(i.e., not retroactive) effective date. Refer to §60.4 for more information regarding retroactive

enrollments.

40.5 - Enrollment Processing During Closed Periods

42 CFR 422.60(a)(2) and 422.60(b)

(Rev. 1, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

As described in §40.3, an MA organization must process elections in order by date of receipt of

completed enrollment election when it is open for enrollment. However, an MA organization may

close an MA plan to OEP and OEPI enrollments or when it reaches a CMS-approved capacity limit.

This section addresses procedures for handling enrollment requests that arrive at the MA organization

when an MA plan is closed for enrollment, either through voluntary closure to OEP and OEPI

enrollments or because a CMS-approved capacity limit has been reached, and for processing those

enrollments when the MA plan re-opens or a vacancy occurs.

If an MA organization believes its MA plan does not have the capacity to accept additional members,

or as the MA plan enrollment grows and the MA organization estimates it may reach capacity during

its next open enrollment period, the MA organization may request a CMS-approved limit on

enrollment.

A capacity limit allows an MA organization to close or limit enrollment for all election periods. Only

with a reserved vacancy may an MA organization set aside vacancies for enrollment of conversions.

40.5.1 - Procedures After Reaching Capacity Limit

42 CFR §§ 422.60(a)(2) and 422.60(b)

(Rev. 1, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

If the number of individuals who elect to enroll in an MA plan exceeds a CMS-approved capacity

limit, then the MA organization may limit enrollment of these individuals, but only if it provides

priority in acceptance.

If an MA organization receives completed enrollment requests between the time it reaches its limit and

the time CMS approves the limit, it may follow one of two options after it receives approval from

CMS to limit enrollment: (1) Deny the enrollment due to the onset of the capacity limit, or (2) Place

the enrollment on a waiting list to be processed as vacancies occur in the priority of acceptance. This

priority requires that the MA organization process enrollments from individuals who elected the MA

plan prior to CMS’ determination that the capacity has been exceeded, in order based on date of

receipt of the completed enrollment request, and in a manner that does not discriminate on the basis of

any factor related to health as described in 42 CFR §422.110.

The MA organization must take the same action for all enrollment requests received. See below for

procedures for following options 1 or 2.

After the enrollments discussed in the above paragraph are acted upon, the MA organization has

similar options for handling any additional enrollment requests received while the plan is closed for

enrollment. The MA organization may follow one of two options: (1) Deny the enrollment due to the

capacity limit, or (2) Place the enrollment on a waiting list to be processed when the plan re-opens for

enrollment. However, to ensure no discrimination is applied to applications processed, all MA

organizations that use option 1 (i.e., deny enrollment) for enrollments discussed in the above

paragraph, must continue to deny all enrollments received while the plan is closed for enrollment, and

may not use option 2. The MA organization must take the same action for all enrollment forms

received. In the case of enrollments received after the plan closes for enrollment, the date the MA plan

re-opens becomes the “receipt date” of enrollment forms received when the plan was closed.

EXAMPLE: If the plan was closed in April and re-opens on May 1, then the receipt date of

enrollment requests received in April is May 1. See below for procedures for following options 1

or 2.

If the MA Organization Uses Option 1 - It must notify the individual in writing that it is denying the

enrollment, and should do so within ten calendar days after it receives the enrollment request or after

the MA organization receives approval from CMS to limit enrollment (Exhibit 7). Please note that

CMS encourages MA organizations to use this option if they expect that there will be no enrollment

opportunities for longer than one month. This reduces the likelihood of multiple transactions and/or

mistaken disenrollments that would occur if a potential applicant enrolls in another MA plan while

waiting for the original MA plan to re-open.

If the MA Organization Uses Option 2 - It must notify the individual in writing that he/she has been

placed on a waiting list, and should do so within ten calendar days after the MA organization receives

the enrollment request or after the MA organization receives approval from CMS to limit enrollment.

The notice must also provide an estimated length of time that the individual will be on a waiting list

and instruct the individual that he may cancel his enrollment before a vacancy occurs.

As enrollment spaces become available, if the plan was closed for more than 30 calendar days since

the receipt of the enrollment form, the MA organization must contact (orally or in writing) the

individual to re-affirm the individual’s intent to enroll before processing the enrollment. (The MA

organization may make this contact even if the plan was closed for less than 30 days.) Within ten

calendar days after contacting the individual, the MA organization must send written notice of intent

to not process the enrollment to all individuals who state they are no longer interested in being

enrolled in the MA plan.

For individuals who indicate their continued interest in enrollment, the MA organization must

document the individual’s expressed interest to continue enrollment. This may be done via phone

contact report, notation on the enrollment form, etc.

There may be situations in which the MA organization has closed enrollment in a service area, yet

receives an approval for a capacity limit for a portion of that same service area. Given that MA plans

are either open or closed to OEP and OEPI enrollments for an ENTIRE plan service area, any

vacancies which may open up may only be filled by individuals making AEP, ICEP or SEP enrollment

elections by applying the rules for accepting enrollments when MA plans are closed (see §40.5.2

below). Further, it must take those individuals based upon enrollments received in chronological order.

40.5.2 - Procedures After Closing During the OEP and OEPI

42 CFR §§ 422.60(a)(2) and 422.60(b)

(Rev. 1, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

As stated in §30, an MA organization must accept all enrollment requests for its MA plans made

during the AEP, ICEP, or SEP. However, an MA organization may not process OEP or OEPI

enrollments for a plan when the plan is closed to OEP and OEPI enrollments.

If an MA plan is closed to OEP and OEPI enrollments and receives new OEP or OEPI enrollment

requests or documentation to complete OEP enrollment requests already received by the MA

organization, then the MA organization may do one of the following. The MA organization must take

the same action for all enrollment forms received while the plan is closed:

1. Deny the enrollment;

2. Continue to accept the completed enrollment requests to be placed on a waiting list.

If the MA Organization uses option #1 above - It must notify the individual in writing that it is

denying the enrollment, and should do so within ten calendar days after it receives the enrollment

request (Exhibit 7). Please note that CMS encourages MA organizations to use this option if they

expect that there will be no enrollment opportunities for longer than one month. This reduces the

likelihood of multiple transactions and/or mistaken disenrollments that would occur if a potential

applicant enrolls in another MA plan while waiting for the original MA plan to re-open.

If the MA Organization uses option #2 above - it must notify the individual in writing that he or she

has been placed on a waiting list. The notice must inform the individual that the enrollment request

will not be processed until the plan re-opens for enrollment, must include the date the plan will re-

open, and must inform the individual that he or she may cancel the request for enrollment before the

plan re-opens. All individuals who wish to wait for an opening must be placed on the waiting list.

After the MA plan re-opens, if the plan was closed for more than 30 calendar days since the MA

organization received the enrollment request, it must contact (orally or in writing) the individual to re-

affirm the individual’s intent to enroll before processing the enrollment. (The MA organization may

make this contact even if the plan was closed for less than 30 days.) The MA organization must send

written notice of intent to not process the enrollment to all individuals who state they are no longer

interested in being enrolled in the MA plan, and should do so within ten calendar days after contacting

the individual.

For individuals who indicate their continued interest in enrollment, the MA organization must

document the individual’s expressed interest to continue enrollment. This may be done via phone

contact report, notation on the enrollment form, etc. The date the MA plan re-opened becomes the

“receipt date” of enrollment forms received when the plan was closed.

EXAMPLE: If the plan was closed in February and re-opens on March 1, then the receipt date of

enrollment requests received in February is March 1.

40.6 - Enrollments Not Legally Valid

When an enrollment is not legally valid, a retroactive cancellation of enrollment action may be

necessary (refer to §60.5 for more information on retroactive disenrollments). In addition, a

reinstatement to the plan in which the individual was originally enrolled may be necessary if the

invalid enrollment resulted in an individual’s disenrollment from his/her original plan of choice.

An enrollment that is not complete, as defined in §10, is not legally valid. In addition, an enrollment is

not legally valid if it is later determined that the individual did not meet eligibility requirements at the

time of enrollment. For example, an enrollment is not legally valid if an MA organization determines

at a later date that the individual provided an incorrect permanent address at the time of enrollment and

the actual address is outside the MA plan’s service area. A second example could be an instance

where an individual not authorized by State law to make an enrollment request on another’s behalf

attempts to complete an enrollment request.

There are also instances in which an enrollment that appears to be complete can turn out to be legally

invalid. In particular, CMS does not regard an enrollment as actually complete if the member or

his/her legal representative did not intend to enroll in the MA organization. If there is evidence that the

individual did not intend to enroll in the MA organization, the MA organization should submit a

retroactive disenrollment request to CMS. Evidence of lack of intent to enroll by the individual may

include:

• An enrollment request signed by the individual when a legal representative should have signed

for the individual;

• Request by the individual for cancellation of enrollment before the effective date (refer to

§60.2 for procedures for processing cancellations);

• Enrolling in a supplemental insurance program immediately after enrolling in the MA

organization; or

• Receiving non-emergency or non-urgent services out-of-plan immediately after the effective

date of coverage under the plan.

Payment of the premium does not necessarily indicate an informed decision to enroll. For example, the

individual may believe that he/she was purchasing a supplemental health insurance policy, as opposed

to enrolling in an MA organization. In addition, use of an MA plan doctor does not necessarily

indicate an understanding of the lock-in requirement if the doctor also treats non-plan members.

40.7 - Enrollment Procedures for Medicare MSA Plans

MA organizations offering a Medicare MSA plan must follow the procedures outlined in §§40.2, 40.3,

40.4, 40.5.1, and 40.6. MSA plans must have a paper enrollment form available for eligible individuals

to request enrollment. Exhibit 1b is a model MSA plan enrollment form. Organizations may use this

model form as it appears or may customize their enrollment forms based on this model, if they follow

usual Medicare marketing material approval practices and ensure all the required MSA specific

elements are included. Applications for Medicare MSAs must include a question regarding election of

the Medicare hospice benefit.

All information necessary to successfully enroll the individual in the MSA plan must be provided to

consider the enrollment request complete, including the answers to questions 1 – 4 on the model MSA

enrollment form. Additionally, the organization must obtain the necessary banking and account

information before the enrollment can be considered complete. The MA organization must ensure its

materials describing the MSA plan explain the details of having the MSA account and what options

the individual will have regarding the account.

Beneficiaries may enroll into a Medicare MSA plan only through the MA organization offering that

plan. Beneficiaries may enroll directly with the plan by completing an approved paper enrollment

form. Additionally, MSA plans may offer an online enrollment mechanism as defined in §40.1.2

through the organization’s website. MSA plans are not available through the Online Enrollment

Center on the Medicare.gov website.

40.7.1 - Establishing the MSA Banking Account during the Enrollment Process

Medicare beneficiaries interested in enrolling in a MSA plan will need to establish an MSA bank

account to accept MSA deposits in accordance with the MSA plan’s procedures. The MA

Organization must have documentation that a beneficiary will open the MSA account before

submitting an enrollment transaction to MARx for that beneficiary. CMS will make the annual deposit

payment to the plan on the same schedule as the monthly capitation payment. Per Section 1853(e)(2)

of the Act, payment of an MSA deposit cannot be made until the beneficiary account has been

established.

Acceptable documentation that an MSA account has been established includes a

written/electronic notice from the bank that the beneficiary has opened an MSA account, or a

written/electronic communication from the beneficiary that the MSA account has been opened, with

the bank routing number and account number reported on the communication. The MSA organization

must retain this documentation. Described below are several procedures that the MSA Organization

could implement to facilitate the establishment of these MSA accounts:

1. The organization provides the beneficiary with specific banking enrollment materials to begin the

process necessary for establishment of the MSA banking account. The specified bank supplies the

beneficiary with the required signature card and items needed for establishing the account. The

beneficiary completes and returns the required documents to the specified bank. The bank

provides the information to the MSA plan to complete the enrollment transaction.

2. For an employer/union sponsored MSA plan, the plan’s designated bank deals directly with the

employer or union allowing the employer or union to facilitate the establishment of an account on

behalf of the Medicare beneficiaries enrolling in the MSA plan.

Finally, these procedures must accommodate the following guidance:

• MSA organizations must educate beneficiaries that the enrollment is not complete until the MSA

account is set up.

• The organization must have documentation that the account has been established prior to

submitting the enrollment transaction to CMS.

• MSA organizations must educate beneficiaries that once the enrollee’s initial deposit has been

received in the MSA account the enrollee may then transfer the funds to his or her own banking

institution.

MARx will not reject an MSA enrollment transaction if CMS records show an open period of

Medicaid or Hospice coverage; however, MARx will provide information about these statuses. MSA

plans should contact the beneficiary to confirm or deny this information.

50 - Disenrollment Procedures

42 CFR 422.74

Except as provided for in this section, an MA organization may not, either orally or in writing, or by

any action or inaction, request or encourage any member to disenroll. While an MA organization may

contact members to determine the reason for disenrollment, the MA organization must not discourage

members from disenrolling after they indicate their desire to do so. The MA organization must apply

disenrollment policies in a consistent manner for similar members in similar circumstances.

All notice requirements are summarized in Appendix 1.

NOTE: It is not necessary for an MA plan to send a notice of disenrollment to beneficiaries whose

plan benefit package (PBP) number is changed as part of a CMS-approved plan renewal. The annual

notice of change that the MA organization sends to the beneficiaries as part of the end-of-year

activities serves this function. Instructions and information on the annual notice of change can be

found in§60.7 of Chapter 3 of the Medicare Managed Care Manual.

50.1 - Voluntary Disenrollment by Member

A member may request disenrollment from an MA plan only during one of the election periods

outlined in §§30 and 30.7. The member may disenroll by:

1. Enrolling in another plan (during a valid enrollment period);

2. Giving or faxing a signed written notice to the MA organization, or through his/her employer

or union, where applicable;

3. Submitting a request via the Internet to the MA organization (if the MA organization offers

such an option); or

4. Calling 1-800-MEDICARE.

If a member verbally requests disenrollment from the MA plan, the MA organization must instruct the

member to make the request in one of the ways described above. The MA organization may send a

disenrollment form to the member upon request (see Exhibits 9, 9a, and 10).

The disenrollment request must be dated when it is initially received by the MA organization.

Per §40.2.1, when someone other than the Medicare beneficiary completes a disenrollment request, he

or she must:

1. Attest that he or she has the authority under State law to make the disenrollment request on

behalf of the individual;

2. Attest that proof of this authorization (if any), as required by State law that empowers the

individual to effect a disenrollment request on behalf of the applicant is available upon

request by the MA organization or CMS; and

3. Provide contact information.

50.1.1 – Requests Submitted via Internet

The MA organization has the option to allow members to submit disenrollment requests via the

Internet; however, certain conditions must be met. The MA organization must, at a minimum, comply

with the CMS security policies - found at http://www.cms.hhs.gov/informationsecurity/. However, the

MA organization may also include additional security provisions. The CMS policies indicate that with

regard to receiving such disenrollments via the Internet, an acceptable method of encryption must be

utilized to provide for confidentiality and integrity of this data, and that authentication or identification

procedures are employed to assure that both the sender and recipient of the data are known to each

other and are authorized to receive and decrypt such information.

In addition, CMS policies require MA organizations to provide the CMS Office of Information

Services with a pro forma notice of intent to use the Internet for these purposes. The notice is

essentially an attestation that the MA organization is complying with the required encryption,

authentication, and identification requirements. The CMS reserves the right to audit the MA

organization to ascertain whether it is in compliance with the security policy. The effective date of the

request is determined by the election period in which the valid request was received by the MA

organization. The election period is determined by the date the request is received at the site

designated by the MA organization, as described in member materials.

The option of online disenrollment is limited to requests submitted via the MA organization’s website.

Online disenrollment via other means, such as a broker website, as well as disenrollment requests

submitted via email, are not permitted.

50.1.2 - Request Signature and Date

When providing a written request, the individual must sign the disenrollment request. If the individual

is unable to sign, a legal representative must sign the request (refer to §40.2.1 for more detail on who

may complete enrollment and disenrollment requests). If a legal representative signs the request for the

individual, then he or she must attest to having the authority under State law to do so, and confirm that

a copy of the proof of court-appointed legal guardian, durable power of attorney, or proof of other

authorization required by State law that empowers the individual to effect a disenrollment request on

behalf of the applicant is available and can be presented upon request to the MA organization or CMS.

The individual and/or legal representative should write the date he/she signed the disenrollment

request; however, if he/she inadvertently fails to include the date, then the date of receipt that the MA

organization places on the request form will serve as the signature date.

If a written disenrollment request is received and the signature is not included, the MA organization

may verify with the individual or legal representative with a phone call and document the contact,

rather than return the written request as incomplete.

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50.1.3 - Effective Date of Disenrollment

The election period during which the organization received a valid request to disenroll will determine

the effective date of the disenrollment; refer to §§30.6 and 30.7 for information regarding

disenrollment effective dates.

With the exception of some SEPs and when election periods overlap, beneficiaries may not choose

their effective date. Instead, the MA organization is responsible for assigning the appropriate effective

date based on the election period. During face-to-face disenrollments, or when a beneficiary calls

about a disenrollment, the MA organization staff are responsible for ensuring that a beneficiary does

not choose an effective date that is not allowed under the requirements outlined in §§30.6 and 30.7.

If a beneficiary submits a disenrollment request with an unallowable effective date, or if the MA

organization allowed the beneficiary to choose an unallowable effective date, the MA organization

must call or write the beneficiary to explain that the disenrollment must be processed with a different

effective date. The organization should resolve the issue with the beneficiary as to the correct effective

date, and the call must be documented. If the beneficiary refuses to have the disenrollment processed

with the correct effective date, the beneficiary can cancel the disenrollment request according to the

procedures outlined in §60.2.2.

50.1.4 - Notice Requirements

After the member submits a request, the MA organization must provide the member with a

disenrollment notice within ten (10) calendar days of receipt of the request to disenroll. The

disenrollment notice must include an explanation of the lock-in restrictions for the period during

which the member remains enrolled in the organization, and the effective date of the disenrollment

(see Exhibit 11). The MA organization may also advise the disenrolling member to hold Original

Medicare claims for up to one month so that Medicare computer records can be updated to show that

the person is no longer enrolled in the plan. For these types of disenrollments, i.e., disenrollments in

which the member has disenrolled directly through the MA organization, MA organizations are

encouraged, but not required, to follow up with a confirmation of disenrollment notice after receiving

CMS confirmation of the disenrollment from the DTRR.

Since Medicare beneficiaries have the option of disenrolling through sources other than the MA

organization (such as 1-800-MEDICARE or by enrolling in another Medicare managed care plan or

PDP), the MA organization will not always receive a request for disenrollment directly from the

member and will instead learn of the disenrollment through the CMS DTRR. If the MA organization

learns of the voluntary disenrollment from the CMS DTRR (as opposed to through written request

from the member), the MA organization must send a written confirmation notice of the disenrollment

to the member within ten calendar days of the availability of the DTRR (see Exhibit 12).

Organizations may choose, but are not required, to issue a disenrollment confirmation notice for an

automatic disenrollments resulting from an individual’s enrollment in a PBP within the same MA

contract.

If the MA organization receives a disenrollment request that it must deny, the organization must notify

the enrollee within 10 calendar days of the receipt of the request, and must include the reason for the

denial (see Exhibit 12a).

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An MA organization may deny a voluntary request for disenrollment only when:

1. The request was made outside of an allowable period as described in §30 of this guidance; or

2. The request was made by someone other than the enrollee and that individual is not the enrollee’s

legal representative (as described in §40.2.1).

3. The request was incomplete and the required information is not provided within the required time

frame (as described in §50.4.2).

50.1.5 - Optional Employer/Union MA Disenrollment Request Mechanism

As described in §20.4.1 of this chapter, beginning April 1, 2003, MA organizations that offer

employer or union group-sponsored MA plans may choose to accept voluntary disenrollment requests

from beneficiaries enrolled in those plans directly from the employer or union (or its TPA) without

obtaining a written disenrollment request from each individual. The disenrollment must be prospective

from the date the request is received by the employer/union group.

• The MA organization must inform its Regional Office Account Manager of its intent to use this

mechanism and identify the employer(s) or union(s) for which it will be accepting

disenrollments made in this manner.

• The disenrollment information (i.e., the electronic file) submitted to the MA organization by

the employer or union (or TPA) must accurately reflect the employer’s or union’s record of the

disenrollment made by each individual according to the processes the employer or union has in

place, and may be accepted without a paper MA disenrollment request form.

• This alternate disenrollment request mechanism is used in place of paper MA disenrollment

request forms and does not require a signature. For purposes of compatibility with existing

instructions in this chapter, the MA organization receipt date will be the date the employer’s or

union’s record of an individual’s disenrollment choice is received by the MA organization. MA

organizations must record these dates.

• Effective date calculation of voluntary disenrollments and the collection and submission of

disenrollments to CMS will follow existing procedures.

• To accept electronic records of employer or union disenrollment requests, the MA organization

must, at minimum, comply with the CMS security policies regarding the acceptable method of

encryption utilized to provide for data security, confidentiality and integrity, and authentication

and identification procedures to ensure both the sender and recipient of the data are known to

each other and are authorized to receive and decrypt the information.

• The employer’s or union’s record of the disenrollment request must exist in a format that can

be easily, accurately and quickly reproduced for later reference by each individual member, the

MA organization and/or CMS as necessary, and be maintained (by the employer/union or the

MA organization, as they agree) for at least 6 years following the effective date of the

individual’s disenrollment from an MA plan. The MA organization must maintain its record of

information received from the employer or union following the guidelines for MA

disenrollment request forms (see §60.9).

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50.1.6 - Group Disenrollment for Employer/Union Sponsored Plans

CMS is providing a process for group disenrollment from an employer or union sponsored MA plan.

CMS will allow an employer or union to disenroll its retirees from an employer or union sponsored

MA plan using a group disenrollment process.

The group disenrollment process must include notification to each beneficiary as follows:

• All beneficiaries must be notified that the employer or union intends to disenroll them from the

MA plan that the employer or union is offering; and

• This notice must be provided by the MA organization, employer, or union not less than 21

calendar days prior to the effective date of the beneficiary’s disenrollment from the

employer/union sponsored MA plan.

Additionally, the information provided must include an explanation on how to contact Medicare for

information about other MA plan options that might be available to the beneficiaries.

The employer/union must have and provide all the information required for the MA organization to

submit a complete disenrollment request transaction to CMS, as described in this and other CMS MA

systems guidance. Records must be maintained as outlined in §60.9 of this chapter.

50.1.7 - Medigap Guaranteed Issue Notification Requirements for Disenrollments

to Original Medicare during a SEP

MA organizations are required to notify members of their Medigap guaranteed issue rights when

members disenroll from the MA plan and into Original Medicare during a SEP. Model language

discussing these Medigap rights has been provided in Exhibit 11 and Exhibit 12.

There may be cases when a Medigap issuer requires the beneficiary to provide additional

documentation that s/he disenrolled as a result of an SEP and is eligible for such guaranteed issue

rights. A beneficiary may contact the MA organization for assistance in providing such

documentation. The MA organization may provide such a notice to the beneficiary upon request (see

Exhibit 24).

50.2 - Required Involuntary Disenrollment

The MA organization must disenroll a member from an MA plan in the following cases. Refer to

§50.6 for some exceptions to required disenrollment for grandfathered members.

1. A change in residence (includes incarceration – see below) makes the individual ineligible to

remain enrolled in the plan (§50.2.1);

2. The member loses entitlement to either Medicare Part A or Part B (§50.2.2);

3. The SNP enrollee loses special needs status and does not reestablish SNP eligibility prior to the

expiration of the period of deemed continued eligibility (§20.11).

4. The member dies (§50.2.3);

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5. The MA organization contract is terminated, or the MA organization reduces its service area to

exclude the member. There is an exception to this rule, which is described in §50.2.4;

6. The member fails to pay his or her Part D-IRMAA to the government and CMS notifies the

plan to effectuate the disenrollment (§50.2.6); or

7. The member is not lawfully present in the United States (§50.2.7).

Incarceration – A member who is incarcerated resides outside the plan’s service area, even if the

correctional facility is located within the plan’s service area (see §10 for definition of “incarcerated”).

Notice Requirements - Disenrollment notices must be sent when:

• The individual has a change in residence and is determined to be out of the plan’s service area;

• CMS disenrolls the individual due to incarceration;

• The individual loses SNP status and doesn’t regain eligibility within the period of continued

deemed eligibility;

• The individual loses eligibility for enrollment due to contract termination or service area

reduction by the MA organization; or

• CMS disenrolls the individual for non-payment of Part D-IRMAA.

For disenrollments effectuated by the MA organization, all disenrollment notices must:

1. Advise the member that the MA organization is planning to disenroll the member and why such

action is occurring;

2. Be mailed to the member before submission of the disenrollment transaction to CMS; and

3. Include an explanation of the member’s right to a hearing under the MA organization’s

grievance procedures. (This explanation is not required if the disenrollment is a result of the

MA plan termination or service area or continuation area reduction, since a hearing would not

be appropriate for that type of disenrollment. There are different notice requirements for

terminations and service area reductions, which are provided in separate instructions to MA

organizations.)

For disenrollments effectuated by CMS due to incarceration or nonpayment of Part D-IRMAA, the

disenrollment notice must advise the member that the plan has disenrolled him or her, why such action

is occurring and be mailed within ten (10) calendar days of receiving the disenrollment DTRR from

CMS.

Plans are strongly encouraged, but not required, to send notices for certain CMS-effectuated

disenrollments, including:

• Death (Exhibit 13);

• Loss of entitlement (Exhibit 14); and

• Unlawful presence in the United States (Exhibit 38).

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For plans that provide disenrollment notices for these situations, the disenrollment notices should

advise the member that the plan has disenrolled him or her and why such action is occurring. Plans are

encouraged to mail these notices within ten (10) calendar days of receiving the disenrollment DTRR

from CMS.

Medigap Guaranteed Issue Notification Requirements for Disenrollments to Original Medicare

during a SEP

MA organizations are required to notify members of their Medigap guaranteed issue rights when

members disenroll to Original Medicare during a SEP. Model language discussing these Medigap

rights has been provided in Exhibit 11 and Exhibit 12.

There may be cases when a Medigap issuer requires the beneficiary to provide additional

documentation that they disenrolled as a result of an SEP and are eligible for such guaranteed issue

rights. A beneficiary may contact you for assistance in providing such documentation. The MA

organization may provide such a notice to the beneficiary upon request (see Exhibit 24).

50.2.1 - Members Who Change Residence

MA organizations may offer (or continue to offer) extended “visitor” or “traveler” programs to

members of coordinated care plans who have been out of the service area for up to 12 months. The

MA organizations that offer such programs do not have to disenroll members in these extended

programs who remain out of the service area for more than 6 months but less than 12 months. As

mentioned at 42 CFR 422.74(d)(4)(iii), MA organizations offering a plan with a visitor/traveler

program must make this option available to all enrollees who are absent for an extended period from

the MA plan’s service area. However, MA organizations may limit this option to enrollees who travel

to certain areas, as defined by the MA organization, and who receive services from qualified

providers. Organizations offering MA-PFFS plans may allow continued enrollment of individuals

absent from the plan service area for up to 12 months, given that PFFS plans provide access to plan

benefits and services from providers located outside the plan service area.

MA organizations offering plans without these programs must disenroll members who have

been out of the service area for more than 6 months.

An SEP, as defined in §30.4.1, applies to individuals who are disenrolled due to a change in residence.

An individual may choose another MA or Part D plan (either a PDP or MA-PD) during this SEP.

50.2.1.1 - General Rule

The MA organization must disenroll a member if:

1. He/she permanently moves out of the service area and his/her new residence is not in a

continuation area;

2. The member’s temporary absence from the service area (or continuation area, for continuation

of enrollment members) exceeds 6 consecutive months;

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3. The member is enrolled in an MA plan that offers a visitor/traveler program and his/her

temporary absence exceeds 12 consecutive months (or the length of the visitor/traveler

program if less than 12 months);

4. The member is an out-of-area member (as defined in §10), and permanently moves to an area

that is not in the service area or continuation area;

5. He/she permanently moves out of the continuation area of an MA local plan and his/her new

residence is not in the service area or another continuation area of the MA local plan;

6. The member permanently moves out of the service area (or continuation area, for continuation

of enrollment members in MA local plans) and into a continuation area, but chooses not to

continue enrollment in the MA local plan (refer to §60.7 for procedures for choosing the

continuation of enrollment option);

7. The member is an out-of-area member (as defined in §10), who leaves his/her residence for

more than 6 months;

8. The member is incarcerated and, therefore, resides out of area for the duration of the

incarceration.

50.2.1.2 - Effective Date of Disenrollment

Generally disenrollments for reasons 1, 4, 5, 6 and 8 above are effective the first day of the calendar

month after the date the member begins residing outside of the MA plan’s service area (or

continuation area, as appropriate) AND after the member or his or her legal representative notifies the

organization that he or she has moved and no longer resides in the plan service area. In the case of an

individual who provides advance notice of the move, the disenrollment will be the first of the month

following the month in which the individual indicates he or she will be moving.

In the case of incarcerated individuals, CMS will involuntarily disenroll individuals who are

incarcerated based on data CMS receives from SSA. CMS will report the disenrollments to the

organization via the daily DTRR using a specific Transaction Reply Code (TRC). For all such

disenrollments, the effective date of disenrollment will be the first of the month after the incarceration

start date.

MA organizations may receive notification of the individual’s possible incarceration status via another

source. In this situation, the MA organization needs to investigate and, following processes in

§50.2.1.3, determine if the member resides in the plan’s service area and, if appropriate, involuntarily

disenroll the member. If the incarceration information is received from a public entity or other source

with direct access to confirmed incarceration data, such as a penal facility, state Medicaid agency or

other state or federal agency, additional investigation is not necessary. Disenrollment is effective the

first of the month following the organization’s confirmation of a current incarceration. The MA

organization is required to send notification of the disenrollment to the member.

If the member establishes that a permanent move occurred retroactively and requests retroactive

disenrollment (not earlier than the first of the month after the move), the MA organization can submit

this request to CMS (or its designee) for consideration of retroactive action.

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Disenrollment for reasons 2 and 7 above is effective the first day of the calendar month after 6

months have passed. Disenrollment for reason 3 is effective the 1st day of the 13th month (or the

length of the visitor/traveler program if less than 12 months) after the individual left the service area.

Unless the member elects another Medicare managed care plan during an applicable election period,

any disenrollment processed under these provisions will result in a change to enrollment in Original

Medicare.

50.2.1.3 - Researching and Acting on a Change of Address

Within ten (10) calendar days of receiving a notice of a change of address or an indication of possible

out-of-area residency from the member, the member’s legal representative, a CMS DTRR, or another

source, the MA organization must make an attempt to contact the member to confirm whether the

move is permanent (may use Exhibit 34 if contacting the member in writing). The MA organization

must also document its efforts. The requirement to attempt to contact the member does not apply to a

prospective enrollment for which the organization receives either transaction reply code 011

(Enrollment Accepted) or 100 (PBP Change Accepted as Submitted) accompanied by 016 (Enrollment

Accepted – Out of Area) on the same DTRR, as these represent new enrollments for which the

organization recently confirmed the individual’s permanent residence in the plan service area. MA

organizations may obtain either written or verbal verification of changes in address, as long as the MA

organization applies the policy consistently among all members.

In the case of individuals for which the plan learns of possible incarceration status from a source other

than CMS, the MA organization must confirm the individual’s out of area (i.e., incarcerated) status.

Confirmation may include contacting the individual or other sources to determine confirmation of

incarceration and incarceration start and end dates, if applicable. As described in §50.2.1.2, additional

investigation is not necessary if the incarceration information is received from a public entity or other

source with direct access to confirmed incarceration data. When an organization is notified of a current

member’s past period of incarceration and has confirmed that this member’s period of incarceration

has ended (i.e. individual is no longer incarcerated), the organization must continue the individual’s

enrollment, unless otherwise directed by CMS.

If the MA organization confirms an individual’s current incarceration status but does not obtain the

start date of the current incarceration, the organization must disenroll the individual prospectively for

the first of the month following the date on which the current incarceration was confirmed. If the MA

organization confirms an individual’s current incarceration status as well as the start date of the current

incarceration, the organization must disenroll the individual for the first of the month following the

start date of the incarceration. If that disenrollment effective date is outside the range of effective

dates allowed by MARx (based on the current calendar month), the MA organization must submit the

retroactive disenrollment request to the CMS Retroactive Processing Contractor (see §60.5).

The MA organization must retain documentation from the member or member’s legal representative of

the notice of the change in address, including the determination of whether the member’s out-of-area

status is temporary or permanent.

1. If the MA organization receives notice of a permanent change in address from the member

or the member’s legal representative, and the new address is outside the MA plan’s service

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area (or continuation area, for continuation of enrollment members), the MA organization must

disenroll the member and provide proper notification (Exhibit 36). The only exception is if the

member has permanently moved into the continuation area and chosen the continuation of

enrollment option (procedures for electing a continuation of enrollment option are outlined in

§60.8).

2. If the MA organization receives notice (or indication) of a potential change in address from a

source other than the member or the member’s legal representative, and the new address

is outside the MA plan’s service area (or continuation area, for continuation of enrollment

members), the MA organization may not assume the move is permanent until it has received

confirmation from the member, the member’s legal representative or, for incarcerated

individuals, public sources (such as a state/federal government entity or other public records).

The MA organization must initiate disenrollment when it verifies a move is permanent or when

the member has been out of the service area (or continuation area, for continuation of

enrollment members) for six months from the date the MA organization learned of the change

in address. The MA organization must notify the member in writing of the disenrollment. If the

member responded and confirmed the permanent move out of the service area, the MA

organization must send the notice (Exhibit 36) within 10 calendar days of the member’s

confirmation that the move is permanent. If the member failed to respond to the request for

address confirmation the MA organization must send the notice (Exhibit 35) in the first ten

days of the sixth month from the date the MA organization learned of the change in address.

MA organizations may consider the six months to have begun on the date given by the

beneficiary as the date that he/she will be leaving the service area. If the beneficiary did not

inform the MA organization of when he/she left the service area, the MA organization can

consider the six months to have begun on the date it received information regarding the

member’s potential change in address (e.g. DTRR, out-of-area claims).

If the member does not respond to the request for verification within the time frame given by

the MA organization, the MA organization cannot assume the move is permanent and may not

disenroll the member until six months have passed. The MA organization may continue its

attempts to verify address information with the member.

3. Temporary absences - If the MA organization determines the change in address is temporary,

the MA organization may not initiate disenrollment until six months have passed from the date

the MA organization received information regarding the member’s absence from the service

area (or from the date the member states that his/her address changed, if that date is earlier).

If the MA organization offers a visitor/traveler program, the MA organization must initiate

disenrollment if it learns that the individual continues to remain out of the service area during

the 12 months (or the length of its visitor/traveler program if less than 12 months).

50.2.1.4 - Procedures for Developing Addresses for Members Whose Mail is Returned as

Undeliverable

If an address is not current, the USPS will return any materials mailed first-class by the organization as

undeliverable.

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In the event that any member materials are returned as undeliverable, the organization must take the

following steps:

1. If the USPS returns mail with a new forwarding address, forward plan materials to the

beneficiary and advise the plan member to change his or her address with the Social Security

Administration.

2. If the organization receives documented proof of a beneficiary change that is outside of the

plan service area or mail is returned without a forwarding address, follow the procedures

described in §50.2.1.3.

3. If the organization receives claims for services from providers located outside the plan service

area, the organization may choose to follow up with the provider to obtain the member’s

address.

4. If the organization is successful in locating the beneficiary, advise the beneficiary to update

records with the Social Security Administration by:

a. Calling their toll-free number, 1-800-772-1213. TTY users should call 1-800-325-0778

weekdays from 7:00 a.m. to 7:00 p.m. EST;

b. Going to http://www.ssa.gov/changeaddress.html on the SSA website; or

c. Notifying the local SSA field office. A beneficiary can get addresses and directions to

SSA field offices from the Social Security Office Locator which is available on the

Internet at: http://www.socialsecurity.gov/locator/.

An organization is expected to continue to mail materials to the member’s address of record. If the

postal service returns a piece of beneficiary communication to the organization, the plan should

document the return and retain the returned material. It should continue to send future correspondence

to that same address, as a forwarding address may become available at a later date. Additionally, CMS

encourages the MA organization to continue its efforts, as discussed above, to attempt to locate the

beneficiary using any available resources, including CMS systems, to identify new address

information for the beneficiary. If a forwarding address becomes available, an organization can send

materials to that address as in item #1 above.

50.2.1.5 - Notice Requirements

1. MA organization notified of out-of-area permanent move - When the organization receives

notice of a permanent change in address from the member or the member’s legal

representative, it must provide notification of disenrollment to the member. This notice to the

member, as well as the disenrollment transaction to CMS, must be sent within ten (10) calendar

days of the MA organization’s learning of the permanent move.

In the notice, the MA organization is encouraged to inform the member who moves out of the

service area that he or she may have certain Medigap enrollment opportunities available to

them. These opportunities end 63 days after coverage with the MA organization ends. The MA

organization can direct the beneficiary to contact the State Health Insurance Assistance

Program (SHIP) for additional information on Medigap insurance.

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In the case of incarcerated individuals disenrolled by CMS, we will report the disenrollments to

the organization via the daily DTRR using a specific TRC. An MA organization must send

each affected individual a written notice of the disenrollment within ten (10) calendar days of

receipt of the DTRR indicating disenrollment due to incarceration.

2. Out of area for 6 months - When the member has been out of the service area for 6 months

after the date the MA organization learned of the change in address from a source other than

the member or the member’s legal representative (or the date the member stated that his

address changed, if that date is earlier), the MA organization must provide notification of the

upcoming disenrollment to the member. Organizations are encouraged to follow up with

members and to issue interim notices prior to the expiration of the 6 month period.

The notice of disenrollment must be provided within the first ten calendar days of the sixth

month. The transaction to CMS must be sent within three (3) business days following the

disenrollment effective date.

This notice must also be provided to out-of-area members (as defined in §10) who leave their

residence and that absence exceeds six (6) months.

The CMS strongly encourages that MA organizations send a final confirmation of

disenrollment notice to the member to ensure the individual does not continue to use MA

organization services.

EXAMPLE: MA organization receives a DTRR on January 20 indicating an “out of area”

State and County Code. The 6-month period ends on July 20. The MA organization sends a

notice to the member within ten (10) calendar days of receipt of the DTRR and does not

receive any response from the member indicating this information is incorrect. Therefore,

the MA organization will proceed with the disenrollment, effective August 1. The MA

organization sends a notice to the member during the first ten (10) calendar days of July

notifying him that he will be disenrolled effective August 1. The transaction to CMS must

be sent no later than three (3) business days following July 31.

3. Visitor/Traveler Program Option - When the member has been out of the service area for 12

months (or the length of its visitor/traveler program if less than 12 months), the MA

organization must provide notification of the upcoming disenrollment to the member.

The notice of disenrollment must be provided during the first ten calendar days of the 12

month (or the length of its visitor/traveler program). The transaction to CMS must be sent

within 3 business days following the disenrollment effective date.

The CMS strongly encourages that MA organizations send a final confirmation of

disenrollment notice to the member to ensure the individual does not continue to use MA

organization services.

50.2.2 - Loss of Medicare Part A or Part B

With the exception of Medicare Part B-only grandfathered members (as described in §§20.6 and 50.6),

the MA organization cannot retain a member in an MA plan if the member is no longer entitled to both

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Medicare Part A and Part B benefits. The organization will be notified by CMS that entitlement to

either Medicare Part A or Part B has ended, and CMS will make the disenrollment effective the first

day of the month following the last month of entitlement to either Medicare Part A or Part B benefits

(whichever occurred first).

If a member loses entitlement to Medicare Part A, the MA organization may not allow the member to

remain a member of the plan and receive Medicare Part B-only services. In addition, the MA

organization may not offer Part A-equivalent benefits and charge a premium for such coverage to

members who lose entitlement to Medicare Part A. Likewise, if a member loses entitlement to

Medicare Part B at any time, the MA organization may not allow the member to remain in the MA

plan.

Notice Requirements - CMS strongly suggests that notices be provided when the disenrollment is due

to the loss of entitlement to either Medicare Part A or Part B (see Exhibit 14) so that any erroneous

disenrollments can be corrected as soon as possible. In cases of erroneous disenrollment and

notification, see §60.3.1.

50.2.3 - Death

The CMS will disenroll a member from an MA organization upon his/her death and CMS will notify

the MA organization that the member has died. This disenrollment is effective the first day of the

calendar month following the month of death. Organizations may not submit disenrollment

transactions to CMS in response to the apparent death of a member. If the eligibility query shows a

date of death, the MA organization must submit the enrollment only when the date of death is equal to

or greater than the effective date. In anticipation of official notification from CMS via the DTRR,

organizations may, at their discretion, make note of the reported death in internal plan systems in order

to suppress premium bills and member notices.

Notice Requirements – Following receipt of a CMS notification (via DTRR) of disenrollment due to

death, CMS strongly suggests that a notice be sent to the member or the estate of the member (see

Exhibit 13) so that any erroneous disenrollments can be corrected as soon as possible. In cases of

erroneous disenrollment and notification, see §60.3.1.

50.2.4 - Terminations/Nonrenewals

The MA organization must disenroll a member from an MA plan if the MA organization contract is

terminated or if the MA organization discontinues offering the plan or reduces its service area to

exclude the member.

A member who is disenrolled under these provisions has an SEP, as described in §30.4.3, to elect a

different MA plan or Original Medicare. A member who fails to make an enrollment request during

this SEP is deemed to have elected Original Medicare.

EXCEPTION

MA organizations can offer an option to continue enrollment in an MA local plan in the organization

to members affected by MA plan service area reductions in areas where no other MA plans are

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available at that time. If the organization chooses to offer this option, it must notify CMS, and must

notify members in the beneficiary non-renewal notification letter.

Members must indicate their desire to take advantage of this option. Members who take this option to

continue enrollment become known as “out-of-area members,” as defined in §10. The organization

may require individuals who choose to continue enrollment in an MA local plan in the organization to

agree to receive the full range of basic benefits (excluding emergency and urgently needed care, renal

dialysis, and post stabilization) exclusively at facilities designated by the MA organization within the

MA local plan service area.

Notice Requirements - The MA organization must give each Medicare member a written notice of

the effective date of the termination or service area or continuation area reduction, and include a

description of alternatives for obtaining benefits under the Medicare program. Required time frames

for these notices are outlined in

42 CFR 422.506 - 422.512.

50.2.5 – Loss of Special Needs Status

A SNP can determine to continue to provide care for an individual that no longer meets the unique

eligibility criteria of the plan (i.e., special needs status), if the individual can reasonably be expected to

again meet the special needs criteria within a period of time not to exceed six (6) months. For

example, a dual eligible individual who loses Medicaid eligibility can be deemed to continue to be

eligible for the plan if that individual would likely regain eligibility within six months. The SNP may

choose any length of time from one month to six months for deeming continued eligibility, as long as

it applies the criteria consistently to all members of the plan and fully informs members of its policy.

CMS expects the plan to take into account the ability to meet the needs of an individual that no longer

meets special needs status if and when applying the period of deemed continued eligibility. If the

member of a SNP does not re-qualify within the plan’s period of deemed continued eligibility, the

SNP should involuntarily disenroll him or her, with proper notice, at the end of this period. The period

of deemed continued eligibility begins the first of the month following the month in which information

regarding the loss is available to the organization and communicated to the enrollee, including cases of

retroactive Medicaid terminations.

For information on premiums, benefits and cost sharing during the period of deemed continued

eligibility, see Chapter 16b of the Medicare Managed Care Manual.

If the SNP is unable to provide continuity of care to a member who loses eligibility, the organization is

expected to involuntarily disenroll the member. For example, when a member of an institutional SNP

leaves the long-term care facility, he or she should be disenrolled from that SNP if the SNP providers

are limited to those within the facility.

Regardless of the date on which the beneficiary loses special needs status, the organization must

provide him/her with a minimum of 30 days advance notice of disenrollment.

Refer to Chapters 1 and 16b of the Medicare Managed Care Manual for additional information on

Special Needs Plans.

Notice Requirements - The SNP is expected to provide each member a written notice regarding the

loss of special needs status within 10 calendar days of learning of the loss of special needs status. This

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notice should provide the member an opportunity to prove that he or she is still eligible to be in the

plan. In addition, the notice should include information regarding the period of deemed continued

eligibility, including its duration, a complete description of the SEP for which such individuals are

eligible (see §30.4.4, item #10), the consequences of not regaining special needs status within the

period of deemed continued eligibility and the effective disenrollment date (see Exhibit

32). Organizations are encouraged to follow up with members and to issue interim notices prior to the

expiration of the period of deemed continued eligibility.

In the event the individual fails to regain special needs status during the period of deemed continued

eligibility, the SNP is expected to provide the individual a written notice regarding involuntary

disenrollment (see Exhibit 33)

and must submit a disenrollment transaction to CMS. The disenrollment

notice to the individual and the transaction to CMS should be sent within 3 business days following the last

day

of the period of deemed continued eligibility; however, in no case should the disenrollment notice to

the individual be sent after the transaction is submitted to CMS

In the event the SNP fails to process disenrollments timely, the organization is expected to take the

following action(s):

a. If the SNP has not provided timely notification to the member of the potential for involuntary

disenrollment due to loss of special needs status (see Exhibit 32), the SNP should provide

this notice to the member and include a proposed disenrollment date that provides the

member the full length of the period of deemed continued eligibility. The SNP may not

shorten the grace period due its delay in issuing the notice.

b. If the SNP has not provided timely notification to the member of the involuntary

disenrollment due to loss of special needs status (see Exhibit 33), the SNP should provide

this notice to the member, revise the disenrollment date accordingly and include an

explanation of the delay and of the revised disenrollment date.

50.2.6 – Failure to Pay a Part D-Income Related Monthly Adjustment Amount

(Part D-IRMAA)

Individuals with Part D-IRMAA must pay this additional premium directly to the government, not to

their plans. CMS has established a 3-month initial grace period before individuals in an MA plan with

Part D coverage (MA-PD) who fail to pay their assessed Part D-IRMAA will be disenrolled from the

MA-PD plan. CMS will report the disenrollments to the organization via the daily DTRR using a

specific Transaction Reply Code (TRC). The effective date of the disenrollment is the first of the

month following the end of the initial grace period.

EXAMPLE: Ms. Jones owes a Part D-IRMAA. CMS bills Ms. Jones her monthly Part D-IRMAA

amount in March, April and May. Ms. Jones does not pay all the Part D-IRMAA amounts owed by the

due date of the May bill. CMS generates a disenrollment and sends the plan a specific TRC via the

daily DTRR. The effective date of the disenrollment will be June 1.

An MA organization must send each affected individual a written notice of the disenrollment within

ten (10) calendar days of receipt of the DTRR indicating disenrollment for non-payment of the Part D-

IRMAA.

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Notice Requirements - MA organizations are required to notify members of their disenrollment due

to failure to pay Part D-IRMAA (see Exhibit 21a.)

When an individual fails to pay both Part D-IRMAA and the plan premium, and the disenrollment

effective dates are the same, the TRC for the disenrollment action will reflect the first disenrollment

transaction that is processed by MARx. For example, if the plan-generated disenrollment transaction,

resulting from the failure to pay plan premiums, is processed by MARx before CMS initiates a

disenrollment transaction for failure to pay Part D-IRMAA, the TRC will reflect the plan-generated

disenrollment. Thus, plans would issue Exhibit 21 as outlined in Section 50.3 regarding notice

requirements.

Similarly, if the CMS-generated disenrollment transaction for failure to pay Part D-IRMAA is

processed first, plans will receive the TRC reflecting this action. In such cases, CMS will be unable to

process the plan-generated disenrollment transaction (because the individual is already disenrolled);

however, plans may review their own billing records to determine if an individual was slated for

disenrollment for non-payment of plan premiums. If so, and the effective date of the disenrollment

matches the Part D-IRMAA disenrollment effective date, plans have three options for notifying

beneficiaries:

1. Plans may send the notice for failure to pay Part D-IRMAA (Exhibit 21a);

2. Plans may send both the notice for failure to pay Part D-IRMAA (Exhibit 21a) and the

plan notice for failure to pay premiums (Exhibit 21); or

3. Plans may send the plan notice for failure to pay premiums and include information

regarding the Part D-IRMAA disenrollment (Exhibit 21).

Reinstatement for Good Cause – Individuals involuntarily disenrolled from their MA-PD plan for

failure to pay Part D-IRMAA have the opportunity to ask CMS for reinstatement into the plan from

which they were disenrolled. CMS may reinstate enrollment, without interruption of coverage, if the

individual demonstrates good cause and pays in full within three (3) calendar months of the

disenrollment effective date:

• The Part D-IRMAA amounts that caused the disenrollment for nonpayment of Part D-IRMAA,

and

• Any plan premium amounts owed at the time he or she was disenrolled.

For more information on good cause, see §60.3.4.

50.2.7 – Unlawful Presence Status

The MA organization cannot retain a member in a MA plan if the member is not lawfully present in

the United States. The organization may not request from a member any documentation of U.S.

citizenship or alien status, as CMS provides the official status to the MA organization. CMS will

notify the organization (via DTRR) that the individual is not lawfully present, and CMS will make the

disenrollment effective the first day of the month following the notification by CMS.

Notice Requirements – Following the receipt of a CMS notification (via DTRR) of the disenrollment

due to unlawful presence, CMS strongly suggests that a notice be provided within ten (10) calendar

days of receipt of the DTRR (see Exhibit 38) so that the member is aware of the loss of coverage in the

plan and any erroneous disenrollments can be corrected as soon as possible. See §60.3.1 for cases of

possible erroneous disenrollment or notification.

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50.3 - Optional Involuntary Disenrollments

An MA organization may disenroll a member from an MA plan it offers if:

• Premiums are not paid on a timely basis (§50.3.1);

• The member engages in disruptive behavior (§50.3.2); or

• The member provides fraudulent information on an enrollment request, or if the member

permits abuse of an enrollment card in the MA plan (§50.3.3).

Notice Requirements - In situations where the MA organization disenrolls the member involuntarily

for any of the reasons addressed above, the MA organization must send notice of the upcoming

disenrollment that meets the following requirements:

• Advises the member that the MA organization is planning to disenroll the member and why

such action is occurring;

• Provides the effective date of termination; and

• Includes an explanation of the member’s right to a hearing under the MA organization’s

grievance procedures.

Unless otherwise indicated, all notices must be mailed to the member before submission of the

disenrollment transaction to CMS.

50.3.1 - Failure to Pay Premiums

42 CFR 422.74(d) and Section 504 of the Rehabilitation Act of 1973

(Rev. 1, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

MA organizations may not disenroll a member who fails to pay MA plan cost sharing under this

provision. However, an MA organization has three options when a member fails to pay the MA plan’s

basic and supplementary premiums. This includes any Part D late enrollment penalty (per Chapter 4 of

the Medicare Prescription Drug Benefit Manual).

For each of its MA plans (i.e. each PBP), the MA organization must take action consistently among all

members of the discrete plan. For example, an MA organization may have different policies among

each of its plans, but it may not have different policies within a plan (other than the optional exception

for dual-eligible individuals and individuals who qualify for the Part D low income subsidy, as

described below).

The MA organization may:

1. Do nothing, (i.e., allow the member to remain enrolled in the same premium plan);

2. Disenroll the member after a grace period and proper notice; or

3. If the member fails to pay the premium for optional supplemental benefits (that is, a package of

benefits that the member is not required to accept), but pays the premium for basic and

mandatory supplemental benefits, reduce the member’s coverage (also known as “downgrade”)

by discontinuing the optional supplemental benefits and retaining the member in the same plan

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after proper notice. Given these requirements for a downgrade, this option is available only for

MA plans that have optional supplemental benefits offered at a higher premium than the basic

benefit package. Such an action would be considered an addendum to the member’s original

request to enroll in the MA plan, and would not be considered a new enrollment request. Refer

to Chapter 4 (Benefits and Beneficiary Protections) for a definition of “basic benefit,”

“mandatory supplement,” and “optional supplemental benefits.”

If an MA organization chooses to disenroll members for failure to pay premiums, it must apply its

disenrollment policy consistently to all members of a plan including applying a consistent grace period

of no less than two (2) months. Additionally, the organization must promptly effectuate such

disenrollments at the end of the plan’s grace period for payment of premiums.

The MA organization may increase the length of the initial grace period or establish a policy of not

disenrolling members for failure to pay the plan premium during the calendar year. For example, an

MA organization may increase the grace period from 2 months to 6 months to ease the burden for

individuals affected by a natural disaster; however, it must provide this extended grace period to

everyone in the PBP and not only those in the area affected by the natural disaster. An organization

must report any changes to its policy for disenrollment for failure to pay premiums to its CMS account

manager before implementing such changes.

If the MA organization chooses to disenroll the member or reduce coverage, the action may only be

accomplished after the MA organization has made a reasonable effort to collect the premium and

notice has been provided (as described below). If payment has not been received within the grace

period, the individual will be disenrolled (or coverage reduced, as applicable).

Organizations may not disenroll members for failure to pay premiums (or notify them of impending

disenrollment) in cases where the member has requested that premiums be withheld from his/her

Social Security benefit check until the organization receives a reply from CMS indicating that the

member’s request has been rejected. The organization must then notify the member of the premium

owed, provide the appropriate grace period, and comply with other applicable requirements prior to

disenrolling the member.

Organizations may not involuntarily disenroll individuals who are considered to be in premium

withhold status by CMS. Individuals who have requested premium withhold are considered to

remain in premium withhold status until either (1) CMS notifies the organization that the premium-

withhold request has rejected, failed, or been unsuccessful; or (2) the member requests that he/she be

billed directly. Only after one of these actions occurs may a member’s status be changed to “direct

bill.” Once the member is considered to be in “direct bill” status, the organization must notify the

member of the premium owed and provide the appropriate grace period, as described below.

Organizations must always provide members the opportunity to pay premiums owed before initiating

any disenrollment action.

However, even if a member’s premium payment status has been changed to “direct bill,” if the

member can demonstrate that Social Security Administration (SSA) or the Railroad Retirement Board

(RRB) has withheld Part C and/or Part D premiums during the coverage month(s) in question, the

member will be considered to remain in premium withhold status. Such a member cannot be

disenrolled for failure to pay his/her premium(s), whether or not the organization actually receives

these premiums on a timely basis.

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Example 1 – Incorrect Continuation of Premium Withhold: Individual was enrolled in Plan

A and selected premium withhold. Individual subsequently enrolls in Plan B and does not select

premium withhold. Upon receiving a direct bill from Plan B, the individual provides Plan B with

proof that a premium deduction continues from his SSA benefit check. Since the member

provided Plan B with evidence that a premium amount is currently being deducted from his

check, Plan B cannot initiate the process to disenroll the individual for failure to pay premiums.

Plan B must work with CMS to obtain appropriate premium reimbursement.

Further, an individual will continue to be considered in premium withhold status if an organization is

notified by CMS that the member’s request for premium withholding is not successful as a result of

systems/fund transfer issues between CMS and SSA or RRB, or between CMS and the organization.

CMS recognizes that in some instances organizations have not received premium amounts in their

monthly CMS plan payment for members who have elected SSA or RRB withholding; however,

organizations cannot hold their members responsible for such issues, nor penalize them by attempting

to disenroll them from their plan. Therefore, the organization may not initiate the billing (and

subsequent disenrollment process, if necessary) until a member is in “direct bill” status.

Example 2 – Incorrect Data Due to Systems Miscommunication: An individual requests

premium withhold, and Plan A correctly submits the request to CMS. The transaction request is

submitted successfully by CMS to SSA or RRB and the appropriate premium amount is deducted

from the individual’s SSA or RRB benefit check. However, due to a systems issue between CMS

and SSA or RRB, the premium withhold data is not correctly reflected in CMS systems. Thus,

CMS does not pay the correct premium amount to Plan A. Plan A must work with CMS to obtain

appropriate premium reimbursement and may not initiate the disenrollment process for the

individual for failure to pay premiums while the premium continues to be withheld.

In addition, organizations may not disenroll a member or initiate the disenrollment process if the

organization has been notified that the Part D portion of the premium is being paid by a SPAP, or

other payer, and the organization has not yet coordinated receipt of the premium payments with the

SPAP or other payer (refer to §50.6 of Chapter 14 of the Medicare Prescription Drug Benefit Manual

for additional information regarding coordination of premium payments).

While the MA organization may accept partial payments, it has the right to ask for full payment within

the grace period. If the member does not pay the required amount within the grace period, the effective

date of disenrollment or reduction in coverage is the first day of the month after the period ends.

Unless the member elects another MA plan during an applicable election period, any disenrollment

processed under these provisions will always result in a change of enrollment request to Original

Medicare. The MA organization has the right to take action to collect the unpaid premiums from

the beneficiary at any point during or after this process.

If a member is disenrolled for failure to pay premiums and attempts to re-enroll in the organization,

the MA organization may require the individual to pay any outstanding premiums owed to the MA

organization before considering the enrollment request to be “complete.”

If the individual is involuntarily disenrolled for failure to pay premiums, in order to re-enroll in that

plan, or to enroll in another plan, the individual must request enrollment during a valid period.

Payment of past due premiums after the disenrollment date does not create an opportunity for

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reinstatement into the plan from which the individual was disenrolled for failure to pay premiums.

Likewise, disenrollment for failure to pay premiums does not, in itself, provide the beneficiary an

opportunity (SEP) to enroll in a different MA plan.

Calculating the Grace Period

An MA organization must provide plan enrollees with a grace period of not less than 2 calendar

months; however, it may provide a grace period that is longer than 2 calendar months, at its discretion

(e.g. organizations may elect to provide a 3-month initial grace period to match the Part D-IRMAA

initial grace period), provided that similarly situated enrollees are treated equally. The grace period

must be a whole number of calendar months and cannot include fractions of months. The grace period

cannot begin until the individual has been notified of (billed for) the actual premium amount due, with

such notice/bill specifying the due date for that amount and providing an opportunity to pay. For new

enrollees of an MA-PD plan, the MA organization must wait until notified by CMS of the actual Part

D premium which the beneficiary is responsible for paying directly before the individual can be

notified of/billed for the amount due; for these individuals, the due date cannot be until after the

organization receives notification from CMS as to the beneficiary’s premium and notifies the

individual of the amount due. The grace period may begin no earlier than the first of the month for

which the premium was unpaid.

NOTE: For individuals who have requested communications in an accessible format, the grace period

cannot begin until the organization provides notification (e.g. the bill) in an accessible format.

MA organizations have the following options in calculating and applying the grace period. The

organization must apply the same option for all members of a plan.

Option 1 - MA organizations may consider the grace period to end not less than 2 calendar

months after the first day of the month for which premium is unpaid.

If the overdue premium and all other premiums that become due during the grace period (in

accordance with the terms of the member’s agreement with the MA organization) are not paid in full

by the end of the grace period, the MA organization may terminate or reduce the member’s coverage.

As mentioned previously, the individual must be notified of/billed for the actual premium amount due

before the premium can be considered “unpaid.” For new enrollees, at a minimum, this cannot occur

until CMS notifies the organization of the total premium due from the individual. Upon CMS

notification, the organization would notify the individual of the amount due, with a prospective due

date.

Under this scenario, MA organizations are encouraged to send subsequent notices as reminders or to

show that additional premiums are due. Subsequent notices, therefore, should determine the

expiration date of the grace period by reference to this date. Notice requirements are summarized in

this section under the heading “notice requirements.”

EXAMPLE A: Plan XYZ has a 2-month grace period for premium payment. Plan member Mr.

Stone’s premium was due on February 1, 2009. He did not pay this premium and on February 7

the MA organization sent an appropriate notice. Mr. Stone ignores this notice and any subsequent

premium bills. The grace period is the months of February and March. If Mr. Stone does not pay

his plan premium before the end of March, he will be disenrolled as of April 1, 2009.

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EXAMPLE B: Plan QRS has a 3-month grace period for premium payment. Plan member Mrs.

Monsoon’s premium was due on July 1, 2009. She did not pay this premium and on July 6

, the

MA organization sent an appropriate notice. Mrs. Monsoon ignores this notice and subsequent

premium bills. The grace period is the months of July, August and September. If Mrs. Monsoon

does not pay her owed premiums by the end of this period (September 30), she will be disenrolled

effective October 1, 2009.

In short, the MA organization may require that the member pay the overdue premiums in full within

the grace period, as well as all other payments becoming due within that period, in order to avoid

disenrollment (or a reduction in coverage, where applicable). If the MA organization requires the

member to make full payment within the grace period and pay all premiums falling due within that

period; however, the MA organization must state so in its initial delinquency notice to the member.

Option 2 - MA organizations may use a “rollover” approach in applying the grace period.

Under this scenario, the grace period would begin on the first of the month for which the premium is

unpaid, but if the member makes a premium payment within the grace period, the grace period stops

and is revised to reflect the new disenrollment date, depending on the number of months for which

premiums are received. The member would then have a new grace period beginning on the 1

day of

the next month for which the premium is due. The subsequent notice also would have to be sent within

15 calendar days, as described below, of the next premium due date. This process continues until the

member’s balance for delinquent premiums is paid in full or until the grace period expires with no

premium payments being made, at which time the MA organization may disenroll the member.

Organizations are not required to issue new notices each time the member submits a partial premium

payment (i.e. less than one month’s premium), since this would not result in a change in the proposed

disenrollment date. However, since payment of at least one month’s past-due premium causes the

disenrollment date to “roll over” (i.e. move forward) commensurate with the number of month’s

premium received, organizations must issue a notice warning of the potential for involuntary

disenrollment (see Exhibit 19) which includes the new disenrollment date whenever payment of at

least one month’s premium is received during the grace period. These subsequent notices are required

to be sent within 15 calendar days of the premium due date that follows receipt of the premium

payment.

EXAMPLE

Plan WXY has decided to offer a 2 month grace period for non-payment of plan premiums and has

chosen the “rollover” approach to calculating the grace period. A member fails to pay his January

premium due January 1. The MA organization sends a notice to the member on January 7

stating

that his coverage will be terminated if the outstanding premium is not paid within the grace period.

The notice advises him that his termination date would be March 1. The member then pays the

January premium, but does not pay the February premium. The grace period is recalculated to

begin on the 1

of the next month for which the premium is unpaid (February 1). On February 9

the MA organization sends a notice to the member reflecting the new grace period and the new

anticipated termination date of April 1

. The member pays off his balance in full before the grace

period expires; therefore, the member’s coverage in the MA plan remains intact.

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Notice Requirements - If it is the MA organization’s policy to disenroll the member or to reduce

coverage when a member has not paid premiums, the MA organization must send an appropriate

written notice of non-payment of premium to the member within 15 calendar days of the premium

due date (see Exhibit 19

The MA organization may send interim notices after the initial notice.

In addition to the notice requirements outlined in §50.3

, this notice must:

• Alert the member that the premiums are delinquent;

• Provide the member with an explanation of disenrollment procedures advising the member that

failure to pay the premiums within the grace period that began on the 1

of the month for which

premium was unpaid will result in termination or reduction of MA coverage, whichever is

appropriate according to the MA organization policy, and the proposed effective date of this

action;

• Explain whether the MA organization requires full payment within the grace period (including

the payment of all premiums falling due during the intervening days, when and as they become

due, according to the terms of the membership agreement) in order to avoid termination of

membership or reduction in benefits; and,

• Explain the implications of a reduction in coverage (e.g., description of lower level of benefits),

if the MA organization policy is to reduce coverage for the nonpayment of optional supplemental

benefit premiums.

If a notice is returned to the organization as undeliverable, the organization should immediately

implement its procedure for researching a potential change of address (see §§50.2.1.3 and 50.2.1.4) as

well. The beneficiary may have moved out of the service area. If the organization confirms the

permanent move such that a disenrollment date earlier than the end of the grace period is required, the

organization must disenroll the beneficiary for the earlier disenrollment date.

If a member does not pay within the grace period, and the MA organization’s policy is to disenroll the

member, the MA organization must notify the member in writing providing the effective date of the

member’s disenrollment (refer to Exhibit 20) and submit a disenrollment transaction to CMS. The

disenrollment notice to the individual and the transaction to CMS must be sent within 3 business days

following the last day of the grace period; however, in no case may the disenrollment notice to the

individual be sent after the transaction is submitted to CMS. In the event the organization submits a

disenrollment request to CMS and later learns that payment was received timely, a reinstatement

request must be submitted to CMS (or its designee). In addition, CMS strongly encourages that MA

organizations send final confirmation of disenrollment to the member after receiving the DTRR (refer

to Exhibit 21 for a model letter).

If a member does not pay within the grace period, and the MA organization policy is to reduce

coverage by eliminating optional supplemental benefits within the current plan, for the nonpayment of

optional supplemental benefit premiums, the MA organization must notify the member in writing no

later than 3 business days after the expiration of the grace period that the MA organization is reducing

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the coverage and provide the effective date of the change in benefits (refer to Exhibit 22 for a model

letter).

Optional Exception for Dual-Eligible Individuals and Individuals who Qualify for the Low

Income Subsidy

MA organizations offering MA-PD plans have the option to retain dually eligible members and

individuals who qualify for the low income subsidy (LIS) who fail to pay premiums even if the MA

organization has a policy to disenroll members for non-payment of premiums. For MA-only plans,

organizations may retain individuals who are dually eligible for both Medicare and Medicaid (i.e.

individuals who are entitled to Medicare Part A and Part B and receive any type of assistance from the

Title XIX (Medicaid) program).

The MA organization has the discretion to offer this option to dually eligible individuals and

individuals who qualify for LIS within each of its MA plans. If the MA organization offers this option

in one of its plans, it must apply the policy to all such individuals in that MA plan.

The policy to retain individuals is based upon non-payment of premium for the standard benefit

package of the MA plan. If the MA organization chooses this option, any dually eligible individual or

individual who qualifies for LIS who fails to pay premiums for any optional supplemental benefit

offered would be downgraded to the standard benefit package within that MA plan.

CMS requires that organizations provide members advance notice of plan policy changes. An MA

organization will have the discretion as to how it will notify its members of the change, e.g. in an

upcoming newsletter or other member mailing, such as the Annual Notice of Change. CMS

recommends a general statement in such notifications to avoid confusing other members for whom the

policy does not apply.

EXAMPLE: “If you have Medicaid or receive extra help in paying for your Medicare prescription

drugs and are having difficulty paying your plan premiums or cost sharing, please contact us.”

The plan must document this policy internally and have it available for CMS review.

50.3.2 - Disruptive Behavior

42 CFR 422.74(d)(2)

The MA organization may request to disenroll a member if his/her behavior is disruptive to the extent

that his/her continued enrollment in the MA plan substantially impairs the MA organization’s ability

to arrange for or provide services to either that particular member or other members of the plan.

However, the MA organization may disenroll a member for disruptive behavior only after it has met

the requirements of this section and with CMS’ approval. The MA organization may not disenroll a

member because he/she exercises the option to make treatment decisions with which the MA

organization disagrees, including the option of no treatment and/or no diagnostic testing. The MA

organization may not disenroll a member because he/she chooses not to comply with any treatment

regimen developed by the MA organization or any health care professionals associated with the MA

organization.

Before requesting CMS’ approval of disenrollment for disruptive behavior, the MA organization must

make a serious effort to resolve the problems presented by the member. Such efforts must include

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providing reasonable accommodations, as determined by CMS, for individuals with mental or

cognitive conditions, including mental illness and developmental disabilities. The MA organization

must also inform the individual of his or her right to use the organization’s grievance procedures.

The MA organization must submit documentation of the specific case to CMS for review. This

includes documentation:

• Of the disruptive behavior;

• Of the MA organization’s serious efforts to resolve the problem with the individual;

• Of the MA organization’s effort to provide reasonable accommodations for individuals with

disabilities, if applicable, in accordance with the Americans with Disabilities Act;

• Establishing that the member’s behavior is not related to the use, or lack of use, of medical

services;

• Describing any extenuating circumstances cited under 42 CFR 422.74(d)(2)(iii) and (iv);

• That the MA organization provided the member with appropriate written notice of the

consequences of continued disruptive behavior (see Notice Requirements); and

• That the MA organization then provided written notice of its intent to request involuntary

disenrollment (see Notice Requirements).

The MA organization must submit to its CMS Regional Office account manager:

• The above documentation;

• The thorough explanation of the reason for the request detailing how the individual’s behavior

has impacted the MA organization’s ability to arrange for or provide services to the individual

or other members of the MA plan;

• Member information, including age, diagnosis, mental status, functional status, a description of

his or her social support systems and any other relevant information;

• Statements from providers describing their experiences with the member; and

• Any information provided by the member.

The MA organization may request that CMS consider prohibiting re-enrollment in the MA plan (or

plans) offered by the MA organization in the service area.

The MA organization’s request for involuntary disenrollment for disruptive behavior must be

complete, as described above. The CMS Regional Office will review this documentation and consult

with CMS Central Office (CO), including staff with appropriate clinical or medical expertise, and

decide whether the organization may involuntarily disenroll the member. Such review will include any

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documentation or information provided either by the organization and the member (information

provided by the member must be forwarded by the organization to the CMS RO). CMS will make the

decision within 20 business days after receipt of all the information required to complete its review.

The CMS will notify the MA organization within 5 (five) business days after making its decision.

The Regional Office will obtain Central Office concurrence before approving an involuntary

disenrollment. The disenrollment is effective the first day of the calendar month after the month in

which the organization gives the member a written notice of the disenrollment, or as provided by

CMS. Any disenrollment processed under these provisions will always result in a change of

enrollment request to Original Medicare.

If the request for involuntary disenrollment for disruptive behavior is approved, CMS may require the

MA organization to provide reasonable accommodations to the individual in such exceptional

circumstances that CMS deems necessary. An example of a reasonable accommodation in this context

is that CMS could require the MA organization to delay the effective date of involuntary disenrollment

to coordinate with an MA enrollment request or Part D enrollment period that would permit the

individual an opportunity to obtain other coverage. If necessary, CMS will establish an SEP on a case-

by-case basis.

Notice Requirements

The disenrollment for disruptive behavior process requires 3 (three) written notices:

1. Advance notice to inform the member that the consequences of continued disruptive behavior will

be disenrollment;

2. Notice of intent to request CMS’ permission to disenroll the member; and

3. A planned action notice advising that CMS has approved the MA organization’s request.

Advance Notice

Prior to forwarding an involuntary disenrollment request to CMS, the MA organization must provide

the member with written notice describing the behavior it has identified as disruptive and how it has

impacted the MA organization’s ability to arrange for or provide services to the member or to other

members of the MA plan. The notice must explain that his/her continued behavior may result in

involuntary disenrollment and that cessation of the undesirable behavior may prevent this action. The

MA organization must include a copy of this notice and the date it was provided to the member in any

information forwarded to CMS. NOTE: If the disruptive behavior ceases after the member receives

notice and then later resumes, the MA organization must begin the process again. This includes

sending another advance notice.

Notice of Intent

If the member’s disruptive behavior continues despite the MA organization’s efforts, then the MA

organization must notify him/her of its intent to request CMS’ permission to disenroll him/her for

disruptive behavior. This notice must also advise the member of his/her right to use the organization’s

grievance procedures and to submit any information or explanation. Refer to Chapter 13, “Grievances,

Organizations Determinations, and Appeals,” for the appropriate procedures for grievances. The MA

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organization must include a copy of this notice and the date it was provided to the member in any

information forwarded to CMS.

Planned Action Notice

If CMS permits an MA organization to disenroll a member for disruptive behavior, the MA

organization must provide the member with a written notice that, in addition to the notice requirements

outlined in §50.3, a statement that this action was approved by CMS and meets the requirements for

disenrollment due to disruptive behavior described above. The MA organization may only provide the

member with this required notice after CMS notifies the MA organization of its approval of the

request.

The MA organization can only submit the disenrollment transaction to CMS after providing the notice

of disenrollment (Planned Action Notice) to the individual. The disenrollment is effective the first day

of the calendar month after the month in which the MA organization gives the member a written notice

of the disenrollment, or as provided by CMS.

50.3.3 - Fraud and Abuse

42 CFR 422.74(e)(1)

An MA organization may request to cancel the enrollment of a member who knowingly provides, on

the enrollment request form or by another enrollment request mechanism, fraudulent information that

materially affects the determination of an individual’s eligibility to enroll in the plan. The organization

may also request to disenroll a member who intentionally permits others to use his/her enrollment card

to obtain services or supplies from the plan or any authorized plan provider. Such a disenrollment is

effective the first day of the calendar month after the month in which the organization gives the

member the written notice.

When such a cancellation or disenrollment occurs, the organization must immediately notify the CMS

RO so the Office of the Inspector General may initiate an investigation of the alleged fraud and/or

abuse. Any disenrollment processed under these provisions will always result in a change of

enrollment to Original Medicare.

Notice Requirements - The MA organization must give the member a written notice of the

disenrollment that contains the information required at §50.3.

50.4 - Processing Disenrollments

50.4.1 - Voluntary Disenrollments

After receipt of a completed disenrollment request from a member, the MA organization is responsible

for submitting the disenrollment transaction to CMS in a timely, accurate fashion. Such transmissions

must occur within 7 calendar days of receipt of the completed disenrollment request, in order to ensure

the correct effective date.

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The MA organization must maintain a system for receiving, controlling, and processing voluntary

disenrollments from the MA organization. This system should include:

• Dating each disenrollment request as of the date it is received (regardless of whether the request

is complete at the time it is received by the MA organization) to establish the date of receipt;

• Dating supporting documents for disenrollment requests as of the date they are received;

• Processing disenrollment requests in chronological order by date of receipt of completed

disenrollment requests;

• Transmitting disenrollment information to CMS within 7 calendar days of the receipt of the

completed disenrollment request from the individual or the employer or union (whichever

applies). If the disenrollment information is received through the employer or union, the MA

organization must obtain the member’s written disenrollment request from the employer or

union;

• For disenrollment requests received by the MA organization, notifying the member in writing

within ten calendar days after receiving the member’s written request, to acknowledge receipt of

the completed disenrollment request, and to provide the effective date (see Exhibit 11 for a

model letter). MA organizations are encouraged, but not required, to follow up with a

confirmation of disenrollment letter after receiving CMS confirmation of the disenrollment from

the DTRR;

• For all other voluntary disenrollments (i.e., voluntary disenrollments made by the beneficiary

through 1-800-MEDICARE, by enrolling in another MA plan or PDP or by consenting to

passive enrollment into a Medicare-Medicaid demonstration plan, which the MA organization

would not learn of until receiving the DTRR), notifying the member in writing to confirm the

effective date of disenrollment within ten calendar days of the availability of the TRR (see

Exhibits 12 and 12c for model letters). This notice requirement does not apply to a disenrollment

resulting from a member switching from one benefit package to another within the same

organization (i.e., a PBP change), unless enrollment in the new PBP is the result of passive

enrollment into a Medicare-Medicaid demonstration plan.

50.4.2 – When the Disenrollment Request is Incomplete

When the disenrollment request is incomplete, the MA organization must document all efforts to

obtain additional documentation to complete the disenrollment request and have an audit trail to

document why additional documentation was needed before the request could be considered complete.

The organization must make this determination, and within 10 calendar days of receipt of the

disenrollment request, must notify the individual that additional information is needed.

If a written disenrollment request is submitted and the signature is not included, the MA organization

may verify with the individual with a phone call and document the contact, rather than return the

written request as incomplete.

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For AEP disenrollment requests, additional documentation to make the request complete must be

received by December 7, or within 21 calendar days of the request for additional information

(whichever is later). For all other enrollment periods, additional documentation to make the request

complete must be received by the end of the month in which the disenrollment request was initially

received, or within 21 calendar days of the request for additional information (whichever is later).

50.4.3 - Involuntary Disenrollments

The MA organization is responsible for submitting involuntary disenrollment transactions to CMS in a

timely, accurate fashion.

The MA organization must maintain a system for controlling and processing involuntary

disenrollments from the MA organization. This includes:

• Maintaining documentation leading to the decision to involuntarily disenroll the member; and

• For all involuntary disenrollments except disenrollments due to death and loss of Medicare Parts

A and/or B, notifying the member in writing of the upcoming involuntary disenrollment,

including providing information on grievances rights.

In addition, CMS strongly encourages MA organizations to send confirmation of involuntary

disenrollment to ensure the member discontinues use of MA organization services after the

disenrollment date.

50.5 - Disenrollments Not Legally Valid

When a disenrollment is not legally valid, a reinstatement action may be necessary (refer to §60.3 for

more information on reinstatements). In addition, the reinstatement may result in a retroactive

disenrollment from another plan. Since optional involuntary disenrollments (as stated in §50.3) are

considered legal and valid disenrollments, individuals would not qualify for reinstatements in these

cases.

A voluntary disenrollment that is not complete, as defined in §10, is not legally valid. In addition,

there are instances in which a disenrollment that appears to be complete can turn out to be legally

invalid. For example, automatic disenrollments due to an erroneous death indicator or an erroneous

loss of Medicare Part A or Part B indicator are not legally valid.

The CMS also does not regard a voluntary disenrollment as actually complete if the member or his/her

legal representative did not intend to disenroll from the MA organization. If there is evidence that the

member did not intend to disenroll from the MA organization, the MA organization should submit a

reinstatement request to CMS (or its designee). Evidence that a member did not intend to disenroll

may include:

• A disenrollment request signed by the member when a legal representative should be signing for

the member; or

• Request by the member for cancellation of disenrollment before the effective date (refer to §60.2

for procedures for processing cancellations).

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Discontinuation of payment of premiums alone does not necessarily indicate that the member has

made an informed decision to disenroll.

In contrast, CMS believes that a member’s deliberate attempt to disenroll from a plan (e.g. sending a

written request for disenrollment to the MA organization, or calling 1-800-MEDICARE) implies intent

to disenroll. Therefore, unless other factors indicate that this disenrollment is not valid, what appears

to be a deliberate, member-initiated disenrollment should be considered valid.

50.6 - Disenrollment of Grandfathered Members

As discussed in §20.6, any individual who was enrolled in a §1876 risk plan effective December 1,

1998, or earlier, and remained enrolled with the risk plan on December 31, 1998, automatically

continued to be enrolled in the MA organization on January 1, 1999, even if he/she was not entitled to

Medicare Part A or did not live in an MA plan service area or MA organization continuation area.

Disenrollment procedures for grandfathered members are generally the same as those for other

members. The MA organization must disenroll any grandfathered member if:

• The member dies;

• The member loses either Medicare Part A or Part B (or for Part B only members, enrollment in

Medicare Part B ends for the member);

• The member permanently moves into the continuation area, but does not choose to continue

enrollment or moves to an area that is out of the service or continuation area;

• The member permanently moves out of the vicinity, making continued enrollment no longer

reasonable. For example, a move of only a short distance may not affect the member’s ability

to continue to access the plan; therefore, continued enrollment would be reasonable; or,

• The MA organization contract is terminated or the service area or continuation area is reduced

with respect to all MA individuals who live in the area where the individual resides.

NOTE: The member may be offered the option to continue enrollment, as described in

§50.2.4.

50.7 - Disenrollment Procedures for Employer/Union Sponsored Coverage

Terminations

When the contract between an employer or union group and an MA organization is terminated, or the

employer/union determines that a beneficiary is no longer eligible to participate in the employer/union

sponsored MA plan

, the MA organization has the option to follow one of two procedures to disenroll

beneficiaries from the current employer/union sponsored MA plan in which the individual is enrolled:

The employer/union establishes criteria for its retirees to participate in the employer/union sponsored MA plan. These

criteria are exclusive of and in addition to the eligibility criteria for MA enrollment. Eligibility criteria to participate and

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For both of the following options, the MA organization must ensure that the employer or union agrees

to the following:

• The employer or union will provide the MA organization with timely notice of contract

termination or the ineligibility of an individual to participate in the employer or union group

sponsored MA plan. Such notice must be prospective, not retroactive.

• The employer or union must provide a prospective notice to its members alerting them of the

termination event and of other insurance options that may be available to them through their

employer or union.

Option 1: Enroll the individual(s) in another MA plan (i.e. individual plan) offered by the same MA

organization unless the beneficiary makes another choice. The individual must be eligible to enroll in

this plan, including residing in the plan’s service area. The individual plan selected for this option

must be the same type of plan. For example, if the employer/union sponsored plan was an MA-PD

coordinated care plan, the individual plan in this option must be an MA-PD coordinated care plan.

• Beneficiaries may elect another MA plan offered by the employer or union, join Original

Medicare or join another MA plan as an individual member instead of electing the individual

MA plan offered by the same MA organization.

• If the beneficiary prefers not to be enrolled in the individual plan, he/she may contact

the MA organization.

• If the beneficiary would prefer enrolling in a different MA plan as an individual

member, he/she must submit an enrollment request to his/her newly chosen MA

organization.

• If the individual takes no other action, he/she will become a member of the individual plan

offered by the same MA organization that offered the employer/union sponsored plan.

• MA Notice requirements - The MA organization (or the employer or union, acting on its

behalf) must provide prospective notice to the beneficiary that his/her plan is changing,

including information about benefits, premiums, and/or copayments, at least 21 calendar days

prior to the effective date of enrollment in the individual plan.

Option 2: Disenroll individual(s) from the employer/union sponsored MA plan to Original Medicare

following prospective notice.

• MA Notice requirements - The MA organization (or the employer or union, acting on its

behalf) must provide prospective notice to the beneficiary that his/her plan enrollment is

ending at least 21 calendar days prior to the effective date of the disenrollment. The notice

must include information about other individual plan options the beneficiary may choose and

how to request enrollment.

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.

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• If the employer/union sponsored plan was an MA-PD plan, the individual must be advised that

the disenrollment action means the individual will not have Medicare drug coverage. Notice

must include information about the potential for late-enrollment penalties that may apply in the

future.

The MA organization must outline in its written policies and procedures the option(s) it follows and

must apply the same option for all members of a particular employer/union sponsored plan. It is the

MA organization’s responsibility to ensure that the required elements of the disenrollment procedures

described above are understood by the employer or union and are part of the agreement with each

employer or union, including contract termination notification requirements.

50.8 - Disenrollment Procedures for Medicare MSA Plans

Members of Medicare MSA plans may only disenroll in writing through the MA organization offering

the Medicare MSA plan; they may not disenroll through 1-800-MEDICARE. Election periods and

effective dates for disenrollment from Medicare MSA plans are outlined in §30.7.

MA organizations offering Medicare MSA plans must otherwise follow the disenrollment policies and

procedures outlined in §§50.2 through 50.5.

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60 - Post-Enrollment Activities

42 CFR 422.60 & 422.66

Post-enrollment activities begin after the MA organization receives the enrollment request from the

individual (e.g., cancellations) and last until a decision is made with respect to an individual’s

enrollment request (e.g., retroactive transactions).

60.1 - Multiple Transactions

Multiple transactions occur when CMS receives more than one enrollment request for the same

individual with the same effective date in the same reporting period. An individual may generally not

be enrolled in more than one MA, cost, HCPP or PDP plan at any given time (however, an individual

may be simultaneously enrolled in a cost plan and a separate PDP plan or in certain MA plan types and

a separate PDP plan).

Generally, the last enrollment request the beneficiary makes during an enrollment period will be

accepted as the plan into which the individual intends to enroll. If an individual elects more than one

plan for the same effective date and with the same application date, the first transaction successfully

processed by CMS will take effect. Because simultaneous enrollment in certain MA plan types and a

separate PDP is permitted, CMS systems will accept both enrollments.

Generally, given the use of the application date to determine the intended enrollment choice,

retroactive enrollments will not be processed for multiple transactions that reject because the

enrollment requests have the same application date.

EXAMPLES

• Two MA organizations receive enrollment forms from one individual. MAO #1 receives a form

on March 4th and MAO #2 receives a form on March 10. Both organizations submit enrollment

transactions, including the applicable effective date and application date. The enrollment in

MAO #2 will be the transaction that is accepted and will be effective on April 1 because the

application date on the enrollment transaction is the later of the 2 submitted. Both plans receive

the appropriate reply on the DTRR.

• Two MA organizations (MAOs) receive enrollment requests from one individual for an April 1

effective date. MAO #1 receives a paper enrollment form with all required information on March

. The beneficiary completed an enrollment request for MAO #2 by telephone on the same

day, March 5th. Both enrollment requests have the same application date, since they were

received by the MAO on the same date. Both enrollments were submitted to CMS prior to the

April cut-off date. MAO #1 transmitted the enrollment to CMS on March 5th, the day it received

the enrollment request; however, MAO #2 waited until March 8

to transmit the enrollment to

CMS. The enrollment for MAO #1 will be the transaction that is effective on April 1, as it was

the first transaction successfully processed by CMS.

In the event a rejection for a multiple transaction is reported to the MA organization, the organization

may contact the individual. If the individual wishes to enroll in a plan offered by the organization that

received the multiple transaction reject, s/he must submit a new enrollment request during a valid

enrollment period.

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60.2 - Cancellations

Cancellations may be necessary in cases of mistaken enrollment made by an individual and/or

mistaken disenrollment made by a member. Unless otherwise directed by CMS, an individual may

cancel his/her enrollment (or disenrollment) request only by contacting the organization prior to the

effective date of the enrollment (or disenrollment). For enrollments into employer or union sponsored

plans, cancellations received by the employer or union prior to the enrollment effective date are also

acceptable.

If a cancellation occurs after CMS records have changed, retroactive disenrollment and reinstatement

actions may be necessary. Refer to §§60.3 and 60.5.

If a beneficiary verbally requests a cancellation, the MA organization should document the request.

MA organizations have the right to request that a cancellation be in writing. However, they may not

delay processing of a cancellation until the request is made in writing if they have already received a

verbal cancellation request from the beneficiary.

For facilitated enrollment as described in §40.1.5 of this chapter, a beneficiary may cancel the

enrollment and affirmatively decline Part D benefits by telephone. The MA organization may not

require these cancellations in writing.

60.2.1 - Cancellation of Enrollment

An individual’s enrollment request can be cancelled only if the cancellation request is received by the

organization prior to the effective date of the enrollment via phone, in writing or in person, unless

otherwise directed by CMS.

To ensure the cancellation is honored, the MA organization should not transmit the enrollment to

CMS. If, however, the organization had already transmitted the enrollment by the time it receives the

valid request for cancellation, it must submit a cancellation transaction to CMS to cancel the now-void

enrollment transaction. In the event the cancellation transaction fails or the MA organization has other

difficulty, the MA organization must submit the request to cancel the action to the CMS Retroactive

Processing Contractor in order to cancel the enrollment.

When canceling an enrollment transaction, the MA organization must send a letter to the individual

that states that the cancellation is being processed (see Exhibit 25). This notice should be sent within

ten calendar days of receipt of the cancellation request. This notice must inform the member that the

cancellation should result in the individual remaining enrolled in the health plan in which he/she was

originally enrolled, so long as the individual remains eligible to be enrolled in that health plan.

An MA organization may submit a transaction to cancel only those enrollment transactions it

submitted. To cancel an enrollment, the MA organization must submit an enrollment cancellation

transaction (transaction code 80) with an effective date equal to the effective date of the enrollment

being cancelled.

If the member’s request for cancellation occurs after the effective date of the enrollment, the

cancellation generally cannot be processed. (An exception to this is a cancellation requested during the

Outbound Education and Verification (OEV) process.) The organization must inform the beneficiary

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that he/she is a member of its MA plan. If he/she wants to return to the other MA plan he/she will have

to submit an enrollment request during a valid election period for a prospective enrollment effective

date.

If the member wants to return to Original Medicare instead of returning to his/her previous plan, the

member must be instructed to disenroll from the previous plan as described in §50.1 of this chapter.

The member must be informed that the disenrollment must be made during an election period

(described in §30.5) and will have a current effective date (as prescribed in §30.5), and must be

instructed to continue to use plan services until the disenrollment goes into effect.

Regardless of the plan personnel receiving the request, the plan must document all contact with the

beneficiary associated with the cancellation request.

When an organization receives notification of an individual’s reinstatement, the organization has ten

(10) calendar days to send the individual a notice of reinstatement (Exhibit 25a).

CANCELLATION OF MEDICARE MSA ENROLLMENT REQUEST:

An individual who elects a Medicare MSA plan during an AEP, and who has never before enrolled in

a Medicare MSA plan, may revoke (i.e., “cancel”) that enrollment request, preferably by December 7

(but law allows beneficiaries to do so by December 15) of the year in which s/he requested enrollment

in the Medicare MSA plan. This cancellation will ensure the enrollment request does not go into effect

on January 1. After December 7 and up to December 15, the beneficiary may only return to Original

Medicare and cannot enroll into another MA plan or into a stand-alone PDP.

60.2.2 - Cancellation of Disenrollment

A member’s disenrollment can be canceled only if the request is made prior to the effective date of the

disenrollment, unless otherwise directed by CMS.

To ensure the cancellation is honored, the MA organization should not transmit the disenrollment to

CMS. If, however, the organization had already transmitted the disenrollment by the time it receives

the verbal request for cancellation, it must submit a cancellation of disenrollment transaction,

transaction code 81, to CMS to cancel the now-void disenrollment transaction. In the event the MA

organization has submitted the disenrollment and is unable to submit the transaction code 81, or has

other difficulty, the organization should submit the request to cancel the action to the CMS Retroactive

Processing Contractor in order to cancel the disenrollment.

An MA organization may submit a transaction to cancel only those disenrollment transactions it

submitted. To submit an action to cancel a disenrollment, the MA organization must submit a

transaction code 81 (cancellation of disenrollment), with the effective date equal to the effective date

of the disenrollment being cancelled.

The MA organization must send a letter to the member that states that the cancellation is being

processed and instructs the member to continue using MA plan services (see Exhibit 26). This notice

should be sent within ten calendar days of receipt of the cancellation request.

Within ten (10) calendar days of receipt of confirmation of the individual’s reinstatement, the

organization must send the member written notification of the reinstatement (Exhibit 25a).

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If the member’s request for cancellation occurs after the effective date of the disenrollment, the

cancellation cannot be processed. In some cases, reinstatement due to a mistaken disenrollment will be

allowed, as outlined in §60.3.2. If a reinstatement will not be allowed, the MA organization should

instruct the member to submit a new enrollment request during a valid election period (described in

§30), and with a current effective date, as prescribed in §30.5.

60.2.3 – When A Cancellation Transaction is Rejected by CMS Systems

(Transaction Reply Code (TRC) 284)

When an MA organization receives a TRC 284 (Cancellation Rejected), while the cancellation

remains valid, it could not be processed automatically in CMS’ systems. The MA organization must

investigate the circumstances behind the rejection. If the rejection was due to incorrect data on the

transaction, the MA organization must correct the data and resubmit it to CMS. If the rejection was

not due to such an error, and the request to cancel is valid, the MA organization must promptly submit

the request to CMS (or its designee) for resolution.

60.2.4 – Cancellation Due to Notification from CMS (TRC 015)

When an MA organization receives a TRC 015 (Enrollment Cancelled), it indicates that an enrollment

must be cancelled. A cancellation may be the result of an action on the part of the beneficiary, CMS or

another plan.

Within ten (10) days of receiving the TRC 015, the plan must send the individual an acknowledgment

notice of the cancellation (Exhibit 25b).

60.3 - Reinstatements

Reinstatements may be necessary if a disenrollment is not legally valid (refer to §50.5 to determine

whether a disenrollment is not legally valid) or if the circumstances justify a reinstatement. The most

common reasons warranting reinstatements are:

1. Disenrollment due to erroneous death indicator;

2. Disenrollment due to erroneous loss of Medicare Part A or Part B indicator;

3. Disenrollment due to erroneous incarceration or unlawful presence information;

4. Reinstatements Based on Beneficiary Cancellation of New Enrollment;

5. Plan error;

6. Demonstration of good cause for failure to pay plan premiums or Part D-IRMAA timely.

When a disenrolled individual contacts the MA organization to state that he or she was disenrolled due

to item 1 (erroneous death indicator), item 2 (erroneous loss of Medicare Part A or Part B indicator) or

item 5 (plan error), and states that he or she wants to remain a member of the MA plan, the MA

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organization must instruct the member in writing to continue to use MA plan services (refer to

Exhibits 15, 16 and 17). The MA organization must send the notice within ten (10) calendar days of

the individual’s contact with the organization to report the erroneous disenrollment. Accordingly, plan

systems should indicate active membership as of the date the organization instructs the individual to

continue to use plan services.

When a disenrolled individual contacts the MA organization about either item 3 (erroneous

incarceration or unlawful presence information), item 4 (reinstatement based on enrollment

cancellation of new enrollment) or item 6 (good cause), plans should follow the guidance outlined

below pertaining to those unique situations.

A reinstatement is viewed as a correction necessary to “erase” an invalid disenrollment action, and, as

such, does not require an election period. Therefore, reinstatements may be made back to a date when

an MA plan was closed for enrollment. Payment alone of past due premiums after the disenrollment

date does not create an opportunity for reinstatement into the plan from which the individual was

disenrolled for failure to pay premiums.

CMS (or its designee) will review requests for reinstatements on a case-by-case basis.

Within ten (10) calendar days of receipt of DTRR confirmation of the individual’s reinstatement, the

organization must send the member notification of the reinstatement (Exhibit 25a).

60.3.1 - Reinstatements for Disenrollment Due to Erroneous Death Indicator, or

Erroneous Loss of Medicare Part A or Part B, Erroneous Incarceration

Information, or Erroneous Unlawful Presence Information

A member must be reinstated if he or she was disenrolled in error, since the individual continues to be

eligible. This may occur in the following situations:

• Erroneous death indicator;

• Erroneous loss of Part A or Part B;

• Erroneous lawful presence status; or

• Erroneous incarceration information.

As outlined in 42 CFR 422.74(c), MA organizations have the option of sending notification of

disenrollment due to:

• Death;

• Loss of Part A or Part B entitlement; or

• Unlawful presence in the U.S.

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The CMS strongly suggests that MA organizations send these notices in these three situations, to

ensure any erroneous disenrollments are corrected as soon as possible. Refer to Exhibits 13, 14 and 38

for model letters.

If CMS involuntarily disenrolls an individual due to incarceration, a notice is required because the

individual resides out of the plan’s service area. See §50.2.1.5 for notice requirements for

disenrollment due to incarceration. Refer to Exhibit 37.

Erroneous disenrollments must be corrected and the corresponding reinstatements processed,

regardless of the date on which the individual disputes the erroneous disenrollment or provides

evidence of MA eligibility.

Reinstatements for erroneous death indicator or loss of Part A or Part B entitlement:

Individuals can dispute the disenrollment due to death indicator or loss of Part A or Part B entitlement.

In such cases, the MA organization is expected to acknowledge the individual’s request for

reinstatement and direct him or her to continue to use the MA plan services while the issue is resolved

with the Social Security Administration (SSA). Organizations may request that such individuals

provide evidence of MA eligibility by a particular date; however, should the individual provide

evidence after that date, the error must still be corrected by the MA organization.

To request consideration for reinstatement following disenrollment due to erroneous death indicator,

erroneous loss of Medicare Part A or Part B, the MA organization must submit to CMS (or its

designee) a copy of the letter to the member informing him or her to continue to use MA plan services

until the issue is resolved. The organization must indicate the date the letter was sent. Refer to model

letters in Exhibits 15and 16. Within ten (10) calendar days of receipt of DTRR confirmation of the

individual’s reinstatement, the organization must send the member notification of the reinstatement

(Exhibit 25a).

CMS will attempt to automatically reinstate individuals that were auto-disenrolled by a report of date

of death if there is a subsequent date of death correction that impacts the plan enrollment.

Reinstatements for erroneous incarceration or unlawful presence status information:

Individuals alleging disenrollment due to erroneous incarceration information or erroneous unlawful

presence status must have their complaints reviewed by the MA organization and possibly referred to

SSA. MA organizations are not required to provide coverage to such individuals while the issue is

reviewed by the plan or SSA.

For individuals who contest their disenrollment on these bases, the MA organization should check

CMS’ systems to see if the incarceration or unlawful presence status has been removed (via audit

notification in MARx) and that the person is otherwise eligible to remain enrolled as of the

disenrollment effective date. If the individual is otherwise eligible for enrollment, the reinstatement

request may be sent to the CMS Retroactive Processing Contractor (RPC) instead of referring the

individual to SSA. However, if CMS systems continue to reflect an incarcerated or unlawful presence

status, the plan should refer the beneficiary to SSA so that they may review their records and make

corrections, as appropriate. If the information or status is determined to be erroneous by SSA, CMS’

systems will be updated. The plan may check CMS systems to see if the incarceration or unlawful

presence status has been removed, and, if the person is otherwise eligible to remain enrolled, may send

the reinstatement request to the CMS RPC. The MA organization will receive notification of the

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individual’s reinstatement from CMS or via the TRR. At that time, services should resume and

coverage should be seamless, as though the individual was never disenrolled. CMS suggests that the

organization send the member notification of the reinstatement (Exhibit 25a) within ten (10) days of

receipt of DTRR confirmation of the individual’s reinstatement.

60.3.2 - Reinstatements Based on Beneficiary Cancellation of New Enrollment

As stated in §50.5, deliberate member-initiated disenrollments imply intent to disenroll. Therefore,

reinstatements generally will not be allowed if the member deliberately initiated a disenrollment. An

exception is made for those members who were automatically disenrolled because they enrolled in

another plan but subsequently cancelled the enrollment in the new plan before the effective date.

In this situation, that is, if an individual has since changed his/her mind and wants to remain enrolled

in the previous plan, the individual must cancel the enrollment into the new plan, as described in

section 60.2.1. When a cancellation of enrollment in a new plan is properly made, the associated

automatic disenrollment from the previous MA plan becomes invalid. Upon successful cancellation of

enrollment in the new plan, CMS systems will attempt to automatically reinstate enrollment in the

previous plan. Because this process is automatic, it is generally not necessary to request reinstatement

via the Regional Office or Retroactive Processing Contractor. Within ten (10) days of receipt of DTRR

confirmation of the individual’s reinstatement, the organization must send the member notification of

the reinstatement (Exhibit 25a).

In cases where the valid cancellation request is not processed timely or CMS systems cannot complete

the request, the new plan must submit a request to the Retroactive Processing Contractor to cancel the

enrollment. This request will require complete documentation, including evidence that the beneficiary

requested cancellation of enrollment in the new plan within required timeframes.

If the previous plan becomes aware of an unsuccessful reinstatement, the previous plan may contact a

CMS Account Manager to investigate the issue with the new plan.

If the disenrolled individual contacts the previous plan requesting to remain a member of that plan, the

MA organization should inform the individual that reinstatement of enrollment is an option only if the

individual successfully cancels enrollment in the “new” plan; accordingly, the organization should

refer the individual to the “new” plan to inquire about his or her options.

60.3.3 - Reinstatements Due to Mistaken Disenrollment Due to Plan Error

A disenrollment that is not the result of either a valid voluntary request or a valid circumstance that

requires involuntary disenrollment is erroneous. When an erroneous disenrollment is the result of plan

error, the plan must reinstate the individuals who were disenrolled.

In the case of an erroneous disenrollment by the organization that is a result of an error the part of the

organization, the organization must restore the enrollment in its records. Additionally, the organization

must cancel the disenrollment action from CMS’s records, if the organization had previously

submitted such a transaction to CMS. Organizations must use the disenrollment cancellation function

to complete this action for effective dates within the parameters that CMS systems allow for such

corrections. For effective dates outside these parameters, the organization must process the request

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according to the guidance for processing retroactive enrollment and disenrollment requests including

full documentation and explanation as required.

Within ten (10) days of receipt of DTRR confirmation of the individual’s reinstatement, the

organization must send the member notification of the reinstatement (Exhibit 25a).

60.3.4 - Reinstatements Based on a Determination of Good Cause for Failure to

Pay Plan Premiums or Part D-IRMAA Timely

If an individual has been involuntarily disenrolled for failure to pay either plan premiums (under

§50.3.1) or Part D-IRMAA (under §50.2.6), he or she may request reinstatement no later than 60

calendar days following the effective date of disenrollment. Reinstatement for good cause, pursuant to

42 CFR 422.74(d)(1)(v), will occur only when:

1. The individual requests reinstatement within 60 days of disenrollment effective date;

2. The individual has been determined to meet the criteria specified below (i.e., receives a

favorable determination); and

3. (a) Within three (3) months of disenrollment for nonpayment of plan premiums, the

individual pays in full the plan premiums owed at the time he or she was disenrolled or

(b) Within three (3) months of disenrollment for nonpayment of Part D-IRMAA, the

individual pays in full the Part D-IRMAA and any plan premiums owed at the time he or

she was disenrolled.

Criteria for Reinstatement: Reinstatement of enrollment for good cause is provided only in rare

circumstances in which the member or his or her authorized representative (i.e. the individual

responsible for the member’s financial affairs) was unable to make timely payment due to

circumstances over which they had no control and they could not reasonably have been expected to

foresee. Requests for reinstatement must be accompanied by a credible statement (verbal or written)

explaining the unforeseen and uncontrollable circumstances causing the failure to make timely

payment. An individual may make only one reinstatement request for good cause in the 60-day period.

Generally, these circumstances constitute good cause:

• A serious illness, institutionalization and/or hospitalization of the member or his or her

authorized representative (i.e. the individual responsible for the member’s financial affairs),

that lasted for a significant portion of the grace period for plan premium or Part D-IRMAA

payment;

• Prolonged illness that is not chronic in nature, a serious (unexpected) complication to a chronic

condition or rapid deterioration of the health of the member, a spouse, another person living in

the same household, person providing caregiver services to the member, or the member’s

authorized representative (i.e., the individual responsible for the member’s financial affairs)

that occurs during the grace period for the plan premium or Part D-IRMAA payment;

• Recent death of a spouse, immediate family member, person living in the same household or

person providing caregiver services to the member, or the member’s authorized representative

(i.e., the individual responsible for the member’s financial affairs); or

• Home was severely damaged by a fire, natural disaster or other unexpected event, such that the

member or the member’s authorized representative was prevented from making arrangement

for payment during the grace period for plan premium or Part D-IRMAA;

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• An extreme weather-related, public safety or other unforeseen event declared as a Federal or

state level of emergency prevented premium payment at any point during the plan premium or

Part D-IRMAA grace period. For example, the member’s bank or U.S. Post Office closes for a

significant portion of the grace period; or

• For disenrollments effectuated by CMS for failure to pay Part D-IRMAA, Federal government

error (i.e., CMS, SSA or RRB) caused the payment to be incorrect or late, and the member was

unaware of the error or unable to take action prior to the disenrollment effective date.

There may be situations in addition to those listed above that result in favorable good cause

determinations. If an individual presents a circumstance which is not captured in the listed examples, it

must meet the regulatory standards of being outside of the member’s control or unexpected such that

the member could not have reasonably foreseen its occurrence, and this circumstance must be the

cause for the non-payment of plan premiums or Part D-IRMAA. CMS expects non-listed

circumstances will be rare.

Examples of circumstances that do not constitute good cause include:

• Allegation that bills or warning notices were not received due to unreported change of address,

out of town for vacation, visiting out of town family, etc.;

• Authorized representative did not pay timely on member’s behalf;

• Lack of understanding of the ramifications of not paying plan premiums or Part D-IRMAA;

• Could not afford to pay premiums during the grace period; or

• Need for prescription medicines or other plan services.

For examples of cases for favorable and unfavorable good cause determinations, see Appendix 4.

For the purpose of determining good cause for members with authorized representatives, the criteria

for both favorable and unfavorable determinations apply as though the authorized representative is the

member.

The inability to afford premiums or failure to make timely payment by a member or an authorized

representative alone is not grounds for a favorable good cause determination and reinstatement. In

addition, good cause determinations are not organization determinations related to coverage and,

therefore, are not appealable. (See 42 CFR 422, subpart M.) An individual may not make more than

one reinstatement request for good cause in the same 60-day period following disenrollment, including

instances in which the initial request resulted in an unfavorable determination. However, an individual

has the right to file a grievance against the plan related to the involuntary disenrollment.

An individual who has been disenrolled for failure to pay plan premium, regardless of whether he or

she has also been assessed Part D-IRMAA, remains disenrolled from the plan and does not have

access to plan coverage of services until he or she receives a favorable good cause determination and

the plan receives full payment of the plan premium amounts owed at the time he or she was

disenrolled.

An individual who has been disenrolled by CMS for failure to pay Part D-IRMAA remains disenrolled

from the plan and does not have access to plan coverage of services until the reinstatement occurs and

is reported to the plan on the DTRR or the plan is contacted by the CMS caseworker after he or she

has successfully updated the member’s enrollment record in MARx. Once a reinstatement occurs, the

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individual’s disenrollment will be cancelled and his or her coverage will be continuous, assuming the

individual continues to be eligible for enrollment in that plan.

60.3.4.1 - Process for Good Cause Determinations for Nonpayment of Plan Premiums

Pursuant to 42 CFR 422.74(d), CMS has assigned the handling of good cause determinations to plans.

When a disenrolled individual initially contacts the MA organization following disenrollment for

failure to pay plan premiums and indicates that he or she “has a good reason for not having paid the

premiums”, the MA organization must:

• Confirm that the request for reinstatement is being made within 60 calendar days of the

disenrollment effective date;

• Inform the individual that reinstatement is a possibility only if it is determined that his or her

failure to make timely payment was due to circumstances over which he or she had no control

and could not reasonably have been expected to foresee;

• Obtain a credible statement from the individual regarding the circumstance that prevented him

or her from making timely payment; and

• Obtain affirmation from the individual indicating his or her willingness and ability to pay all

overdue plan premiums within three (3) months of the disenrollment date in order for

reinstatement to occur.

If all of these preliminary requirements are not met, the individual is not eligible to be considered for

reinstatement for good cause. An individual may not make more than one reinstatement request for

good cause during the same 60-day period. For example, an individual requesting reinstatement

indicates that he had no unusual or unexpected circumstance that caused the nonpayment of premiums

and the plan determines that he does not qualify for his case to be reviewed under good cause. The

plan is expected to clearly communicate that the individual’s request will not be reviewed because the

situation does not meet the criteria (e.g., not unusual or unexpected). The individual remains

disenrolled and may not make another request for good cause during the same 60-day period following

the involuntary disenrollment.

If all of the above criteria are met, the plan will review the request and will make a favorable or

unfavorable good cause determination. CMS expects that plans make such determinations within five

(5) business days of initial receipt of the request, so that the individual has a reasonable amount of

time to make full payment for reinstatement. For requests received by mail, the initial request is

considered received by the plan at the time it arrives in the organization’s mailbox or mailroom. For

requests received by fax, the initial request is considered received by the plan at the time when the fax

is received on the organization’s fax machine. For requests received by telephone, the initial request is

considered received by the plan at the time the organization’s representative receives the incoming

call.

There is no additional time allotted for plans to gather information not collected at the point of initial

contact. Plans would need to collect any additional data they feel is needed to make a determination

and make that determination within five (5) business days of the date on which the individual first

contacts the plan. In such cases where the plan does not have sufficient information to determine if the

member’s circumstances meet the requirements, it should make a good faith effort to collect it within

that timeframe (e.g., making multiple attempts on different days or at different times). However, if

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attempts are unsuccessful, the plan must use the information provided with the initial request to make

its determination.

If the plan makes a favorable determination and there are amounts owed to the plan for past due

premiums, the plan should notify the individual of this decision within three (3) business days of

making the determination. If the plan offers immediate payment options, such as payment by credit

card via phone, it may provide the notification verbally; however, if the individual does not complete

the payment at that time, the plan should issue a written notice to ensure that the individual has the

information necessary to pay the owed amounts. This notice will specify the amount owed (i.e., the

premiums owed at the time of disenrollment), the date by which payment must be received for

reinstatement (i.e., last day of the third month following the disenrollment effective date), where to

send payment, and/or other payment options such as credit card or direct withdrawal from a bank

account, if offered by the plan. (See Exhibit 22b).

If, at the time the plan makes a favorable determination, there are no amounts owed to the plan for past

due premiums, the plan should notify the individual of this decision either verbally or in writing within

three (3) business days of making the determination. Exhibit 22e is

a model notice for the scenario in

which an individual receives a favorable good cause determination and has already paid the amount

required for reinstatement.

If verbal notification is attempted but unsuccessful, a written notice should

be provided. Verbal notification must be documented by the plan to meet CMS’ retroactive processing

contractor reinstatement submission requirements.

If the plan makes an unfavorable determination, the plan should notify the individual of this decision

by phone or in writing within three (3) business days of making the determination.

If an individual has received a favorable good cause determination, reinstatement in CMS systems

may not occur until and unless all required payments are made within three (3) months of the

disenrollment effective date. If the individual pays all the owed amounts prior to the three-month

deadline, the plan should resume coverage at that time and submit the reinstatement request to the

CMS Retroactive Processing Contractor.

Plans have additional time beyond the deadline (i.e., three (3) months from the disenrollment effective

date) to verify payment by the bank and credit the payment to the member’s account with the plan. To

provide adequate protections for individuals who make timely payment of their owed amounts, plans

have five (5) calendar days beyond the payment deadline to process the payment and submit the

reinstatement request to the CMS Retroactive Processing Contractor..

Reinstatements for good cause are considered complete by CMS when TRC 287 (Enrollment

Reinstated) is sent by CMS to the plan.

Within ten (10) calendar days of receipt of DTRR confirmation of the individual’s reinstatement, the

organization must send the member notification of the reinstatement (Exhibit 25a). In an effort to

prevent members from falling behind in premium payments in the future, plans are encouraged to

educate them on any automated payment mechanisms their plan offers, as well as the availability of

selecting automatic premium withhold through their SSA or RRB benefits.

An individual may not be reinstated in cases where:

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• the individual pays all plan premiums owed, but does not receive a favorable good cause

determination; or

• the individual receives a favorable good cause determination, but does not pay the plan

premiums owed within three (3) months of the disenrollment effective date.

In both of these cases, the plan may re-enroll the individual for a prospective enrollment effective date

at the individual’s request only if he or she has a valid election period (i.e., AEP, SEP, etc.), following

enrollment procedures outlined in Sections 30 and 40.

Example A: Mr. Smith is disenrolled for failure to pay plan premiums on April 1. Mr. Smith contacts

the plan and makes his request for reinstatement on April 15 and receives a favorable good cause

determination on April 23. The plan notifies Mr. Smith of the amount he owes by June 30 in order to

be reinstated into the plan. Mr. Smith pays the amount due on June 15. Mr. Smith is reinstated into the

plan. (Note: If Mr. Smith did not pay his owed amount by June 30, he would not be reinstated.)

Example B: Mr. Smith is disenrolled by the plan for failure to pay plan premiums on July 1. Mr. Smith

mails in his past due amounts to the plan on July 30. He contacts the plan and makes his request on

August 10, and does not receive a favorable good cause determination. Mr. Smith may not be

reinstated.

Example C: Mr. Smith is disenrolled by the plan for failure to pay plan premiums on November 1. Mr.

Smith mails in his owed amounts to the plan on December 15, but does not contact the plan to request

reinstatement. Thus, Mr. Smith does not have a favorable good cause determination, and he may not

be reinstated.

NOTE: In cases where the involuntary disenrollment for failure to pay plan premiums is the result of

plan error, plans should follow the reinstatement process outlined in Section 60.3.3. Plans should not

refer these individuals to 1-800-MEDICARE, nor should these cases be considered for reinstatement

for good cause.

60.3.4.2 – Process for Good Cause Determinations for Nonpayment of Part D-IRMAA

When a disenrolled individual contacts the MA organization following disenrollment for failure to pay

Part D-IRMAA and indicates that he or she “has a good reason for not paying the Part D-IRMAA,” the

MA organization must advise the individual to contact 1-800-MEDICARE (1-800-633-4227; TTY: 1-

877-486-2048) within 60 calendar days of the disenrollment effective date to make the good cause

reinstatement request. The organization should also inform the individual that in order to be reinstated,

he or she must meet specific good cause standards and must pay all overdue plan premiums and Part

D-IRMAA amounts within three (3) months of the disenrollment date in order for reinstatement to

occur.

Once a request is made with CMS via 1-800-MEDICARE, a Complaint Tracking Module (CTM) case

will be generated for CMS caseworker action. The CMS caseworker will review the request and will

make a favorable or unfavorable good cause determination. If the individual provides any

documentation to the plan regarding the inability to make timely payment of the Part D-IRMAA, the

plan must provide that documentation to CMS (through the CMS account manager) so that it may be

considered in making the determination. If CMS makes an unfavorable determination, CMS will

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notify the individual of the determination. Notes of the good cause reinstatement request will be

captured in the CTM for CMS and plan viewing.

NOTE: Requests for reinstatement are not considered complaints against the plan; therefore, these

types of CTM cases are excluded from tracking for the purposes of plan ratings.

If CMS makes a favorable determination, a notation will be made in the CTM and the CTM will be

sent to the plan. If there are amounts owed to the plan for past due premiums, the plan should send

notification to the individual within three (3) business days of being informed of the favorable good

cause determination. This notice will specify the amount owed, the date by which payment must be

received for reinstatement (i.e., last day of the third month following effective date of disenrollment),

where to send payment, and other payment options such as credit card or direct withdrawal from a

bank account, if offered by the plan. (See Exhibit 22a).

Plans have additional time beyond the payment deadline (i.e., three months from the disenrollment

effective date) to verify payment by the bank and credit the payment to the individual’s account. To

provide adequate protections for individuals who make timely payment of their owed amounts, plans

have five (5) calendar days beyond the payment deadline to process the payment and notify CMS via

CTM. Even if an individual has received a favorable good cause determination, the actual

reinstatement will not occur until all required payments are made within three (3) months of the

disenrollment effective date.

Within ten (10) calendar days of receipt of DTRR confirmation of the individual’s reinstatement, the

organization must send the member notification of the reinstatement (Exhibit 25a). In an effort to

prevent members from falling behind in premium payments in the future, plans are encouraged to

educate them on any automated payment mechanisms offered by the plan, as well as the availability of

automatic premium withhold from SSA or RRB benefits.

An individual may not be reinstated in cases where:

• the individual pays all Part D-IRMAA amounts and any plan premium amounts owed, but does

not receive a favorable good cause determination; or

• the individual receives a favorable good cause determination, but does not pay the Part D-

IRMAA amounts and/or any plan premiums owed with three (3) months of the disenrollment

effective date.

In both of these cases, the plan may re-enroll the individual for a prospective enrollment effective date

at the individual’s request, but only if he or she has a valid election period (i.e., AEP, SEP, etc.),

following enrollment procedures outlined in Sections 30 and 40.

Example: Mr. Smith is disenrolled by CMS for failure to pay Part D-IRMAA on August 1. He

contacts Medicare and makes his request on September 29 and receives a favorable good cause

determination on October 5. Mr. Smith is also delinquent on his plan premiums. CMS notifies Mr.

Smith that he must pay the Part D-IRMAA amount he owes by October 31. The plan notifies Mr.

Smith that he must also pay the plan premium amount he owes by October 31. Mr. Smith pays his Part

D-IRMAA owed amount on October 25. Mr. Smith pays his plan premium owed amount on

November 5. Because the plan received Mr. Smith’s payment for his owed plan premium amount

after the due date, Mr. Smith may not be reinstated. (Note: If Mr. Smith had paid both his owed Part

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D-IRMAA and plan premiums by October 31, the plan would have had the additional five (5) days to

process the payment and he would have been reinstated.)

60.4 - Retroactive Enrollments

If an individual has fulfilled all enrollment requirements, but the MA organization or CMS is unable to

process the enrollment for the required effective date (as outlined in §30.5), CMS (or its designee) will

process a retroactive enrollment.

In addition, auto-enrollment for full-benefit dual eligible as described in §40.1.5 may be retroactive to

ensure no coverage gap between the end of Medicaid coverage for Part D drugs and the beginning of

Medicare drug coverage.

In other limited cases, CMS may determine that an individual is eligible for an SEP due to an

extraordinary circumstance beyond his/her control (e.g. a fraudulent enrollment request or misleading

marketing practices) and may also permit a retroactive enrollment in an MA plan as necessary to

prevent a gap in coverage or liability for the late enrollment penalty.

Unlike a reinstatement, which is a correction of records to “erase” an action, a retroactive enrollment

is viewed as an action to enroll a beneficiary into a plan for a new time period. Therefore, retroactive

enrollments may NOT be made back to a date when an MA plan was closed for enrollment.

NOTE: Keep in mind that unless an approved capacity limit applies, all MA plans are open for

ICEP, IEP/D, AEP and SEP enrollment requests; therefore, all MA plans are open for retroactive

enrollments for these types of enrollment requests.

Occasionally, obtaining the information necessary to complete an enrollment request within the

allowable timeframes will extend beyond the CMS systems cut-off date for transaction submission,

thus making the effective date of enrollment “retroactive” to the current payment month. MA

organizations must use the Code 61 enrollment transaction to submit the enrollment transaction

directly to CMS within the Current Calendar Month transaction processing timeframe.

When a valid request for enrollment has not been communicated to CMS successfully within the

required timeframes in this guidance and the Current Calendar Month transaction submission

timeframe, MA organizations are required to submit the appropriate documentation to CMS (or its

designee) for manual review and potential action. The request for a retroactive enrollment should be

made within the timeframes provided in the Standard Operating Procedures for the CMS Retroactive

Processing Contractor. When an individual has fulfilled all enrollment requirements, but the

organization or CMS has been unable to process the enrollment in a timely manner, the following

documentation must be submitted to CMS (or its designee):

• A copy of signed completed enrollment form (the form must have been signed by the

beneficiary (or authorized representative) and received by the organization prior to the

requested effective date of coverage, in order to effectuate the requested effective date of

coverage); or

• A copy of the enrollment request record (the enrollment request record must show that the

enrollment request was made and received by the organization prior to the requested effective

date of coverage).

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The retroactive enrollment request may be denied if CMS determines that the MA organization did not

notify the member that he/she must use MA plan services during the period covered by the retroactive

enrollment request.

If the request for retroactive enrollment action is due to plan error, the organization must provide a

clear and detailed explanation of the plan error including why the retroactive action is necessary to

correct the error. The explanation must include clear information regarding what the organization has

communicated to the affected beneficiary throughout the period in question. The organization must

also include any relevant information or documentation supporting the requested correction. Such

information could include a copy of the enrollment request form (or clear evidence of the use of

another enrollment mechanism) and evidence of notices sent to the beneficiary related to or caused by

the error.

Special note regarding Regional Office Casework actions

When an MA organization is directed by CMS, such as via an RO caseworker, to submit a retroactive

enrollment or disenrollment request to resolve a complaint, the organization must provide the

following 2 (two) items as documentation to CMS (or its designee):

• A screen print from the Complaint Tracking Module (CTM) or other documentation showing

the CMS RO decision and direction to submit the request to the CMS Retroactive Processing

Contractor, and;

• A copy of the enrollment or disenrollment request, if one is available. Occasionally, due to the

nature of casework, this item may not be available. When that occurs, the organization should

submit a brief statement of explanation for the missing documentation.

60.5 - Retroactive Disenrollments

42 CFR 422.66

If an enrollment was never legally valid (§40.6) or if a valid request for disenrollment was properly

made, but not processed or acted upon (as outlined in the following paragraph), which includes not

only system error, but plan error (see §10 for a definition of “system error” and “plan error”), CMS (or

its designee) may grant a retroactive disenrollment. CMS (or its designee) may also process a

retroactive disenrollment if the reason for the disenrollment is related to a permanent move out of the

plan service area (as outlined in §50.2.1.2), a contract violation (as outlined in 42 CFR 422.62(b)(3))

or other limited exceptional conditions established by CMS (e.g. fraudulent enrollment or misleading

marketing practices).

When a valid request for disenrollment has not been communicated to CMS successfully within the

required timeframes in this guidance and the Current Calendar Month transaction submission

timeframe, MA organizations are required to submit the appropriate documentation to CMS (or its

designee) for manual review and potential action. Retroactive disenrollment requests can be submitted

to CMS (or its designee) by the beneficiary or an MA organization. Requests from an MA

organization must include a copy of the disenrollment request, as well as an explanation as to why the

disenrollment was not processed correctly. MA organizations must submit retroactive disenrollment

requests to CMS (or its designee) within the timeframes provided in the Standard Operating

Procedures for the CMS Retroactive Processing Contractor. If CMS approves a request for retroactive

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disenrollment, the MA organization must return any premium paid by the member for any month for

which CMS processed a retroactive disenrollment. In addition, CMS will retrieve any capitation

payment for the retroactive period.

A retroactive request must be submitted by the MA organization (or by the member) to CMS (or its

designee) in cases in which the MA organization has not properly processed a required involuntary

disenrollment or acted upon the member’s request for disenrollment as required in §50.4.1 of these

instructions. A disenrollment request would be considered not properly acted upon or processed if the

effective date is a date other than as required in §30.6.

If the request for retroactive disenrollment action is due to the MA organization’s confirmation of an

incarcerated status with a retroactive start date (see § 50.2.1.3), the organization must provide written

confirmation of the incarcerated status, including the start date. Such confirmation could include

documentation of telephonic communications.

If the request for retroactive action is due to plan error, the organization must provide a clear and

detailed explanation of the plan error including why the retroactive action is necessary to correct the

error. The explanation must include clear information regarding what the organization has

communicated to the affected beneficiary throughout the period in question, including evidence that

the beneficiary was notified prospectively of the disenrollment. The organization must also include

any relevant information supporting the requested correction. Such information could include a copy

of the disenrollment request and evidence of notices sent to the beneficiary related to or caused by the

error in question and which demonstrate that the retroactive disenrollment is appropriate under the

circumstances.

60.6 - Retroactive Transactions for Employer/Union Group Health Plan (EGHP)

Members

In some cases an MA organization that has a contract with an EGHP arranges for the employer or

union to process enrollment requests for Medicare-entitled group members who wish to enroll in an

employer or union sponsored MA plan. However, there can be a delay between the time the member

completes the enrollment request through the EGHP and when the enrollment request is received by

the MA organization. Therefore, retroactive transactions for these routine delays may be necessary and

are provided for under this section. Errors made by an EGHP, such as failing to forward a valid

enrollment or disenrollment request within the timeframes described below, must be submitted to

CMS (or its designee) for review. Repeated errors may indicate an ongoing problem and therefore will

be forwarded to the MA organization’s CMS Account Manager for compliance monitoring purposes.

The MA organization’s agreement with the EGHP must include the need to meet the requirements

provided in this chapter that ensure the timely submission of enrollment and disenrollment requests to

reduce the need for retroactivity and to help avoid such errors.

60.6.1 - EGHP Retroactive Enrollments

(Rev. 1, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

The effective date of EGHP enrollments cannot be earlier than the date the enrollment request was

completed by the beneficiary. The effective date may be retroactive up to, but may not exceed, 90 days

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from the date the MA organization received the request (which was completed prior to the effective

date) from the employer or union group.

EXAMPLE

In March 2007, the CMS system processing date was March 13, 2007. Enrollment requests processed

by CMS for the March 13, 2007, due date were for the prospective April 1, 2007, payment. For

EGHPs, an effective date of March 1, February 1, or January 1 would reflect 30, 60 and 90 days of

retroactive payment adjustment, respectively. Therefore, if a completed EGHP enrollment request

were to be received by the MA organization on March 5, 2007, the retroactive effective date could be

January 1, February 1, or March 1, as long as the enrollment request was completed prior to the

effective date.

NOTE: Keep in mind that unless a CMS-approved capacity limit has been reached, all MA

plans are open for ICEP, AEP, and SEP enrollment requests. Therefore, all MA plans are open

for retroactive enrollments for these types of enrollment requests.

No retroactive enrollments may be made unless the individual certifies that the MA organization (or

EGHP) provided him/her with the explanation of enrollee rights (including the lock-in requirement) at

the time of enrollment. The MA organization should submit such enrollments using the appropriate

transaction code. Refer to the Medicare Advantage and Prescription Drug Plan Communications User

Guide (PCUG) for more information. The ability to submit limited EGHP retroactive enrollment

transactions is to be used only for the purpose of submitting a retroactive enrollment into an EGHP

made necessary due to the employer’s delay in forwarding the completed enrollment request to the

MA organization.

60.6.2 - EGHP Retroactive Disenrollments

The MA organization must submit a retroactive disenrollment request to CMS (or its designee) if an

EGHP does not provide the MA organization with timely notification of a member’s requested

disenrollment. Up to 90 day’s retroactive payment adjustment is possible in such a case to conform to

the adjustments in payment described under 42 CFR 422.308(f)(2). The EGHP notification is

considered untimely if it does not result in a disenrollment effective date as outlined in §30.6.

The MA organization must submit a disenrollment notice (i.e., documentation) to CMS (or its

designee) demonstrating that the member acted to disenroll in a timely fashion (i.e., prospectively), but

that the EGHP was late in providing the information to the MA organization. Such documentation may

include an enrollment form for a new MA plan signed by the member and given to the EGHP during

an open enrollment season. The documentation may not include a copy of a Medicare supplemental

plan or Medigap plan enrollment form unless the member indicated on that form that he/she has

canceled any other insurance. Such documentation should be sent to CMS (or its designee) as soon as

possible.

60.7 – User Interface (UI) Transactions Reply Codes (TRC) – Communications

with Beneficiaries

Upon receipt of a CMS transaction reply, MA organizations must update their records to accurately

reflect each individual’s enrollment status. Organizations are also required to provide certain notices

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and information to beneficiaries when enrollment status is confirmed or changes. In the case of UI-

TRC replies, the standard operating procedures for providing these notices and/or information may not

fit some of the unique situations many UI enrollment changes address.

The table below provides guidelines for communicating with beneficiaries when enrollment changes

are reported to MA organizations using the “700 series” TRCs that result from UI enrollment changes.

In all cases, organizations will need to review the situations carefully to determine the necessity and

appropriateness of sending notices. Some UI enrollment change processes will result in multiple 700-

series TRCs being reported. Organizations must determine the final disposition of the beneficiary to

ensure the correct message is provided in any notice sent. In complex situations, CMS encourages

organizations to communicate directly (such as by telephone) with the beneficiary, in addition to any

required notice or materials. When it is necessary to send a notice, organizations must issue the notice

within ten calendar days of receipt of the DTRR.

TRC

Beneficiary Communication Action

701 – New UI Enrollment

Organizations may use existing confirmation notices as provided in

CMS enrollment guidance. If such notice has already been provided

with the same information, it is not necessary to provide it a second

time.

702 – New UI Fill-in

Enrollment

Organizations must use Exhibit 30, “Enrollment Status Update.”

Include the date range covered by the new fill-in period.

703 – UI Enrollment

Cancel

If a cancellation notice applicable to this time period has already been

provided, it is not necessary to provide it a second time. If notice has

not been provided, organizations may use the existing cancellation of

enrollment notice as provided in CMS enrollment guidance. If the

specific situation warrants, organizations may use Exhibit 30 instead,

providing information that clearly indicates that the enrollment period

in question has been cancelled. Include information about the refunding

of plan premiums, if applicable.

704 – UI Enrollment

Cancel - PBP Change

If the UI action is a correction to a plan submission error, the

organization may have already provided the correct plan (PBP)

information; if that’s the case, it is not necessary to send it a second

time. If the beneficiary has not received information about the specific

plan (PBP), the organization must send the materials required in CMS

enrollment guidance that would be provided for any new enrollment.

Organizations must also send Exhibit 30 describing the plan change,

including the effective date. The impact of the change on plan

premiums, cost sharing, and provider networks must be communicated

clearly. It is not necessary to confirm with a notice the associated

“enrollment canceled” TRC that will accompany the enrollment into

the new plan (PBP).

705 – New UI Enrollment

- PBP Change

Follow the guidance provided above for TRC 704.

706 – UI Enrollment

Cancel - Segment change

Plan (PBP) segment changes apply only to MA plans. Provide updated

materials reflecting the new elements of the changed segment, such as

premium and cost sharing increases or decreases.

707- UI New enrollment -

Segment Change

Follow the guidance above for TRC 706.

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708 – UI End Date

Assigned

This UI action has the same effect as a plan submitted disenrollment

(code 51) transaction. Generally, organizations should follow existing

CMS enrollment guidance for providing notice and confirmation of the

disenrollment. However, since many UI initiated changes are

retroactive, organizations may have already provided notice (with

correct effective dates) and if so, need not provide it a second time.

Additional clarification may be appropriate depending on the specifics

of the case.

709 – UI Earlier Start

Date

An existing enrollment period in the plan has changed to start earlier

than previously recorded. If the organization has already provided

notice reflecting this effective date of enrollment, it is not necessary to

provide it a second time. When the individual has not already received

notice reflecting this effective date, organizations may use existing

confirmation of enrollment notices where there is confidence that such

notice will not cause undue confusion. Alternatively, organizations

may use Exhibit 30, including in it the new effective date and

information about additional premium liability (ensure flexibility in

allowing payment arrangements where necessary). Organizations must

also ensure individuals are fully aware of how to access coverage of

services for the new time period, including their right to appeal.

710 – UI Later Start Date

An existing enrollment period start date has been changed to start on a

later date. Organizations must use Exhibit 30. Organizations must

explain the change in the effective date of coverage, and provide

information on the refunding of any premiums paid. Organizations

must also explain the impact on any paid claims from the time period

affected.

711 – UI Earlier End Date

An enrollment period end date has been changed to occur earlier.

Organizations must use Exhibit 30. Organizations must explain the

change in the effective date of the end of coverage, and provide

information on the refunding of any premiums paid. Organizations

must also explain the impact on any paid claims from the time period

affected.

712 – UI Later End Date

An enrollment period end date has been changed to occur later.

Organizations must use Exhibit 30. Organizations must explain the

change in the effective date of the end of coverage, and provide

information on any premiums the individual may owe for the extended

period. Organizations must also ensure beneficiaries are fully aware of

how to access coverage of services for the new time period.

713 – UI Removed End

Date

An enrollment period that previously had an end date is now open (and

ongoing). Organizations must use Exhibit 25a to explain the change

and that enrollment in the plan is now continuous. Organizations must

provide information on any plan premiums and ensure beneficiaries are

fully aware of how to access coverage of services for the new time

period and going forward.

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60.8 - Election of Continuation of Enrollment Option for MA Local Plans

42 CFR 422.54(b)

When a member permanently moves into the MA organization’s continuation area, the member must

make a positive choice to continue enrollment in the MA local plan. The member does not have to

complete and sign a new enrollment form in order for the continuation to occur but must make this

choice in a manner described in the MA organization’s policy and procedure documents.

The MA organization must verify that the member has established permanent residence in the

continuation area. Proof of permanent residence is normally established by the address of the

residence, but the MA organization may request additional information such as voter’s registration

records, driver’s license records, tax records, and utility bills. Such records must establish the

permanent residence address, and not the mailing address, of the individual.

The effective date of a continuation of enrollment change generally is the first day of the month after

the individual moves into the continuation area.

60.9 - Storage of Enrollment and Disenrollment Records

As stated at 42 CFR 422.60(c)(2), MA organizations are required to file and retain enrollment request

forms. MA organizations must retain and have available for evaluation enrollment and disenrollment

records for the current contract period and ten (10) prior years (42 CFR 422.504(e)(4)).

It is appropriate to allow for storage on microfilm, as long as microfilm versions of enrollment forms

and disenrollment requests showing the signature and the date are available to reviewers. Similarly,

other technologies that would allow the reviewer to access signed forms and other enrollment requests

may also be allowed, such as optically scanned forms stored on disk.

Records of MA enrollment and disenrollment requests made by any other enrollment request

mechanism (as described in §40.1) must also be retained as above.

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Appendices

Summary of

Medicare Advantage Notice and

Data Element Requirements

150

Appendix 1: Summary of Notice Requirements

Referenced in sections: 10, 30, 40, 50, and 60

(Rev. 1, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

This Exhibit is intended to be a summary of notice requirements. For exact detail on

requirements and time frames, refer to the appropriate sections within this guidance.

Notice Section(s) Required? Timeframe

Model Enrollment Form (Exh. 1)

10, 40.1.1,

40.2, 40.4.1

Yes

Information to include on or with

Enrollment Mechanism -- Attestation

of Eligibility for an Enrollment Period

(Exh. 1a)

30.4 No NA

MA MSA Enrollment Form (Exh 1b)

40.1.1

Yes

MA PFFS Enrollment Form (Exh 1c)

40.1.1

Yes

Simplified Enrollment Form (Exh.

1d)

40.1.9 No NA

EGHP Enrollment Form (Exh. 2)

10, 40.1.1,

40.2, 40.4.1

No NA

Short Enrollment Forms (Exh. 3 and

3a)

10, 40.1.1,

40.2, 40.4.1

No NA

Acknowledgment of Receipt of

Completed Enrollment Request (Exh.

4 and 4a)

40.4.1, 60.4 Yes

10 calendar days of

receipt of completed

enrollment request

Combination Acknowledgement and

Confirmation Notice (Exh. 4b)

40.4 Yes

7 calendar days of

availability of the DTRR

Acknowledge Receipt of Completed

PFFS Enrollment Request (Exh.4c)

40.4.1, 60.4 Yes

10 calendar days of

receipt of completed

enrollment request

Notice to Acknowledge Receipt of

Completed PFFS Enrollment Request

and to Confirm Enrollment in a PFFS

Plan (Exh. 4d)

40.4.1, 60.4 Yes

7 calendar days of

availability of the DTRR

Other CMS approved enrollment election mechanisms may take the place of an enrollment form

Required unless combined acknowledgment/confirmation notice is issued.

Required if the MAO has chosen to provide a single notice in response to the DTRR, as described in §40.4.1.

Required unless combined acknowledgment/confirmation notice is issued.

151

Notice

Section(s)

Required?

Timeframe

Notice to Acknowledge Receipt of

Completed Enrollment Request and to

Confirm Enrollment in Another Plan

Within the Same Parent Organization

(Exh. 4e)

40.4 Yes

7 calendar days of the

availability of the DTRR

Request for Information (Exh. 5) 30, 40.2.2 No

10 calendar days of

receipt of enrollment

request

Confirmation of Enrollment (Exh.

6,6a, 6d)

40.4.2, 40.6 Yes

10 calendar days of

availability of DTRR

Notice to Individuals Identified on

CMS Records As Members of

Employer or Union Group Receiving

Retiree Drug Subsidy (Exh. 6b)

40.2.5 Yes

10 calendar days of

availability of DTRR

Confirm PFFS Enrollment (Exh. 6c) 40.4.2 Yes

10 calendar days of

availability of DTRR

MAO Denial of Enrollment (Exh. 7) 40.2.3 Yes

10 calendar days of

receipt of enrollment

request OR expiration of

time frame for requested

additional information

CMS Rejection of Enrollment (Exh.

40.4.2 Yes

10 calendar days of

availability of DTRR

(exception described in

§40.4.2)

Sending Out Disenrollment

Form/Disenrollment Form (Exh. 9,

9a, & 10)

50.1 No NA

Information to include on or with

Disenrollment Form -- Attestation of

Eligibility for an Election Period

(Exh. 10a)

30.4 No NA

Acknowledgment of Receipt of

Voluntary Disenrollment Request

from Member (Exh. 11)

50.1, 50.4.1 Yes

10 calendar days of

receipt of request to

disenroll

Request Information (Disenrollment)

(Exh. 11a)

30, 50.4.2 Yes

10 calendar days of

receipt of disenrollment

request

Required unless combined acknowledgment/confirmation notice is issued.

152

Notice

Section(s)

Required?

Timeframe

Final Confirmation of Voluntary

Disenrollment Request from Member

(no exhibit)

50.1 No NA

Confirmation of Voluntary

Disenrollment Identified Through

DTRR (Exh. 12)

50.1, 50.4.1.

60.3.2

Yes

10 calendar days of

availability of DTRR

Denial of Disenrollment (Exh. 12a) 50.1.4 Yes

10 calendar days of

receipt of disenrollment

request

Rejection of Disenrollment (Exh.

12b)

50.1

Yes

10 calendar days of

availability of DTRR

Confirmation of Disenrollment Due to

Passive Enrollment into a Medicare-

Medicaid Plan (Exh. 12c)

50.4.1 Yes

10 calendar days of

availability of DTRR

Final Confirmation of Disenrollment

Due to Out of Area > 6 Months (no

exhibit)

50.2.1 No NA

Disenrollment Due to Death (Exh. 13)

50.2.3,

50.4.2, 60.3.1

No NA

Disenrollment Due to Loss of Part A

and/or Part B Coverage (Exh. 14)

50.2.2,

50.4.2, 60.3.1

No NA

Notices on Terminations/Non-

renewals

50.2.4 Yes

Follow requirements in

42 CFR 422.506 -

422.512

Warning of Potential Disenrollment

Due to Disruptive Behavior (no

exhibit)

50.3.2 Yes NA

Disenrollment for Disruptive

Behavior (no exhibit)

50.3.2 Yes

Before the disenrollment

transaction is submitted

to CMS

Disenrollment for Fraud and Abuse

(no exhibit)

50.3.3 Yes

Before the disenrollment

transaction is submitted

to CMS

Offering Beneficiary Services,

Pending Correction of Erroneous

Death Status (Exh. 15)

60.3, 60.3.1 Yes

10 calendar days of initial

contact with member

Offering Beneficiary Services,

Pending Correction of Erroneous Part

A/B Termination (Exh. 16)

60.3, 60.3.1 Yes

10 calendar days of initial

contact with member

Offering Reinstatement of

Beneficiary Services, Pending

60.3, 60.3.1 Yes

10 calendar days of initial

contact with member

153

Notice

Section(s)

Required?

Timeframe

Correction of Disenrollment Status

Due to Plan Error (Exh 17)

Closing Out Request for

Reinstatement (Exh. 18)

60.3.2 Yes

10 calendar days after

information was due to

MA organization

Failure to Pay Plan Premiums -

Advanced Notification of

Disenrollment or Reduction in

Coverage (Exh. 19)

50.3.1 Yes

Within 15 calendar days

of the premium due date

Failure to Pay Plan Premiums -

Notification of Involuntary

Disenrollment (Exh. 20)

50.3.1 Yes

3 business days following

the last day of the grace

period

Failure to Pay Plan Premiums -

Confirmation of Involuntary

Disenrollment (Exh. 21)

50.3.1 No NA

Notification of Involuntary

Disenrollment by the Centers for

Medicare & Medicaid Services for

Failure to Pay the Part D-Income

Related Monthly Adjustment Amount

(Exh. 21a)

50.2.6 Yes

10 calendar days of

notification on the DTRR

Failure to Pay Plan Premiums -

Notice of Reduction in Coverage

(Exh. 22)

50.3.1 Yes

10 calendar days of the

expiration of the grace

period

Notice of Favorable Good Cause

Determination for Disenrollment Due

to Nonpayment of Part D-IRMAA –

Notification of Plan Premium Amount

Due for Reinstatement (Exh. 22a)

60.3.4 No

3 business days following

the notification by CMS

of favorable good cause

determination

Notice on Favorable Good Cause

Determination for Disenrollment Due

to Nonpayment of Plan Premiums –

Notification of Premium Amount Due

for Reinstatement (Exh 22b)

60.3.4 No

3 business days following

favorable good cause

determination

Notice on Unfavorable Good Cause

Determination for Disenrollment Due

to Nonpayment of Plan Premiums

(Exh 22c)

60.3.4 No

3 business days following

unfavorable good cause

determination

Notice to Close Out Good Cause

Reinstatement Request – Failure to

Pay Plan Premiums within 3 Months

of Disenrollment (Exh 22d)

60.3.4 Yes

10 calendar days of the

expiration of the 3 month

period

154

Notice

Section(s)

Required?

Timeframe

Notice on Favorable Good Cause

Determination for Disenrollment Due

to Nonpayment of Plan Premiums

(No Plan Premium Amount Due for

Reinstatement) (Exh 22e)

60.3.4.1 No

3 business days following

favorable good cause

determination

Public Notices For Closing

Enrollment due to Capacity Limit

(Exh. 23)

40.5 Yes

15 days if related to CMS

approved capacity limit

Notice that Enrollment request Placed

on Waiting List (no exhibit)

40.5.1, 40.5.2 Yes

10 calendar days of

receiving enrollment

request or of approval

from CMS to limit

enrollment

Re-affirming Intent to Not Enroll (no

exhibit)

40.5.1, 40.5.2 No

10 days of contacting

member

Intent to Not Process Enrollment (no

exhibit)

40.5.1, 40.5.2 Yes

10 calendar days of

learning beneficiary no

longer wants to enroll

Medigap Rights per Special Election

Period (Exh. 24)

50.2, 50.1 No Upon request.

Request to cancel enrollment (Exh.

25)

60.2.1 Yes

10 calendar days of

request

Confirmation of Reinstatement Per

Notification From CMS (Exh. 25a)

60.2.1,

60.2.2, 60.3,

60.3.1, 60.3.2

Yes

10 calendar days of

DTRR confirming

reinstatement

Confirmation of Cancellation of

Enrollment Due to Notice from CMS

(TRC 015)(Exh. 25b)

60.2.4 Yes

10 calendar days of

DTRR confirming

cancellation

Request to cancel disenrollment (Exh.

26)

60.2.2 Yes

10 calendar days of

request

Inform Member of Auto-Enrollment

(Exh. 27)

40.1.5 Yes

10 calendar days of

identifying individual as

needing auto-enrollment

Inform FBDE Member of Auto-

Enrollment in PDP (Exh. 27a)

40.1.5 Yes

10 calendar days of

identifying individual as

needing auto-enrollment

Inform Member of Facilitated

Enrollment (Exh. 28)

40.1.5 Yes

10 calendar days of

identifying individual as

needing facilitated

enrollment

155

Notice

Section(s)

Required?

Timeframe

Inform Member of Facilitated

Enrollment into PDP (Exh. 28a)

40.1.5 Yes

10 calendar days of

identifying individual as

needing facilitated

enrollment

Request to Decline Part D (Exh. 29) 40.1.5 Yes

10 calendar days of

request

Enrollment Status Update (Exh. 30) 60.7

necessary

10 calendar days of

availability of DTRR

Model Employer/Union Group

Enrollment Mechanism Notice (Exh

31)

40.1.6 Yes

21 calendar days prior to

effective date of

enrollment

Loss of SNP Status (Exh 32) 50.2.5 Yes

10 calendar days of loss

of special needs status

Loss of SNP Status - Notification of

Involuntary Disenrollment (Exh 33)

50.2.5 Yes

3 business days of

expiration of period of

deemed continued

eligibility

Research Potential Out of Area Status

(Exh 34)

50.2.1.3 Yes

10 calendar days of

receiving notice of

change of address or

indication of possible out-

of-area residency

Disenrollment Due to Out of Area

Status (No Response to Request for

Address Verification) (Exh 35)

50.2.1.3 Yes

Within first 10 calendar

days of the sixth month.

Disenrollment Due to Confirmation of

Out of Area Status (Upon New

Address Verification from Member)

(Exh 36)

50.2.1.3 Yes

10 calendar days of

receiving confirmation of

out of area status

Exhibit 37: Notification of

Involuntary Disenrollment by the

Centers for Medicare & Medicaid

Services due to Incarceration

50.2 Yes

10 calendar days of

notification on the DTRR

Exhibit 38: Notification of

Involuntary Disenrollment by the

Centers for Medicare & Medicaid

Services due to Loss of Lawful

Presence

50.2.1, 50.2.7 No

10 calendar days of

notification on the DTRR

156

Appendix 2: Summary of Data Elements Required for Plan Enrollment

Mechanisms and Completed Enrollment Requests

Referenced in section(s): 20, 20.4, 40.2, 40.4.1

(Rev. 2, Issued: August 12, 2020; Effective/Implementation: 01-01-2021)

All data elements with a “Yes” in the “Beneficiary response required on request” column are

necessary in order for the enrollment election to be complete. For use of simplified enrollment

mechanism, the plan must be able to obtain, from its internal data sharing, all the required

elements that it does not include on the enrollment request. Elements required on the simplified

enrollment mechanism, regardless of data sharing, are marked with an asterisk (*).

Data Element

CMS

requires

Field on

enrollment

mechanism?

Beneficiary

response

required on

request?

Exhibit # in which data

element appears

MA Plan name

Yes*

Yes

1, 1b, 1c, 2, 3, 3a

2 Beneficiary name Yes* Yes 1, 1b, 1c, 2, 3, 3a

Beneficiary Date of Birth

Yes

1, 1b, 1c, 2

Beneficiary Sex

Yes

1, 1b, 1c, 2

5 Beneficiary Telephone Number Yes* No 1, 1b, 1c, 2, 3

Permanent Residence Address (with

the exception of “County” – see

below)

Yes Yes 1, 1b, 1c, 2, 3

County (Optional Field)

1, 1b, 1c, 2, 3

8 Mailing Address Yes No 1, 1b, 1c, 2, 3

Name of person to contact in

emergency, including phone number

and relationship to beneficiary

(Optional Field)

No No 1b, 1c, 2

10 E-mail Address (Optional Field) No No 1, 1b, 1c, 2, 3

Beneficiary Medicare number

Yes*

Yes

1, 1b, 1c, 2, 3

Additional Medicare information

contained on Medicare card, or copy

of card

No No 1b, 1c, 2

Plan Premium Payment Option

Yes

1, 1b, 1c, 3, 3a

14 Response to long term care question No No 1, 1b, 1c, 2

If enrollment mechanism will be used for multiple plans, all plan names must be listed in a way that permits the

applicant to clearly indicate his/her plan choice.

Plans may include the image of the Medicare card in enrollment mechanisms.

Zero premium MA-only plans omit this question

Response defaults to direct bill if applicant fails to provide information

157

Data Element

CMS

requires

Field on

enrollment

mechanism?

Beneficiary

response

required on

request?

Exhibit # in which data

element appears

Response to other insurance COB

information

Yes Yes

1, 1b, 1c, 2

Option to request materials in

language other than English

(language preference) or in accessible

formats

Yes* No 1, 1b, 1c, 2, 3, 3a

Annotation of whether beneficiary is

retiree, including retirement date and

name of retiree (if not the

beneficiary)

No No 2

Question of whether spouse or

dependents are covered under the

plan and, if applicable, name of

spouse or dependents

No No 2

Question of whether beneficiary is

currently a member of the plan and if

yes, request for plan identification

number

No No 2

Name of chosen Primary Care

Physician, clinic or health center

(Optional Field)

No No 1, 1b, 1c, 2, 3

Beneficiary signature and/or

Authorized Representative Signature

Yes*

Yes

1, 1b, 1c, 2, 3,3a

Date of signature

Yes*

1, 1b, 1c, 2, 3, 3a

Authorized representative contact

information

Yes* Yes 1, 1b, 1c, 2,3, 3a

Employer or Union Name and Group

Number

Yes Yes 2

Question of which MA plan the

beneficiary is currently a member of

and to which MA plan the beneficiary

is changing

Yes Yes 3

Refer to CMS COB guidance for additional information

For Employer/Union Group MA enrollment elections as described in §40.1.6, and some other CMS approved

enrollment elections, a signature is not required. For paper enrollment forms submitted without a signature,

organization may verify with the applicant by telephone and document the contact instead of returning form.

As explained in §40.2, the beneficiary and/or legal representative should write the date s/he signed the

enrollment form; however, if s/he inadvertently fails to include the date on the enrollment form, then the stamped

date of receipt that the MA organization places on the enrollment form may serve as the signature date of the form.

Therefore, the signature date is not a necessary element. For employer group MA elections as described in §40.4.1,

the "signature date" is the date the employer’s process was completed as recorded.

158

Data Element

CMS

requires

Field on

enrollment

mechanism?

Beneficiary

response

required on

request?

Exhibit # in which data

element appears

For Special Needs Plans, description

of SNP eligibility criteria

Yes Yes N/A

For MSA plans, all additional

elements including proof that MSA

bank account has been established

Yes Yes N/A

Information provided under “please

read and sign below”

All elements provided in model

language must be included on

enrollment request mechanisms.

Option -- can be provided as narrative

or listed as statements of

understanding

Yes* Yes 1, 1b, 1c, 2

Release of Information

All elements provided in model

language must be included on

enrollment request mechanisms.

Yes* Yes 1, 1b, 1c, 2

Notification of receiving plan

materials electronically and ability to

opt out

No No 1, 1b, 1c, 2, 3, 3a

159

Appendix 3: Setting the Application Date on CMS Enrollment Transactions

(Rev. 1, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

The application date submitted on enrollment transactions plays a key role in CMS system edits

that ensure the beneficiary’s choice of plan is honored. The application date is always a date

prior to the effective date of enrollment. For use of simplified enrollment mechanism, follow the

information based on how the enrollment request is received (e.g., paper, fax, telephone,

electronically.)

Enrollment request

Mechanism

Application Date Special Notes

Paper Enrollment Forms

§40.1.1

The date the paper request is

initially received

Paper requests submitted to or

collected by sales agents or

brokers are received by the MA

organization on the date the

agent or broker receives the form

Enrollment forms received by

Fax

§40.1.1

The date the fax is received on

the MA organization’s Fax

machine

Medicare.gov Online

Enrollment Center (OEC)

§40.1.2

11 hours prior to the time and

date “stamped” by CMS on

the request

Refer to the definition of

Application Date in §10.

MA organization electronic

enrollment process

§40.1.2

The date the enrollee

completes the request via the

electronic enrollment process

The electronic enrollment

process must capture the

application date as the day that

the individual completes the

request as part of the process

itself.

Approved Telephonic

Enrollment

§40.1.3

The date of the call

Default Enrollment Option for

Newly MA Eligible Medicaid

Managed Care Plan Enrollees

§40.1.4

First day of individual’s Initial

Coverage Election Period

(ICEP)

Effective date must always be

the date of the individual’s first

entitlement to both Medicare

Part A and Part B

Other Special Processes for

Application Dates

Application Date

Special Notes

All enrollment requests into

employer or union sponsored

plans using the SEP EGHP,

regardless of mechanism used

day of the month prior to

the effective date of

enrollment

This applies to all mechanisms

including §§40.1.3 and 40.1.6

Auto and Facilitated

Enrollment

§40.1.5

The 1

of the month prior to

the effective date of the

auto/facilitated enrollment

SPAP enrollment requests as

permitted in §40.1.8 made

during the AEP

October 15

The effective date of enrollment

is the following January 1

160

Appendix 4: Examples of Good Cause Determinations

Referenced in section: 60.3

This listing is to provide examples to assist plans in making favorable and unfavorable

determinations for requests of reinstatement for good cause. For exact detail on the criteria and

requirements for good cause reinstatements, see §60.3.

In all these examples, the individual is disenrolled for nonpayment of plan premiums and makes

a timely request for good cause reinstatement.

Favorable determination examples:

Example A: Ms. Grey was disenrolled on May 31, 2015 following a plan’s two month grace

period. She states that she has a caregiver who is responsible for making her premium payments

to the plan. Ms. Grey attests that her caregiver caught pneumonia, was hospitalized for over 2

months from late March to late May 2015 and wasn’t able to make payments. The plan issues a

favorable good cause determination, since the member’s caregiver was unexpectedly ill and

hospitalized for a significant portion of the plan’s grace period, which prevented the caregiver

from making arrangements for timely payment. The plan’s favorable determination is

appropriate because: 1) The credible statement was provided about a serious illness and the

person paying premiums was hospitalized for a significant portion of the plan’s grace period; 2)

The event (illness and hospitalization) was unexpected and out of the person’s control; and 3) It

is reasonable to conclude that the caregiver could not have paid or made arrangements to pay the

owed premiums within the plan’s grace period as a result of the illness and hospitalization.

Example B: Mr. Lieber was disenrolled on April 30, 2015 following a plan’s two month grace

period. He states that he was in a car accident in mid-February, was hospitalized for one month

and then sent to an assisted living facility for rehabilitation for one month. He indicated that he

wasn’t able to pay his bills during that time and didn’t have any family to assist him. Because

Mr. Lieber’s situation was unexpected and he was hospitalized and institutionalized for a

significant portion of the plan’s grace period, the plan issues a favorable good cause

determination. The plan’s favorable determination is appropriate because: 1) The creditable

statement was provided about a serious illness and that the member was hospitalized and

institutionalized for significant portion of the plan’s grace period ; 2) The event (illness and

hospitalization) was unexpected and out of the person’s control; and 3) It is reasonable to

conclude that Mr. Lieber could not have paid or made arrangements to pay the owed premiums

within the plan’s grace period as a result of the illness.

Example C: Ms. Kim was disenrolled on August 31, 2015 following the plan’s two month grace

period. She states that she was displaced from her apartment due to a building fire in early June,

was unable to access her belongings and as a result, was unable to make timely payment. The

plan issues a favorable determination because Ms. Kim’s home was significantly damaged by an

unexpected and uncontrollable event during the plan’s grace period. The plan’s favorable

determination is appropriate because: 1) The creditable statement was provided about that the

member’s home was severely damaged due to an unexpected event; 2) The event (fire) was

unexpected and out of the person’s control; and 3) It is reasonable that the damage to Ms. Kim’s

home impaired her ability to pay or make arrangements to pay the owed premiums within the

plan’s grace period.

161

Example D: Mr. Jones was disenrolled on June 30, 2015 following a plan’s two month grace

period. His son states that he found out that his father lost his coverage when he recently visited

him. The son states that Mr. Jones was recently diagnosed with dementia and his condition is

quickly worsening, which caused him to not pay his premiums. The son states that because of

his father’s condition, he is taking over financial matters for his father and will pay the

arrearages. The plan issues a favorable determination because Mr. Jones was newly diagnosed

with a serious illness that directly impacts his ability to pay his premiums. The plan’s favorable

determination is appropriate because: 1) The creditable statement was provided about a serious

and prolonged illness with rapid deterioration, that directly impacted the member’s ability to pay

premiums timely; 2) The event (serious illness with rapid deterioration) was unexpected and out

of the person’s control; and 3) It is reasonable to conclude that the onset of dementia caused Mr.

Jones to fail to make the timely payment during the grace period.

Example E: Ms. Brown was disenrolled on July 31, 2015 following the plan’s three month grace

period. She states that for the past four months, her husband was receiving intensive treatment

for cancer and she was taking care of him during this time. During this time, she fell behind in

paying bills due to the care he needed. The plan issues a favorable determination because Ms.

Brown’s husband was seriously ill for a prolonged period time during the plan’s grace period.

The plan’s favorable determination is appropriate because: 1) The credible statement was

provided about a serious and prolonged illness of an immediate family member; 2) The event

(serious and prolonged illness) was unexpected and out of the person’s control; and 3) It is

reasonable to conclude that Ms. Brown’s circumstance in providing caregiver services for her

spouse impacted her ability to pay or make arrangements to pay the owed premiums within the

plan’s grace period.

Example F: Mrs. Duke was disenrolled on August 31, 2015 following the plan’s two month

grace period. She states that her husband had been handling her bills and making payments

timely. However, he passed away in July 2015, leaving her with no caregiver or family member

to take over the responsibility. The plan issues a favorable good cause determination because of

the recent death of Mrs. Duke’s husband, which was unexpected and out of her control. The plan

also offers Mrs. Duke the option to set up electronic payments and premium withholding to help

ensure that she remains current in paying her premiums. The plan’s favorable determination is

appropriate because: 1) The credible statement was provided about the recent death of a spouse;

2) The event (death of spouse) was unexpected and out of the person’s control; and 3) It is

reasonable to conclude that the unexpected death impacted Mrs. Duke’s ability to pay or make

arrangements to pay the owed premiums within the plan’s grace period.

Example G: Mr. Santiago lives in Lucas County, Iowa, and was disenrolled on July 31, 2015

following the plan’s two month grace period. He states that there were severe storms and

significant flooding in his town and the Post Office closed for a week during the grace period

while the flooding receded. The plan checks the FEMA.gov website and verifies that Lucas

County, Iowa, was declared as a federal disaster area. The plan issues a favorable good cause

determination because the declared federal state of emergency occurred during the plan’s grace

period and that emergency impacted Mr. Santiago’s ability to pay his premiums timely. The

plan’s favorable determination is appropriate because: 1) The credible statement provided was an

extreme weather-related event The event (declared state of emergency) was unexpected and out

of the person’s control; 2) The event was unexpected and out of the person’s control; and 3) It is

162

reasonable to conclude that this circumstance impacted Mr. Santiago’s ability to pay or make

arrangements to pay the owed premiums within the plan’s grace period.

Unfavorable determination examples:

Example A: Mr. Smith was disenrolled on June 30, 2015 following the plan’s three month grace

period. He states that he was unable to pay his plan premiums because he was in the hospital for

a week in May for a planned surgical procedure, followed by a two week stay in a rehabilitation

facility. The plan issues an unfavorable good cause determination because Mr. Smith was not

unexpectedly hospitalized or institutionalized for a significant portion of the plan’s grace

period. Even though Mr. Smith was away from his home undergoing medical treatment for three

weeks, he had a reasonable opportunity and ability to resolve the delinquency within the plan’s

grace period. The plan’s unfavorable determination is appropriate because: 1) The credible

statement provided was not one in which hospitalization or institutionalization occurred for a

significant portion of the plan’s grace period; 2) The situation (planned hospital procedure) was

not unexpected, nor did it render the individual without control over timely payment of his

premiums; and 3) It is reasonable to expect that Mr. Smith could have paid or made

arrangements to pay the owed amounts within the plan’s grace period. Mr. Smith may not be

reinstated for good cause.

Example B: Mr. Jones was disenrolled on May 31, 2015 following the plan’s two month grace

period. He states that he was unable to pay his plan premiums because he has End-Stage Renal

Disease (ESRD) and goes to a facility for dialysis three times a week. Mr. Jones states that he

sometimes has difficulty keeping track of his monthly premium billing statements because of his

frequent trips to the dialysis facility. The plan issues an unfavorable good cause determination

because Mr. Jones has a known health issue and his need for routine dialysis is not unexpected in

any way. While he has a chronic illness, he was receiving regular care to treat his condition, and

it is reasonable to expect him, or someone acting on his behalf, to resolve the delinquency at

some point during the plan’s grace period. The plan’s unfavorable determination is appropriate

because: 1) The credible statement provided was not one in which a chronic illness had newly

developed serious complications which inhibited the ability to pay premiums timely; 2) The

situation (chronic condition with no complications) did not render the individual without control

over timely payment of his premiums; and 3) It is reasonable to expect that Mr. Jones could have

paid or made arrangements to pay the owed amounts within the plan’s grace period. Mr. Jones

may not be reinstated for good cause.

Example C: Ms. Ferrera was disenrolled on March 31, 2015 following the plan’s two month

grace period. She states that she and her family were away from home on an extended vacation

and she wasn’t aware that she had been disenrolled until they returned home. Ms. Ferrera states

that she is willing and able to pay the plan premiums that were not paid and added that she needs

her coverage due to her many medications for diabetes. The plan issues an unfavorable good

cause determination because Ms. Ferrera did not have a circumstance that was unexpected or

unforeseen in any way. While she has a chronic illness and requires medicines to treat her

condition, Ms. Ferrera had the ability to make arrangements to have the premiums paid on time

while she was out of town. The plan’s unfavorable determination is appropriate because: 1) The

credible statement provided of being away from home on vacation is listed specifically as the

basis for an unfavorable determination; 2) The situation (planned vacation) was not unexpected

in any way; and 3) It is reasonable to expect that Ms. Ferrera could have paid or made

163

arrangements to pay the owed amounts within the plan’s grace period. Ms. Ferrera may not be

reinstated for good cause.

Example D: Mr. Davis was disenrolled on July 31, 2015 following the plan’s two month grace

period. He states that earlier in the year he moved a short distance from his previous residence

but did not inform the plan of his new address. The plan issues an unfavorable good cause

determination because the plan materials clearly state that it is the enrollee’s responsibility to

inform the plan of a change of address. This is not a case of plan error, since the plan sent the

monthly billing statements and the disenrollment notice to the address most recently provided by

Mr. Davis. (See §60.3.3 for information on reinstatement following disenrollment due to plan

error.) The plan’s unfavorable determination is appropriate because: 1) The credible statement

provided of an unreported change of address is listed specifically as the basis for an unfavorable

determination; 2) The situation (permanent residence change) was not unexpected in any way;

and 3) It is reasonable to expect Mr. Davis to inform the plan of his new address, to avoid any

delay in his receipt of important materials, such as monthly billing statements and notices

regarding his enrollment status. Mr. Davis may not be reinstated for good cause.

Example E: Ms. Adams was disenrolled on April 30, 2015 following the plan’s three month

grace period. She states that the basement in her home and her electricity were affected by recent

flooding and that this prevented her from sending her monthly plan premium payments. Local

road closures and power outages lasted for up to a week for some residents. The plan issues an

unfavorable good cause determination because the local storms and subsequent flooding did not

severely damage Ms. Adams home or prevent her from making the premium payments; further,

there was neither a state nor federal disaster declaration. The plan’s unfavorable determination is

appropriate because: 1) The credible statement provided was not one in which the home was

severely damaged nor was there a federal or state declaration of emergency; and 2) While road

closures and power outages impacted some area residents, it isn’t clear that Ms. Adams was

directly impacted by these events or was impeded from being able to make timely payment; and

3) It is reasonable to expect that Ms. Adams could have paid or made arrangements to pay the

owed amounts within the plan’s grace period. Ms. Adams may not be reinstated for good cause.

Example F: Mrs. Johnson was disenrolled on March 31, 2015 following the plan’s two month

grace period. She states that her husband is responsible for making her premium payments to the

plan. Mrs. Johnson attests that her husband became ill, was hospitalized for two weeks in

February 2015 and was not able to make payments. The plan issues an unfavorable good cause

determination since, although her husband’s illness was unexpected, he was not hospitalized for

a significant portion of the plan’s grace period, which would have caused him to be unable to

make the payment in a timely manner. The plan’s unfavorable determination is appropriate

because: 1) The credible statement provided was not that hospitalization or institutionalization

occurred for a significant portion of the plan’s grace period; and 2) It is reasonable to expect that

Mr. Johnson could have paid or made arrangements to pay the owed amounts for this wife’s

coverage within the plan’s grace period. Mrs. Johnson may not be reinstated for good cause.

Example G: Mr. Patel was disenrolled on September 30, 2015 following the plan’s three month

grace period. He states that his income decreased and he was unable to afford to pay his

premiums. The plan issues an unfavorable good cause determination because there wasn’t an

unexpected or unforeseen circumstance that prevented payment from being made by Mr. Patel in

a timely manner. The plan’s unfavorable determination is appropriate because: 1) The credible

statement provided of personal financial issues is listed specifically as the basis for an

164

unfavorable determination; and 2) It is reasonable to expect that Mr. Patel could have paid or

made arrangements to pay the owed amounts within the plan’s grace period. Mr. Patel may not

be reinstated for good cause.

Example H: Ms. Ulman was disenrolled on June 30, 2015 following the plan’s two month grace

period. She states that she needs to refill her medications and that she paid her owed amounts to

the plan on July 20, 2015, following her disenrollment effective date. The plan issues an

unfavorable good cause determination because Ms. Ulman’s need for medications did not inhibit

her ability to pay her premiums timely. The plan’s unfavorable determination is appropriate

because: 1) The situation (medication needs) was not unexpected or out of the person’s control,

nor did it impede her ability to pay timely; and 2) It is reasonable to expect that Ms. Ulman could

have paid or made arrangements to pay the owed amounts within the plan’s grace period. Ms.

Ulman may not be reinstated for good cause.

Example I: Ms. Taylor was disenrolled on March 31, 2015 following a plan’s three month grace

period. She states that when she enrolled in the plan during the fall open enrollment period, she

selected premium withhold as the method of premium payment. She says that she received a

premium bill from the new plan for January and, in addition, received a delinquency notice in

early January warning of disenrollment at the end of March if she did not pay the premium for

January. She stated that she ignored the bill and the delinquency notice, assuming that her plan

premiums were being withheld from her Social Security benefit check starting with the January

premium. The plan issues an unfavorable good cause determination because the plan explained

in its letter to Ms. Taylor following submission of the enrollment transaction and receipt of the

DTRR that her first month’s plan premium was not withheld, that she was responsible for paying

her premiums until premium withholding started and that she could be involuntarily

disenrolled. The plan concluded that Ms. Taylor had been appropriately advised of her obligation

to pay the bill for the January premium and that this was reiterated by means of the subsequent

premium bills and the delinquency letter the plan sent to her in January. The plan’s unfavorable

determination is appropriate because: 1) The situation (misunderstanding of ramifications of

nonpayment of premiums) was not unexpected in any way; 2) The situation did not impede her

ability to pay timely; and 3) It is reasonable to expect that Ms. Taylor could have paid or made

arrangements to pay the owed amounts within the plan’s grace period. Ms. Taylor may not be

reinstated for good cause.

165

EXHIBITS

Model Medicare Advantage

Enrollment Forms & Notices

This section contains model exhibits for plan issued notices to beneficiaries regarding

enrollment matters. MA organizations may make the following modifications to CMS

model materials and still submit the material to CMS under the ten (10) day review

period: populating variable fields, correcting grammatical errors, changing the font

(within standards described in the CMS marketing guidelines), adding the plan

name/logo, and adding the CMS marketing material identification number.

For more information on CMS marketing and mailing requirements as well as the

instructions for submitting model documents for review, see the CMS Medicare

Communication and Marketing Guidelines.

OMB No. 0938-1378

Expires:7/31/2023

166

Exhibit 1: MODEL INDIVIDUAL ENROLLMENT REQUEST FORM TO ENROLL IN

A MEDICARE ADVANTAGE PLAN (PART C)

Who can use this form?

People with Medicare who want to join a Medicare

Advantage Plan

To join a plan, you must:

• Be a United States citizen or be lawfully

present in the U.S.

• Live in the plan’s service area

Important: To join a Medicare Advantage Plan,

you must also have both:

• Medicare Part A (Hospital Insurance)

• Medicare Part B (Medical Insurance)

When do I use this form?

You can join a plan:

• Between October 15–December 7 each year (for

coverage starting January1)

• Within 3 months of first getting Medicare

• In certain situations where you’re allowed to

join or switch plans

Visit Medicare.gov to learn more about when you

can sign up for a plan.

What do I need to complete this form?

• Your Medicare Number (the number on your

red, white, and blue Medicare card)

• Your permanent address and phone number

Note: You must complete all items in Section 1.

The items in Section 2 are optional — you can’t be

denied coverage because you don’t fill them out.

Reminders:

• If you want to join a plan during fall open

enrollment (October 15–December 7), the plan

must get your completed form by December 7.

• Your plan will send you a bill for the plan’s

premium. You can choose to sign up to have

your premium payments deducted from your

bank account or your monthly Social Security

(or Railroad Retirement Board) benefit.

What happens next?

Send your completed and signed form to:

Once they process your request to join, they’ll

contact you.

How do I get help with this form?

Call <Plan Name> at <phone number>. TTY users

can call < phone number >.

Or, call Medicare at 1-800-MEDICARE

(1-800-633-4227). TTY users can call

1-877-486-2048.

En español: Llame a <Plan Name> al <phone

number/TTY> o a Medicare gratis al

1-800-633-4227 y oprima el 2 para asistencia en

español y un representante estará disponible para

asistirle.

<Contract#, alpha-numeric identifier, “CMS Approved/File & Use” [date] (as applicable)>

167

Section 1 – All fields on this page are required (unless marked optional)

Select the plan you want to join:

Product ABC – $XX per month Product XYZ – $XX per month

FIRST name: LAST name: [Optional: Middle Initial]:

Birth date: (MM/DD/YYYY)

(__ __/__ __/__ __ __ __)

Sex:

Male Female

Phone number:

( )

Permanent Residence street address (Don’t enter a PO Box):

City:

[Optional: County]:

State:

ZIP Code:

Mailing address, if different from your permanent address (PO Box allowed):

Street address: City: State: ZIP Code:

Your Medicare information:

Medicare Number: _ _ _ _ - _ _ _ - _ _ _ _

Answer these important questions:

[MA-PD / PDPs insert:

Will you have other prescription drug coverage (like VA, TRICARE) in addition to < Plan>? Yes No

Name of other coverage: Member number for this coverage: Group number for this coverage

___________________________ ____________________________ ________________________]

[Special Needs Plans] insert question(s) regarding the required special needs criteria]

IMPORTANT: Read and sign below:

• [MA plans insert: I must keep both Hospital (Part A) and Medical (Part B) to stay in <Plan Name>.]

• By joining this Medicare Advantage Plan, I acknowledge that <Plan Name> will share my information with

Medicare, who may use it to track my enrollment, to make payments, and for other purposes allowed by

Federal law that authorize the collection of this information (see Privacy Act Statement below).

• Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan.

• The information on this enrollment form is correct to the best of my knowledge. I understand that if I

intentionally provide false information on this form, I will be disenrolled from the plan.

• I understand that people with Medicare are generally not covered under Medicare while out of the country,

except for limited coverage near the U.S. border.

• [MA plans insert: I understand that when my <Plan Name> coverage begins, I must get all of my medical

and prescription drug benefits from <Plan Name>. Benefits and services provided by <Plan Name> and

contained in my <Plan Name> “Evidence of Coverage” document (also known as a member contract or

subscriber agreement) will be covered. Neither Medicare nor <Plan Name> will pay for benefits or services

that are not covered.]

• I understand that my signature (or the signature of the person legally authorized to act on my behalf) on this

application means that I have read and understand the contents of this application. If signed by an authorized

representative (as described above), this signature certifies that:

1) This person is authorized under State law to complete this enrollment, and

2) Documentation of this authority is available upon request by Medicare.

Signature:

Today’s date:

If you’re the authorized representative, sign above and fill out these fields:

Name: Address:

Phone number: Relationship to enrollee:

<Contract#, alpha-numeric identifier, “CMS Approved/File & Use” [date] (as applicable)>

168

PRIVACY ACT STATEMENT

The Centers for Medicare & Medicaid Services (CMS) collects information from Medicare plans to track beneficiary enrollment in Medicare Advantage

(MA) Plans, improve care, and for the payment of Medicare benefits. Sections 1851 and 1860D-1 of the Social Security Act and 42 CFR §§ 422.50 and

422.60 authorize the collection of this information. CMS may use, disclose and exchange enrollment data from Medicare beneficiaries as specified in the

System of Records Notice (SORN) “Medicare Advantage Prescription Drug (MARx)”, System No. 09-70-0588. Your response to this form is voluntary.

However, failure to respond may affect enrollment in the plan.

Section 2 – All fields on this page are optional

Answering these questions is your choice. You can’t be denied coverage because you don’t fill them out.

Select one if you want us to send you information in a language other than English.

[ Plans insert the languages required in your service area.]

Select one if you want us to send you information in an accessible format.

Braille Large print Audio CD

Please contact <plan name> at <phone number> if you need information in an accessible format other than

what’s listed above. Our office hours are <insert days and hours of operation>. TTY users can call <TTY

number.>

Do you work? Yes No Does your spouse work? Yes No

List your Primary Care Physician (PCP), clinic, or health center:

I want to get the following materials via email. Select one or more.

[Plans may list those types or categories of materials that are available for electronic delivery]

E-mail address:

Paying your plan premiums

[Plans with premiums insert: You can pay your monthly plan premium [MA-PD plans with premiums insert:

(including any late enrollment penalty that you currently have or may owe)] by mail <insert optional methods:

“Electronic Funds Transfer (EFT)”, “credit card”> each month <insert optional intervals, if applicable, for

example “or quarterly”>. You can also choose to pay your premium by having it automatically taken out of

your Social Security or Railroad Retirement Board (RRB) benefit each month.]

[MA-PD and PDPs with premiums insert: If you have to pay a Part D-Income Related Monthly Adjustment

Amount (Part D-IRMAA), you must pay this extra amount in addition to your plan premium. The amount

is usually taken out of your Social Security benefit, or you may get a bill from Medicare (or the RRB). DON’T

pay [insert appropriate plan and/or organization name] the Part D-IRMAA.]

<Contract#, alpha-numeric identifier, “CMS Approved/File & Use” [date] (as applicable)>

169

Exhibit 1a: Information to include on or with Enrollment Mechanism –

Attestation of Eligibility for an Enrollment Period

Referenced in section: 30.4

(Rev. 2, Issued: August 25, 2020; Effective/Implementation: 01-01-2021)

Typically, you may enroll in a Medicare Advantage plan only during the annual enrollment

period from October 15 through December 7 of each year. There are exceptions that may

allow you to enroll in a Medicare Advantage plan outside of this period.

Please read the following statements carefully and check the box if the statement applies to you.

By checking any of the following boxes you are certifying that, to the best of your knowledge,

you are eligible for an Enrollment Period. If we later determine that this information is incorrect,

you may be disenrolled.

 I am new to Medicare.

 I am enrolled in a Medicare Advantage plan and want to make a change during the

Medicare Advantage Open Enrollment Period (MA OEP).

 I recently moved outside of the service area for my current plan or I recently moved and

this plan is a new option for me. I moved on (insert date) _______________________.

 I recently was released from incarceration. I was released on (insert date)

______________________________________________________.

 I recently returned to the United States after living permanently outside of the U.S. I

returned to the U.S. on (insert date) ________________________.

 I recently obtained lawful presence status in the United States. I got this status on (insert

date) ______________________________________.

 I recently had a change in my Medicaid (newly got Medicaid, had a change in level of

Medicaid assistance, or lost Medicaid) on (insert date) ___________________________.

 I recently had a change in my Extra Help paying for Medicare prescription drug coverage

(newly got Extra Help, had a change in the level of Extra Help, or lost Extra Help) on

(insert date) _____________________________________.

 I have both Medicare and Medicaid (or my state helps pay for my Medicare premiums) or

I get Extra Help paying for my Medicare prescription drug coverage, but I haven’t had a

change.

 I am moving into, live in, or recently moved out of a Long-Term Care Facility (for

example, a nursing home or long term care facility). I moved/will move into/out of the

facility on (insert date) ____________________________________________________.

 I recently left a PACE program on (insert date) ___________________________.

<Contract#, alpha-numeric identifier, “CMS Approved/File & Use” [date] (as applicable)>

170

 I recently involuntarily lost my creditable prescription drug coverage (coverage as good

as Medicare’s). I lost my drug coverage on (insert date) _________________________.

 I am leaving employer or union coverage on (insert date) _______________________.

 I belong to a pharmacy assistance program provided by my state.

 My plan is ending its contract with Medicare, or Medicare is ending its contract with my

plan.

 I was enrolled in a plan by Medicare (or my state) and I want to choose a different plan.

My enrollment in that plan started on (insert date) ______________________________.

 I was enrolled in a Special Needs Plan (SNP) but I have lost the special needs

qualification required to be in that plan. I was disenrolled from the SNP on (insert date)

_____________________________.

 I was affected by an emergency or major disaster (as declared by the Federal Emergency

Management Agency (FEMA) or by a Federal, state or local government entity. One of

the other statements here applied to me, but I was unable to make my enrollment request

because of the disaster.

If none of these statements applies to you or you’re not sure, please contact <plan name> at

<phone number> (TTY users should call <TTY number>) to see if you are eligible to enroll.

We are open <insert days and hours of operation>.

<Contract#, alpha-numeric identifier, “CMS Approved/File & Use” [date] (as applicable)>

171

Exhibit 1b: Model MA MSA Plan Enrollment Request Form (“Election” may

also be used)

Referenced in §40.1.1

(Rev. 3, Issued: August 12, 2020; Effective/Implementation: 01-01-2021)

Please contact <plan name> if you need information in another language or format (Braille).

To Enroll in <plan name>, Please Provide the Following Information:

[Required if form used for multiple plans: Please check which plan you want to enroll in:

Product ABC $XX per month Product XYZ $XX per month]

LAST name: FIRST Name: Middle Initial

Mr. Mrs.

Ms.

Birth Date:

(__ __/__ __/__ __ __ __)

(M M / D D / Y Y Y Y)

Sex:

M F

Home Phone Number:

( )

[Optional field:

Alternate Phone

Number: ( )]

Permanent Residence Street Address (P.O. Box is not allowed):

City:

[Optional field: County:]

State:

ZIP Code:

Mailing Address (only if different from your Permanent Residence Address):

Street Address: City: State: ZIP

Code:

[Optional field: Emergency contact: _________________

Phone Number: ________________________ Relationship to You: ____________________ ]

[Optional field: E-mail Address: _____________________ ]

Please Provide Your Medicare Insurance Information

Please take out your red, white and blue Medicare

card to complete this section.

• Fill out this information as it appears on

your Medicare card.

- OR –

• Attach a copy of your Medicare card or

your letter from Social Security or the

Railroad Retirement Board.

Name (as it appears on your Medicare card):

Medicare Number:

Is Entitled to: Effective Date:

HOSPITAL (Part A)

MEDICAL (Part B)

You must have Medicare Part A and Part B to join

a Medicare Advantage plan.

Please read and answer these important questions

<Contract#, alpha-numeric identifier, “CMS Approved/File & Use” [date] (as applicable)>

172

1. To enroll in <MSA plan name>, you may not have other health coverage as described below.

Please answer each of the following questions:

A. Are you enrolled in your State Medicaid program? Yes No

B. Are you receiving Medicare Hospice benefits? Yes No

C. Some individuals may have other health coverage, including other private insurance,

TRICARE, Federal employee health benefits coverage, VA benefits, or other health benefits that

cover all or part of the annual Medicare MSA deductible. If you have any other such coverage, you

aren’t eligible to enroll in <MSA plan name>

Will you have other health coverage in addition to <MSA plan name>? Yes No

If “yes”, please list your other coverage and your identification (ID) number(s) for this coverage so

we can decide if you are eligible to enroll in <MSA plan name>:

Name of other coverage: ID # for this coverage: Group # for this

coverage

_______________________________ __________________________ ________________________

2. Will you reside in the United States for at least 183 days during each year you are enrolled in

<MSA plan>?

Yes No

3. Do you or your spouse work? Yes No

Please check one of the boxes below if you would prefer that we send you information in a

language other than English or an accessible format:

Please contact <plan name> at <phone number> if you need information in an accessible format or

language other than what is listed above. Our office hours are <insert days and hours of operation>.

TTY users should call <TTY number>.

[

Optional field:

If plan delivers some documents electronically, insert language explaining the types of

documents it sends and how (e.g., information about your enrollment to the email address you provide

to us on this form), as well as how a member can opt to get paper versions of those documents instead

(e.g., a checkbox to opt-out of getting documents electronically).]

Please Read and Sign Below:

By completing this enrollment application, I agree to the following:

<MSA Plan Name> is a Medicare Advantage plan and has a contract with the Federal government. I

will need to keep my Medicare Parts A and B. I can be in only one Medicare Advantage plan at a time

and I understand that my enrollment in this plan will automatically end my enrollment in another

Medicare health plan. It is my responsibility to inform you of any health coverage that I have or may

get in the future. I understand that if I don’t have Medicare prescription drug coverage, or creditable

<Contract#, alpha-numeric identifier, “CMS Approved/File & Use” [date] (as applicable)>

173

prescription drug coverage (as good as Medicare’s), I may have to pay a late enrollment penalty if I

enroll in Medicare prescription drug coverage in the future. Enrollment in this plan is generally for the

entire year. I may leave this plan (“disenroll”) during the Annual Enrollment Period that is October

through December 7

of every year (effective the following January 1

) or under certain limited

special circumstances, by sending a request in writing to <MSA plan name>. If I choose a Medicare

MSA plan and haven’t before joined an MSA plan, then change my mind, I may cancel my enrollment

by December 15 of the same year by contacting my plan to cancel my enrollment request. I understand

that my enrollment into an MSA plan isn’t complete until the bank account is established. I understand

that I am enrolling in a plan that doesn’t pay for Medicare covered services until a high deductible is

met, but <plan name> allows me to use funds in my MSA account to pay for health services.

Withdrawals made from the MSA bank account aren’t taxed when used for IRS-qualified medical

expenses. I would owe income tax and up to a 50% penalty for withdrawals used for non-medical

expenses. After the deductible is met the plan pays 100% of Medicare-covered services.

[MSA Demonstration Plans insert: If I am enrolling in a MSA demonstration plan, I may be

responsible for cost sharing for certain preventive services, as described by the plan, before the

deductible is met. After the deductible is met, I may be responsible for cost-sharing until my expenses

for covered services reach the out-of-pocket maximum, after which the MSA demonstration plan pays

100% of Medicare covered services.]

If I have any questions regarding the initial set-up of my MSA bank account or any of the information

in this enrollment form, I should contact the <plan name> at < contact number>.

<MSA plan name> serves a specific service area. If I move out of the area that <MSA Plan Name>

serves, I need to notify the plan so I can disenroll and find a new plan in my new area. Once I am a

member of <MSA plan Name>, I have the right to appeal plan decisions about payment or services if I

disagree. I will read the [insert either Member Handbook or Evidence of Coverage document] from

<MSA plan name> when I get it to know which rules I must follow to get coverage with this Medicare

Advantage plan.

I understand that if I am getting assistance from a sales agent, broker, or other individual employed by

or contracted with <plan name>, he/she may be paid based on my enrollment in<plan name>.

I understand that if I disenroll before the end of the plan year (December 31

), <plan name> may debit

my MSA bank account for a prorated share of the current year’s deposit to be returned to Medicare.

The debit amount is based on the number of months left in the year after the disenrollment date. I

understand that, if I die, my estate will be responsible for any money owed to Medicare. My estate

keeps any amount over what is owed to Medicare.

Release of Information: By joining this Medicare health plan, I acknowledge that the Medicare

health plan will release my information to Medicare and other plans as is necessary for treatment,

payment and health care operations. I also acknowledge that <MSA plan name> will release my

information to Medicare, who may release it for research and other purposes which follow all

applicable Federal statutes and regulations. The information on this enrollment form is correct to the

best of my knowledge. I understand that if I intentionally provide false information on this form, I will

be disenrolled from the plan.

I understand that my signature (or the signature of the person authorized to act on my behalf under the

laws of the State where I live) on this application means that I have read and understand the contents of

this application. If signed by an authorized individual (as described above), this signature certifies that

<Contract#, alpha-numeric identifier, “CMS Approved/File & Use” [date] (as applicable)>

174

Office Use Only:

Name of staff member/agent/broker (if assisted in enrollment):___________________________

Plan ID #:_____________________________

Effective Date of Coverage: _______________

ICEP/IEP: __________ AEP: __________ SEP (type): __________ Not Eligible: _______

[optional space for other administrative information needed by plan]

1) this person is authorized under State law to complete this enrollment and 2) documentation of this

authority is available upon request from Medicare.

Signature:

Today’s Date:

If you are the authorized representative, you must sign above and provide the following information:

Name: _________________________________________________

Address: _______________________________________________

Phone Number: (___) ____- _________

Relationship to Enrollee ___________________

Keeping records -- As an authorized representative, it is important that you keep records of when funds

in the MSA account are used, as well as how the funds are used.

<Contract#, alpha-numeric identifier, “CMS Approved/File & Use” [date] (as applicable)>

175

Exhibit 1c: Model PFFS Individual Enrollment Request Form (“Election” may

also be used)

Referenced in section(s): 10, 20.4, 40.1, 40.2

(Rev. 3, Issued: August 12, 2020; Effective/Implementation: 01-01-2021)

Please contact <plan name> if you need information in another language or format (Braille).

To Enroll in <plan>, Please Provide the Following Information:

[Required if form used for multiple plans: Please check which plan you want to enroll in:

Product ABC $XX per month Product XYZ $XX per month]

LAST name: FIRST Name: Middle Initial

Mr. Mrs.

Ms.

Birth Date:

(__ __/__ __/__ __ __ __)

(M M / D D / Y Y Y Y)

Sex:

M F

Home Phone Number:

( )

[Optional field:

Alternate Phone

Number:]

Permanent Residence Street Address (P.O. Box is not allowed):

City:

[Optional field: County:]

State:

ZIP Code:

Mailing Address (only if different from your Permanent Residence Address):

Street Address: City: State: ZIP Code:

[Optional field: Emergency contact: _________________

Phone Number:______________________________ Relationship to You: _________ ]

[Optional field: E-mail Address: __________________ ]

Please Provide Your Medicare Insurance Information

Please take out your red, white and blue Medicare

card to complete this section.

• Fill out this information as it appears on

your Medicare card.

- OR –

• Attach a copy of your Medicare card or

your letter from Social Security or the

Railroad Retirement Board.

Name (as it appears on your Medicare card):

Medicare Number:

Is Entitled to: Effective Date:

HOSPITAL (Part A)

MEDICAL (Part B)

You must have Medicare Part A and Part B to join

a Medicare Advantage plan.

[Zero premium MA-only plans omit this section:

Paying Your Plan Premium

<Contract#, alpha-numeric identifier, “CMS Approved/File & Use” [date] (as applicable)>

176

[Zero premium MA-PD plans insert: If we determine that you owe a late enrollment penalty (or if

you currently have a late enrollment penalty), we need to know how would prefer to pay it. You

can pay by mail <insert optional methods: “Electronic Funds Transfer (EFT)”, “credit card”> each

month <insert optional intervals, if applicable, for example “or quarterly”>. You can also choose to

pay your premium by automatic deduction from your Social Security or Railroad Retirement

Board benefit check each month. If you are assessed a Part D-Income Related Monthly

Adjustment Amount, you will be notified by the Social Security Administration. You will be

responsible for paying this extra amount in addition to your plan premium. You will either have

the amount withheld from your Social Security benefit check or be billed directly by Medicare or

Railroad Retirement Board. DO NOT pay [insert appropriate plan and/or organization name] the

Part D-IRMAA. ]

[MA-only and MA-PD plans with premiums insert: You can pay your monthly plan premium [

MA-

PD plans with premium insert:

(including any late enrollment penalty you have or may owe)] by mail

<insert optional methods: “Electronic Funds Transfer (EFT)”, “credit card”> each month <insert

optional intervals, if applicable, for example “or quarterly”>. You can also choose to pay your

premium by automatic deduction from your Social Security or Railroad Retirement Board

benefit check each month.

[MA-PD plans with premiums insert: If you are assessed a Part D-Income Related Monthly

Adjustment Amount, you will be notified by the Social Security Administration. You will be

responsible for paying this extra amount in addition to your plan premium. You will either have

the amount withheld from your Social Security benefit check or be billed directly by Medicare or

Railroad Retirement Board. DO NOT pay [insert appropriate plan and/or organization name] the

Part D-IRMAA.]

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you

qualify, Medicare could pay for 75% or more of your drug costs including monthly prescription drug

premiums, annual deductibles, and co-insurance. Additionally, those who qualify won’t have a coverage

gap or a late enrollment penalty. Many people qualify for these savings and don’t even know it. For

more information about this Extra Help, contact your local Social Security office, or call Social Security

at 1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for Extra Help online at

www.socialsecurity.gov/prescriptionhelp

If you qualify for Extra Help with your Medicare prescription drug coverage costs, Medicare will pay

all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for

the amount that Medicare doesn’t cover.

If you don’t select a payment option, you will get a bill each month <optional language in place of “bill

each month”: “coupon book” or “payment book”>.

Please select a premium payment option:

Get a bill <option: “coupon”, “payment” book, etc>

[Optional - Include other payment methods, such as EFT & credit card as follows:

Electronic funds transfer (EFT) from your bank account each month. Please enclose a VOIDED

check or provide the following:

Account holder name: ______________________

<Contract#, alpha-numeric identifier, “CMS Approved/File & Use” [date] (as applicable)>

177

Bank routing number: _ _ _ _ _ _ _ _ _ Bank account number: _ _ _ _ _ _ _ _ _ _ _ _

Account type: Checking Saving

Credit Card. Please provide the following information:

Type of Card: ____________________________

Name of Account holder as it appears on card: _________________________

Account number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Expiration Date: _ _/_ _ _ _ (MM/YYYY)]

Automatic deduction from your monthly Social Security/Railroad Retirement Board (RRB) benefit

check.

I get monthly benefits from: Social Security RRB

(The Social Security/RRB deduction may take two or more months to begin after Social Security or

RRB approves the deduction. In most cases, if Social Security or RRB accepts your request for

automatic deduction, the first deduction from your Social Security or RRB benefit check will include all

premiums due from your enrollment effective date up to the point withholding begins. If Social

Security or RRB does not approve your request for automatic deduction, we will send you a paper bill

for your monthly premiums.)]

Please read and answer these important questions:

[PFFS-PD plans insert:

1. Some individuals may have other drug coverage, including other private insurance, TRICARE,

Federal employee health benefits coverage, VA benefits, or State pharmaceutical assistance programs.

Will you have other prescription drug coverage in addition to <PFFS plan>? Yes No

If “yes”, please list your other coverage and your identification (ID) number(s) for this coverage:

Name of other coverage: ID # for this coverage: Group # for this

coverage

_______________________________ __________________________ _______________________]

2. Do you or your spouse work? Yes No

[Optional field: Please tell us the name of your Primary Care Physician (PCP):

Doctor’s Name: _____________________________ Phone Number:

___________________________]

[Optional field: Please tell us the name of your preferred hospital, clinic or health center:

Name: _________________________________ City: _____________________ State: ________]

Please check one of the boxes below if you would prefer that we send you information in a

language other than English or in an accessible format:

Please contact <plan name> at <phone number> if you need information in an accessible format or

language other than what is listed above. Our office hours are <insert days and hours of operation>.

TTY users should call <TTY number>.

<Contract#, alpha-numeric identifier, “CMS Approved/File & Use” [date] (as applicable)>

178

[Optional field: If plan delivers some documents electronically, insert language explaining the types of

documents it sends and how (e.g., information about your enrollment to the email address you provide

to us on this form), as well as how a member can opt to get paper versions of those documents instead

(e.g., a checkbox to opt-out of getting documents electronically).]

Please Read and Sign Below

By completing this enrollment application, I agree to the following:

<Plan Name> is a Medicare Private Fee-For-Service plan and has a contract with the Federal

government. I will need to keep my Medicare Parts A and B. I understand that this plan is a Medicare

Advantage Private-Fee-For-Service plan and I can be in only one Medicare health plan at a time. I

understand that my enrollment in this plan will automatically end my enrollment in another Medicare

health plan [PFFS w/PD insert “or Medicare prescription drug plan.”]. It is my responsibility to inform

you of any prescription drug coverage that I have or may get in the future. [PFFS w/o PD only plans

insert: “I understand that since this plan does not offer Medicare prescription drug coverage, I may get

coverage from another Medicare prescription drug plan. If I don’t have Medicare prescription drug

coverage, or creditable prescription drug coverage (as good as Medicare’s), I may have to pay a late

enrollment penalty if I enroll in Medicare prescription drug coverage in the future.”] Enrollment in this

plan is generally for the entire year. Once I enroll, I may leave this plan or make changes only at certain

times of the year if an enrollment period is available (Example: Annual Enrollment Period from October

15 – December 7 of every year), or under certain special circumstances.

Please Read This Important Information

[All PFFS plans insert: <Plan name>, a Medicare Advantage Private Fee-for-Service plan, works

differently than a Medicare supplement plan as well as other Medicare Advantage plans. Your doctor or

hospital isn’t required to agree to accept our plan’s terms and conditions, and may choose not to treat

you, except in emergencies. You should verify that your provider(s) will accept <plan name> before

each visit Providers can find the plan’s terms and conditions on our website at <insert link to PFFS

terms and conditions>.]

[All PFFS plans insert, except for cases in which beneficiary is switching from one PFFS plan to

another PFFS plan offered by the same MAO: Once <plan name> has your enrollment form, you will

get a call from a plan representative. This call is to make sure that you understand how a Private Fee-

for-Service plan works and to confirm your intent to enroll in <plan name>. If <plan name> isn’t able

to reach you by telephone, then you will get a letter by mail that contains similar information.]

[PFFS-PD plans insert: If you currently have health coverage from an employer or union, joining

<PFFS-PD Name> could affect your employer or union health benefits. If you have health coverage

from an employer or union, joining <PFFS-PD Name> may change how your current coverage works.

You or your dependents could lose your other health or drug coverage completely and not get it back if

you join <plan name>. Read the communications your employer or union sends you. If you have

questions, visit their website, or contact the office listed in their communications. If there is no

information on whom to contact, your benefits administrator or the office that answers questions about

your coverage can help.]

<Contract#, alpha-numeric identifier, “CMS Approved/File & Use” [date] (as applicable)>

179

Office Use Only:

Name of staff member/agent/broker (if assisted in enrollment):___________________________

Plan ID #:_____________________________

Effective Date of Coverage: _______________

ICEP/IEP: ______ AEP: ______ SEP (type): ______ Not Eligible: ______

[optional space for other administrative information needed by plan]

As a Medicare Private Fee-For-Service plan, <plan name> works differently than a Medicare supplement

plan as well as other Medicare Advantage plans. <Plan name> pays instead of Medicare, and I will be

responsible for the amounts that <plan name> doesn’t cover, such as copayments and coinsurances.

Original Medicare won’t pay for my health care while I am enrolled in <plan name>.

Before seeing a provider, I should verify that the provider will accept <plan name>. I understand that

my health care providers have the right to choose whether to accept <plan name>’s payment terms and

conditions every time I see them. I understand that if my provider doesn’t accept <plan name>, I will

need to find another provider that will.

<Plan name> serves a specific service area. If I move out of the area that <plan name> serves, I need to

notify <plan name> so I can disenroll and find a new plan in my new area. Once I am a member of <plan

name>, I have the right to appeal plan decisions about payment or services if I disagree. I will read the

[insert either Member Handbook or Evidence of Coverage document] from <plan name> when I get it to

know which rules I must follow in to get coverage with this Private Fee-For-Service plan. I understand

that people with Medicare aren’t usually covered under Medicare while out of the country except for

limited coverage near the U.S. border.

I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or

contracted with <plan name>, he/she may be paid based on my enrollment in<plan name>.

Release of Information: By joining this Medicare health plan, I acknowledge that the Medicare health

plan will release my information to Medicare and other plans as is necessary for treatment, payment and

health care operations. I also acknowledge that <plan name> will release my information [

PFFS-PD plans

insert:

including my prescription drug event data] to Medicare, who may release it for research and other

purposes which follow all applicable Federal statutes and regulations. The information on this enrollment

form is correct to the best of my knowledge. I understand that if I intentionally provide false information

on this form, I will be disenrolled from the plan.

I understand that my signature (or the signature of the person authorized to act on my behalf under the

laws of the State where I live) on this application means that I have read and understand the contents of

this application. If signed by an authorized individual (as described above), this signature certifies that:

1) this person is authorized under State law to complete this enrollment and 2) documentation of this

authority is available upon request from Medicare.

Signature:

Today’s Date:

If you are the authorized representative, you must sign above and provide the following information:

Name: ________________________

Address: _______________________________________________

Phone Number: (___) ____- ______

Relationship to Enrollee ___________________

<Contract#, alpha-numeric identifier, “CMS Approved/File & Use” [date] (as applicable)>

180

Exhibit 1d: Model Simplified Enrollment Form

Reference: §40.1.9

(Rev. 1, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

[MA Organizations must collect all required data as outlined in Appendix 2. Additional data

elements must be added for any required data not already available.]

You are requesting enrollment into a Medicare Advantage Plan offered by <name of MA

Organization>. You agree to allow <name of MA Organization> to use your personal

information we have on file from your current enrollment in <our non-Medicare coverage [or

optionally: name non-Medicare plan]> to complete your enrollment request.

Tell Us About Yourself:

LAST Name:

FIRST Name:

Middle Initial:

Your current <non-Medicare

plan name> health plan member

number:

Your Medicare Number:

(Optional)

Part A coverage starts:

Part B coverage starts:

Your Telephone Number (in case we need to reach you):

Tell Us Which Plan You Want to Enroll: [Include plan names and premiums. If using form for

multiple plans, display options for beneficiary to clearly indicate plan choice.]

____ Plan A $XX per month _____ Plan B $XX per month

[If offering a zero premium plan or reduction of the Part B premium, may delete or modify the

references to plan and Medicare premiums:] I understand that this plan may have a different

provider network and that I must pay the monthly plan premium in addition to any Medicare Part

A and Part B premiums I may owe.

[May include options for premium payment. If not offering options for premium payment,

include: You will get a bill from <plan name> for your monthly premium. Contact <plan name>

if you want to pay your premium by <payment options offered by the plan>.]

[Add any other items not available via internal data sharing to collect the remainder of required

information]

Please check one of the boxes if you would prefer that we send you information in a language

other than English or in an accessible format:

____ <include list of available languages>

____ <include list of accessible formats (like Braille, audio tape, or large print)>

Please contact <plan name> at phone <phone number> if you need information in an accessible

format or language other than what is listed above. Our office hours are <insert days and hours of

operation >. TTY users should call <TTY number>.

<Contract#, alpha-numeric identifier, “CMS Approved/File & Use” [date] (as applicable)>

181

You are requesting enrollment into a Medicare Advantage Plan offered by <name of MA

Organization>. You agree to allow <name of MA Organization> to use your personal

information we have on file from your current enrollment in <our non-Medicare coverage [or

optionally: name non-Medicare plan]> to complete your enrollment request.

IMPORTANT: Read and Sign Below:

• <Plan name> is a Medicare Advantage prescription drug plan and has a contract with the Federal

government. I must continue to keep both Part A and Part B to stay enrolled in <plan name>.

• I understand that if I am getting assistance from a sales agent, broker, or other individual employed

by or contracted with <plan name>, he/she may be compensated based on my enrollment in <plan

name>.

• Release of Information: By joining this Medicare Advantage Prescription Drug Plan, I

acknowledge that the plan will release my information to Medicare and other plans as is necessary

for treatment, payment and health care operations. I also acknowledge that <plan name> will

release my information, including my prescription drug event data, to Medicare, who may release

it for research and other purposes which follow all applicable Federal statutes and regulations.

• The information on this enrollment form is correct to the best of my knowledge. I understand that

if I intentionally provide false information on this form, I will be disenrolled from the plan. I

understand that people with Medicare are generally not covered under Medicare while out of the

country, except for limited coverage near the U.S. border.

• I understand that when my <plan name> coverage begins, I must get all of my medical and

prescription drug benefits from <plan name>. Benefits and services authorized by <plan name>

and contained in my <plan name> Evidence of Coverage document (also known as a member

contract or subscriber agreement) will be covered. Without authorization, neither Medicare nor

<plan name> will pay for benefits or services.

• I understand that my signature (or the signature of the person legally authorized to act on my

behalf) on this application means that I have read and understand the contents of this application.

If signed by an authorized individual (as described above), this signature certifies that:

1) This person is authorized under State law to complete this enrollment, and

2) Documentation of this authority is available upon request by Medicare.

Signature:

Date:

If you are the authorized representative, you must sign above and provide the following information:

Name:

Address:

Phone Number:

Relationship to Enrollee:

<Contract#, alpha-numeric identifier, “CMS Approved/File & Use” [date] (as applicable)>

182

Exhibit 2: Model Employer/Union Group Health Plan Enrollment Request

Form (“Election” may also be used)

Referenced in section(s): 10, 40.1, 40.2, 50.1

(Rev. 3, Issued: August 12, 2020; Effective/Implementation: 01-01-2021)

Please contact <plan name> if you need information in another language or format (Braille).

To Enroll in <plan name>, Please Provide the following Information:

Employer or Union Name: Group #:

[Required if form used for multiple plans: Please check which plan you want to enroll in:

Product ABC $XX per month Product XYZ $XX per month]

LAST name: FIRST Name: Middle Initial

Mr. Mrs.

Ms.

Birth Date:

(__ __/__ __/__ __ __ __)

(M M / D D / Y Y Y Y)

Sex:

M F

Home Phone Number:

( )

[Optional field:

Alternate Phone

Number:]

Permanent Residence Street Address (P.O. Box is not allowed):

City:

[Optional field: County:]

State:

ZIP Code:

Mailing Address (only if different from your Permanent Residence Address):

Street Address: City: State: ZIP Code:

[Optional field: E-mail Address: _______________________ ]

Please Provide Your Medicare Insurance Information

Please take out your red, white and blue Medicare

card to complete this section.

• Fill out this information as it appears on

your Medicare card.

- OR –

• Attach a copy of your Medicare card or

your letter from Social Security or the

Railroad Retirement Board.

Name (as it appears on your Medicare card):

Medicare Number:

Is Entitled to: Effective Date:

HOSPITAL (Part A)

MEDICAL (Part B)

You must have Medicare Part A and Part B to join

a Medicare Advantage plan.

<Contract#, alpha-numeric identifier, “CMS Approved/File & Use” [date] (as applicable)>

183

Please read and answer these important questions

1. Are you the retiree? Yes No

If yes, retirement date (month/date/year): _________________

If no, name of retiree: ________________________________

2. Are you covering a spouse or dependents under this employer or union plan? Yes No

If yes, name of spouse: ________________________________

Name(s) of dependent(s): _________________________________

3. Do you or your spouse work? Yes No

4. Some individuals may have other drug coverage, including other private insurance, Worker’s

Compensation, VA benefits or State pharmaceutical assistance programs.

Will you have other prescription drug coverage in addition to <plan name>? Yes No

If “yes”, please list your other coverage and your identification (ID) number(s) for this coverage:

Name of other coverage: ID # for Coverage:

_______________________________ __________________________

5. Are you a resident in a long-term care facility, such as a nursing home? Yes No

If “yes” please provide the following information:

Name of Institution: ____________

Address & Phone Number of Institution (number and street):__________________

[Optional field: Please Choose a Primary Care Physician (PCP), clinic or health center: ]

Please check one of the boxes below if you would prefer that we send you information in a

language other than English or in an accessible format:

Please contact <plan name> at <phone number> if you need information in an accessible format or

language other than what is listed above. Our office hours are <insert days and hours of operation>.

TTY users should call <TTY number>.

[Optional field: If plan delivers some documents electronically, insert language explaining the types of

documents it sends and how (e.g., information about your enrollment to the email address you provide to

us on this form), as well as how a member can opt to get paper versions of those documents instead (e.g.,

a checkbox to opt-out of getting documents electronically).]

Please Read and Sign Below

By completing this enrollment application, I agree to the following:

<Plan Name> is a Medicare Advantage plan and has a contract with the Federal government. I will need

to keep my Medicare Parts A and B. I can only be in one Medicare Advantage plan at a time and I

understand that my enrollment in this plan will automatically end my enrollment in another Medicare

health plan. It is my responsibility to inform you of any prescription drug coverage that I have or may

<Contract#, alpha-numeric identifier, “CMS Approved/File & Use” [date] (as applicable)>

184

get in the future. [MA-only plans insert: I understand that if I don’t have Medicare prescription drug

coverage, or creditable prescription drug coverage (as good as Medicare’s), I may have to pay a late

enrollment penalty if I enroll in Medicare prescription drug coverage in the future.] Enrollment in this

plan is generally for the entire year. Once I enroll, I may leave this plan or make changes only at certain

times of the year if an enrollment period is available (Example: Annual Enrollment Period from October

15 – December 7), or under certain special circumstances.

<Plan Name> serves a specific service area. If I move out of the area that <Plan Name> serves, I need to

notify the plan so I can disenroll and find a new plan in my new area. Once I am a member of <Plan

Name>, I have the right to appeal plan decisions about payment or services if I disagree. I will read the

[insert either Member Handbook or Evidence of Coverage document] from <plan name> when I get it to

know which rules I must follow to get coverage with this Medicare Advantage plan. I understand that

people with Medicare aren’t usually covered under Medicare while out of the country except for limited

coverage near the U.S. border.

[

MA PFFS do not include the following paragraph: I understand that beginning on the date <plan name>

coverage begins, I must get all of my health care from <plan name>, except for emergency or urgently

needed services or out-of-area dialysis services. Services authorized by <plan name> and other services

contained in my <plan name> Evidence of Coverage document (also known as a member contract or

subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR <Plan

Name> WILL PAY FOR THE SERVICES.]

I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or

contracted with <plan name>, he/she may be paid based on my enrollment in<plan name>.

Release of Information: By joining this Medicare health plan, I acknowledge that the Medicare health

plan will release my information to Medicare and other plans as is necessary for treatment, payment and

health care operations. I also acknowledge that <plan name> will release my information [

MA-PD plans

insert:

including my prescription drug event data] to Medicare, who may release it for research and other

purposes which follow all applicable Federal statutes and regulations. The information on this enrollment

form is correct to the best of my knowledge. I understand that if I intentionally provide false information

on this form, I will be disenrolled from the plan.

I understand that my signature (or the signature of the person authorized to act on my behalf under the

laws of the State where I live) on this application means that I have read and understand the contents of

this application. If signed by an authorized individual (as described above), this signature certifies that: 1)

this person is authorized under State law to complete this enrollment and 2) documentation of this

authority is available upon request from Medicare.

Signature:

Today’s Date:

If you are the authorized representative, you must sign above and provide the following information:

Name: ________________________

Address: _______________________________________________

Phone Number: (___) ____- _____

Relationship to Enrollee ___________________

<Contract#, alpha-numeric identifier, “CMS Approved/File & Use” [date] (as applicable)>

185

Office Use Only:

Name of staff member/agent/broker (if assisted in enrollment):___________________________

Plan ID #:_____________________________

Effective Date of Coverage: _______________

ICEP/IEP: ______ AEP: ______ SEP (type): _____ Not Eligible: ______

[optional space for other administrative information needed by plan]

<Contract#, alpha-numeric identifier, “CMS Approved/File & Use” [date] (as applicable)>

186

Exhibit 3: Model Short Enrollment Request Form (“Election” may also be

used)

(Rev. 2, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

This form may be used in place of the model individual enrollment form when a member of a

MA plan is enrolling into another MA plan offered by the same parent organization. This form

is not applicable to MSA.

Referenced in section(s): 10, 20.4, 40, 40.1

Name of Plan You are Enrolling In: ______________________________

Name:

Medicare Number: ________________

(Note: may use “member number” instead of “Medicare Number”)

Home Phone Number:

Permanent Street Address (P.O. Box is not allowed)

City:

[Optional field: County:]

State:

ZIP Code:

Mailing Address (only if different from your Permanent Street Address):

Street Address: City: State: ZIP Code:

Please fill out the following:

I am currently a member of the plan in <MAO name> with a monthly

premium of $ .

I would like to change to the plan in <MAO name>. I understand that

this plan has different health benefits and a monthly premium of $ .

[Optional Field: Name of chosen Primary Care Physician (PCP), clinic or health center: ]

Please check one of the boxes below if you would prefer us to send you information in a language

other than English or in an accessible format:

Please contact <plan name> at <phone number> if you need information in an accessible format or

language other than what is listed above. Our office hours are <insert days and hours of operation>. TTY

users should call <TTY number>.

[Optional field: If plan delivers some documents electronically, insert language explaining the types of

documents it sends and how (e.g., information about your enrollment to the email address you provide to

us on this form), as well as how a member can opt to get paper versions of those documents instead (e.g.,

a checkbox to opt-out of getting documents electronically).]

[Zero premium MA-only plans omit this section]

Your Plan Premium

<Contract#, alpha-numeric identifier, “CMS Approved/File & Use” [date] (as applicable)>

187

[Zero premium MA-PD plans insert: If we determine that you owe a late enrollment penalty (or if you

currently have a late enrollment penalty), we need to know how you would prefer to pay it. You can

pay by mail <insert optional methods: “Electronic Funds Transfer (EFT)”, “credit card”> each

month <insert optional intervals, if applicable, for example “or quarterly”>. You can also pay your

premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB)

benefit check each month. If you are assessed a Part D-Income Related Monthly Adjustment

Amount, you will be notified by the Social Security Administration. You will be responsible for

paying this extra amount in addition to your plan premium. You will either have the amount

withheld from your Social Security benefit check or be billed directly by Medicare or the RRB. Do

NOT pay [insert appropriate plan and/or organization name] the Part D-IRMAA.]

[MA-only and MA-PD plans with premiums insert: You can pay your monthly plan premium [

MA-PD

plans with premium insert:

(including any late enrollment penalty you have or may owe)] by mail

<insert optional methods: “Electronic Funds Transfer (EFT)”, “credit card”> each month <insert

optional intervals, if applicable, for example “or quarterly”>. You can also choose to pay your

premium by automatic deduction from your Social Security or Railroad Retirement Board Check

each month.

[MA-PD plans with premiums also insert: If you are assessed a Part D-Income Related Monthly

Adjustment Amount, you will be notified by the Social Security Administration. You will be

responsible for paying this extra amount in addition to your plan premium. You will either have the

amount withheld from your Social Security benefit check or be billed directly by Medicare or the

Railroad Retirement Board. Do NOT pay [insert appropriate plan and/or organization name] the

Part D-IRMAA.

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you

qualify, Medicare could pay for 75% or more of your drug costs including monthly prescription drug

premiums, annual deductibles, and co-insurance. Additionally, those who qualify won’t have a coverage

gap or a late enrollment penalty. Many people qualify for these savings and don’t even know it. For

more information about this Extra Help, contact your local Social Security office, or call Social Security

at 1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for Extra Help online at

www.socialsecurity.gov/prescriptionhelp.

If you qualify for Extra Help with your Medicare prescription drug coverage costs, Medicare will pay all

or part of your plan premium for this benefit. If Medicare pays only a portion of this premium, we will

bill you for the amount that Medicare doesn’t cover.

If you don’t select a payment option, you will get a bill each month <optional language in place of “bill

each month”: “coupon book” or “payment book”>.

Please select a premium payment option:

Get a bill <option: Include other optional methods, such as EFT & credit card>

Automatic deduction from your monthly Social Security or RRB benefit check.

I get monthly benefits from: Social Security RRB

(The Social Security deduction may take two or more months to begin after Social Security or RRB

approves the deduction. In most cases, if Social Security or RRB accepts your request for automatic

deduction, the first deduction from your Social Security or RRB benefit check will include all premiums

due from your enrollment effective date up to the point withholding begins. If Social Security or RRB

<Contract#, alpha-numeric identifier, “CMS Approved/File & Use” [date] (as applicable)>

188

does not approve your request for automatic deduction, we will send you a paper bill for your monthly

premiums.)]

Please Read and Sign Below:

<Plan> is a plan that has a contract with the Federal government.

I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or

contracted with <plan name>, he/she may be paid based on my enrollment in<plan name>.

Release of Information: By joining this Medicare health plan, I acknowledge that the Medicare health

plan will release my information to Medicare and other plans as is necessary for treatment, payment and

health care operations. I also acknowledge that <plan name> will release my information [

MA-PD plans

insert:

including my prescription drug event data] to Medicare, who may release it for research and other

purposes which follow all applicable Federal statutes and regulations. The information on this enrollment

form is correct to the best of my knowledge. I understand that if I intentionally provide false information

on this form, I will be disenrolled from the plan. I understand that people with Medicare aren’t covered

under Medicare while out of the country except for limited coverage near the U.S. border.

[

MA PFFS do not include the following paragraph: I understand that beginning on the date [name of plan]

coverage begins, I must get all of my health care from <plan name>, except for emergency or urgently

needed services or out-of-area dialysis services. Services authorized by <plan name> and other services

contained in my <plan name> Evidence of Coverage document (also known as a member contract or

subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR <Plan

Name> WILL PAY FOR THE SERVICES.

I understand that my signature (or the signature of the person authorized to act on my behalf under the

laws of the State where I live) on this application means that I have read and understand the contents of

this application. If signed by an authorized individual (as described above), this signature certifies that: 1)

Please Read This Important Information

[Insert if enrolling in a PFFS plan: <Plan name>, a Medicare Advantage Private Fee-for-Service plan,

works differently than a Medicare supplement plan and other Medicare Advantage plans. Your doctor or

hospital isn’t required to accept the plan’s terms and conditions, and may choose not to treat you, except

in emergencies. If your doctor or hospital does not agree to accept our payment terms and conditions,

they may choose not to provide health care services to you, except in emergencies. You should verify

that your provider(s) will accept <Plan name> before each visit. Providers can find the plan’s terms and

conditions on our website at <insert link to PFFS terms and conditions>.]

[Insert if enrolling in a PFFS plan, except for cases in which the member is switching from one PFFS

plan to another PFFS plan offered by the same parent organization: Once <plan name> has your

enrollment form, a plan representative will call you. This call is to make sure that you understand how a

Private Fee-for-Service plan works and to confirm your intent to enroll in <plan name>. If <plan name>

isn’t able to reach you by telephone, then you will get a letter by mail that contains similar information.]

<Contract#, alpha-numeric identifier, “CMS Approved/File & Use” [date] (as applicable)>

189

Office Use Only:

Name of staff member/agent/broker (if assisted in enrollment):___________________________

Plan ID #:_____________________________

Effective Date of Coverage: _______________

ICEP/IEP: ______ AEP: ______ SEP (type): ______ Not Eligible: ______

[optional space for other administrative information needed by plan]

this person is authorized under State law to complete this enrollment and 2) documentation of this

authority is available upon request from Medicare.

Signature:

Today’s Date:

If you are the authorized representative, you must sign above and provide the following information:

Name : ________________________

Address: _______________________________________________

Phone Number: (___) ____- _____

Relationship to Enrollee ___________________

<Contract#, alpha-numeric identifier, “CMS Approved/File & Use” [date] (as applicable)>

190

Exhibit 3a: Model Plan Selection Form for MA-PD - Switch From Plan to

Plan Within Parent Organization

This form is not applicable to MSA.

Referenced in section(s): 10, 40, 40.1, 40.2

(Rev. 2, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

Dear <plan name> Member:

<Introduction - In the introduction of cover letter, MA organization may include language

regarding plan choices, description of plans, differences, etc.>. [Insert to describe PFFS plans:

<Plan name>, a Medicare Advantage Private Fee-for-Service plan, works differently than a

Medicare supplement plan. Your doctor or hospital is not required to agree to accept the plan’s

terms and conditions, and thus may choose not to treat you, with the exception of

emergencies. If your doctor or hospital does not agree to accept our payment terms and

conditions, they may choose not to provide health care services to you, except in

emergencies. Providers can find the plan’s terms and conditions on our website at <insert link to

PFFS terms and conditions>.]

To make a change in the Medicare Advantage plan you have with <name of MA organization>,

fill out the enclosed plan selection form to make your choice. Check off the plan you want, and

sign the form. Then mail the completed form back to us <optional: in the postage-paid

envelope> by <date>.

You can change health plans only at certain times during the year. From October 15 - December

7, you can join, switch or drop a Medicare health or drug plan for the following year. In

addition, from January 1 - March 31, anyone enrolled in a Medicare Advantage Plan (except an

MSA plan) can switch plans or return to Original Medicare (and join a stand-alone Medicare

Prescription Drug Plan). Generally, you can’t make changes at other times except in certain

situations, such as if you move out of your plan’s service area, want to join a plan in your area

with a 5-star rating, or qualify for (or lose) Extra Help paying for prescription drug coverage.

[Plans have the option to omit this language for non-ICEP enrollments: If you join our plan

when you first enroll in Medicare, you can switch to another plan or get Original Medicare (and

join a stand-alone Medicare Prescription Drug Plan). If you’re not happy with your choice in our

plan, you can make a change during the first 3 months you have Medicare.]

If you select another plan and we receive your completed selection form by <date>, your new

benefit plan will begin in <month/year>. Your monthly plan premium will be <premium

amount> and you may continue to see any <current plan name> primary care doctors and

specialists.

Complete the attached form only if you wish to change plans.

To help you with your decision, we have also included <year> <Summary of Benefits or benefit

overview> for the available options.

<Contract#, alpha-numeric identifier, “CMS Approved/File & Use” [date] (as applicable)>

191

If you have any questions, please call <plan name> at <phone number - if plan is planning to

have informational meetings - include information about time/place of meetings >. TTY users

should call <TTY number>. We are open <insert days/hours of operation and, if different, TTY

hours of operation>.

Thank you.

<Contract#, alpha-numeric identifier, “CMS Approved/File & Use” [date] (as applicable)>

192

Plan Selection Form

(Rev. 1, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

Date:

Member Name:

Member Number:

I want to transfer from my current plan to the plan I have selected below. I understand that if

this form is received by the end of any month, my new plan will generally be effective the 1st of

the following month.

Please check the appropriate box below <list all available plans>:

____ <Name of Plan>

<brief description of benefit - include items such as: visit copays, emergency room,

durable medical equipment, inpatient care, annual out of pocket maximum on

coinsurance services, etc.>

____ <Name of Plan>

<brief description of benefit - include items such as: visit copays, emergency room,

durable medical equipment, inpatient care, annual out of pocket maximum on

coinsurance services, etc.>

[Insert to describe PFFS plans: <Plan name>, a Medicare Advantage Private Fee-for-Service

plan, works differently than a Medicare supplement plan. Your doctor or hospital is not required

to agree to accept the plan’s terms and conditions, and thus may choose not to treat you, with the

exception of emergencies. If your doctor or hospital does not agree to accept our payment terms

and conditions, they may choose not to provide health care services to you, except in

emergencies. Providers can find the plan’s terms and conditions on our website at <insert link to

PFFS terms and conditions>.]

[Zero premium MA-only plans omit this section:

Your Plan Premium

[Zero premium MA-PD plans insert: If we determine that you owe a late enrollment penalty

(or if you currently have a late enrollment penalty), we need to know how would prefer to

pay it. You can pay by mail <insert optional methods: “Electronic Funds Transfer (EFT)”,

“credit card”> each month <insert optional intervals, if applicable, for example “or

quarterly”>. You can also choose to pay your premium by automatic deduction from your

Social Security or Railroad Retirement Board Check each month.]

<Contract#, alpha-numeric identifier, “CMS Approved/File & Use” [date] (as applicable)>

193

[MA-only and MA-PD plans with premiums insert: You can pay your monthly plan premium

[MA-PD plans with premium insert: (including any late enrollment penalty you have or may

owe)] by mail <insert optional methods: “Electronic Funds Transfer (EFT)”, “credit card”>

each month <insert optional intervals, if applicable, for example “or quarterly”>. You can

also choose to pay your premium by automatic deduction from your Social Security or

Railroad Retirement Board Check each month.

People with limited incomes may qualify for Extra Help to pay for their prescription drug

costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly

prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who

qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are

eligible for these savings and don’t even know it. For more information about this Extra Help,

contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours

per day, 7 days per week. TTY/TDD users should call 1-877-486-2048.

If you qualify for Extra Help with your Medicare prescription drug coverage costs, Medicare will

pay all or part of your plan premium for this benefit. If Medicare pays only a portion of this

premium, we will bill you for the amount that Medicare does not cover.

If you don’t select a payment option, you will receive a bill each month <optional language in

place of “bill each month”: “coupon book” or “payment book”>.

Please select a premium payment option:

Receive a bill <option: Include other optional methods, such as EFT & credit card>

Automatic deduction from your monthly Social Security or RRB benefit check.

I get monthly benefits from: Social Security RRB

(The Social Security or RRB deduction may take two or more months to begin after Social

Security or RRB approves the deduction. In most cases, if Social Security or RRB accepts your

request for automatic deduction, the first deduction from your Social Security or RRB benefit

check will include all premiums due from your enrollment effective date up to the point

withholding begins. If Social Security or RRB does not approve your request for automatic

deduction, we will send you a paper bill for your monthly premiums.)]

Please check one of the boxes below if you would prefer us to send you information in a

language other than English or in an accessible format:

Please contact <plan name> at <phone number> (TTY users should call TTY number> if you

need information in an accessible format or language other than what is listed above. Our office

hours are <insert days and hours of operation>.

<Contract#, alpha-numeric identifier, “CMS Approved/File & Use” [date] (as applicable)>

194

[Optional: If plan delivers some documents electronically, insert language explaining the types

of documents it sends and how (e.g., information about your enrollment to the email address you

provide to us on this form), as well as how a member can opt to get paper versions of those

documents instead (e.g., a checkbox to opt-out of getting documents electronically).]

Signature:

Today’s Date:

If you are the authorized representative, you must sign above and provide the following

information:

Name: __________________________________

Address: _________________________________

Phone Number: (___) ____- _________________

Relationship to Enrollee ____________________

Please mail this form to:

<Contract#, alpha-numeric identifier, “CMS Approved/File & Use” [date] (as applicable)>

195

Exhibit 4: Model Notice to Acknowledge Receipt of Completed Enrollment

Request

Referenced in section(s): 40.4.1, 60.4

(Rev. 2, Issued: August 12, 2020; Effective/Implementation: 01-01-2021)

<RxID>

<RxBin>

<RxPCN>

Dear <Name of Member>:

Thank you for enrolling in <Plan name>. Beginning <effective date>, you must see your <plan

name> doctor(s) for your health care. This means that starting <effective date>, all of your health

care, except emergency or urgently needed care, or out-of-area dialysis services, must be given

or arranged by a <plan name> doctor(s). You will need to pay your plan co-payments and co-

insurance at the time you get health care services as described in your member materials.

[

Optional language: This letter is proof of insurance that you should show at your doctor

appointments until you get your member card from us.] [Optional language for MA-PD: This

letter is also proof of your prescription drug coverage. You should show this letter at the

pharmacy until you get your member card from us.]

[

MA PPO plans use the following paragraph in place of 1

paragraph above: Thank you for enrolling

in <Plan name>. Beginning <effective date>, you must get your health care as provided in your

<insert either ‘Member handbook’ or ‘Evidence of Coverage’>. You will need to pay your plan

co-payments and co-insurance at the time you get health care services, as described in your

member materials. [

Optional language: This letter is proof of insurance that you should show

during your doctor appointments until you get your member card from us.]

What should I do now?

Medicare must review all enrollments. We will send your enrollment to Medicare, and they will

do a final review. When Medicare finishes its review, we will send you a letter to confirm your

enrollment with <plan name>. But, you shouldn’t wait to get this letter before you begin using

<plan name> doctors on <effective date>. Also, don’t cancel any Medigap/Medicare Select or

supplemental insurance that you have until we send you the confirmation letter.

[

MA-PD plans with a premium include the following: If you qualify for Extra Help with your

Medicare prescription drug coverage costs, Medicare may cover all or some portion of your plan

premium.]

[

Plans with a premium include the following:

How do I pay my premium?

<Contract#, alpha-numeric identifier, “CMS Approved/File & Use” [date] (as applicable)>

196

Your enrollment form included the options for paying your plan premium. If you did not choose

one of these options when you enrolled, we will bill you directly. If you chose to have your

monthly premium automatically deducted from your Social Security/Railroad Retirement Board

benefit check, we may have to send you a bill for your first month or two of enrollment if the

deduction doesn’t start right away. Generally, you must stay with the option you choose for the

rest of the year. If you have any questions about how to pay your plan premium, please contact

us at <plan telephone number>. TTY users should call <TTY number>.] [MAOs that disenroll

for non-payment of plan premiums include the following sentence: Members who fail to pay the

monthly plan premium may be disenrolled from <plan name>.]

What do I need to know about getting health care services?

You must have Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) to be a

member of <Plan>. If you don’t have Medicare Parts A and B, we will bill you for any health

care you receive from us, and neither Medicare nor <plan name> will pay for those services.

[

MA PPO plans do not use the following paragraph: Please remember that, except for emergency or

out-of-area urgent care, or out-of-area dialysis services, if you get health care services from a

non-<plan name> doctor without prior authorization, you will have to pay for these services

yourself.]

When can I make changes to my coverage?

You can change health plans only at certain times during the year. From October 15 - December

7, you can join, switch or drop a Medicare health or drug plan for the following year. In

addition, from January 1 - March 31, anyone enrolled in a Medicare Advantage Plan (except an

MSA plan) can switch plans or return to Original Medicare (and join a stand-alone Medicare

Prescription Drug Plan). Generally, you can’t make changes at other times except in certain

situations, such as if you move out of your plan’s service area, want to join a plan in your area

with a 5-star rating, or qualify for (or lose) Extra Help paying for prescription drug costs.

[Plans have the option to omit this language for non-ICEP enrollments: If you join our plan

when you first enroll in Medicare, you can switch to another plan or get Original Medicare (and

join a stand-alone Medicare Prescription Drug Plan). If you’re not happy with your choice in our

plan, you can make a change during the first 3 months you have Medicare.]

[MA-PD plans with a premium include the following two paragraphs:

[Dual-eligible SNPs may omit the following paragraph]

Can I get help paying my premiums and other out-of-pocket costs?

People with limited incomes may qualify for Extra Help to pay for their prescription drug

costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly

prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who

qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are

eligible for these savings and don’t even know it. For more information about this Extra Help,

contact your local Social Security office or call Social Security at 1-800-772-1213. TTY users

should call 1-800-325-0778. You can also apply for Extra Help online at

www.socialsecurity.gov/prescriptionhelp.]

<Contract#, alpha-numeric identifier, “CMS Approved/File & Use” [date] (as applicable)>

197

[Optional: What else do I need to know about my coverage?

If applicable, insert information instructing member in simple terms on how to select a primary

care provider/site (PCP); how to obtain Medicare Advantage Plan services, e.g., provide the

name, phone number, and location of the PCP, include the membership identification card when

possible, explain unique POS and/or PPO procedures (when applicable), explain which services

do not need PCP approval (when applicable), etc.]

If you have any questions, please call <plan name> at <phone number>. TTY users should call

<TTY number>. We are open <days/hours of operation and, if different, TTY hours of

operation>.

Thank you.

<Contract#, alpha-numeric identifier, “CMS Approved/File & Use” [date] (as applicable)>

198

Exhibit 4a: Model Notice to Acknowledge Receipt of Completed Enrollment

Request – Enrollment in another Plan Within the Same Parent Organization

Referenced in section(s): 40.4.1, 60.4

(Rev. 1, Issued: July 31, 2018; Effective/Implementation: 01-01-2019)

<RxID>

<RxBin>

<RxPCN>

Dear <Name of Member>:

Thank you for your request to change your enrollment from <old Plan name> to <new Plan

name>. Starting <effective date>, you must see your <new Plan name> doctor(s) for your health

care. This means that starting <effective date>, all of your health care, except emergency or

urgently needed care, or out-of-area dialysis services, must be given or arranged by a <new

plan name> doctor(s). You will need to pay your plan copayments at the time you get health care

services. [

Optional: This letter is proof of health insurance that you should show during your

doctor appointments.] [Optional language for MA-PD: This letter is also proof of your

prescription drug coverage. You should show this letter at the pharmacy until you get your

member card from us.]

[

MA PPO plans use the following paragraph in place of 1

paragraph above: Thank you for your

request to change your enrollment from <old plan name> to <new plan name>. Beginning

<effective date>, you must get your health care as provided in your <insert either ‘Member

handbook’ or ‘Evidence of Coverage’>. You will need to pay your plan co-payments and co-

insurance at the time you get health care services, as provided in your member materials.

<Optional: This letter is proof of insurance that you should show during your doctor

appointments until you get your member card from us.>] [Optional language for MA-PD: This

letter is also proof of your prescription drug coverage. You should show this letter at the

pharmacy until you get your member card from us.]

What should I do now?

Medicare must review all enrollments. We will send your enrollment to Medicare, and they will

do a final review. When Medicare finishes its review, we will send you a letter to confirm your

enrollment with <new plan name>. But, you shouldn’t wait to get this letter before you begin

using <new plan name> doctors on <effective date>.

[

MA PPO plans do not use the following sentence: Please remember that, except for emergency or

out-of-area urgent care, or out-of-area dialysis services, if you get health care services from a

non-<new plan name> doctor without prior authorization, you will have to pay for these services

yourself.]

<Contract#, alpha-numeric identifier, “CMS Approved/File & Use” [date] (as applicable)>

199

[Zero premium plans do not include the following:

How do I pay my premium?

Your enrollment form included the options for paying your plan premium. If you did not choose

one of these options when you enrolled, we will bill you directly. If you chose to have your

monthly premium automatically deducted from your Social Security or Railroad Retirement

Board check, we may have to send you a bill for your first month or two of enrollment if the

deduction doesn’t start right away. Generally, you must stay with the option you choose for the

rest of the year. If you have any questions about how to pay your plan premium, please contact

us at <plan telephone number>. TTY users should call <TTY number>.][MAOs that disenroll

for non-payment of plan premium include the following sentence: “Members who fail to pay the

monthly plan premium may be disenrolled from <plan name>”.]

[MA-PD plans with a premium include the following: If you qualify for Extra Help with your

Medicare prescription drug coverage costs, Medicare may cover all or some portion of your plan

premium.]

[MA-PD plans with a premium include the following paragraph:]