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In both of the circumstances above, the plan may re-enroll the individual for a prospective enrollment effective date at the individual’s request, but only if the individual has a valid election period (i.e., AEP, SEP, etc.)—see §§ 30 and 50.

Example: Mr. Smith is disenrolled by CMS for failure to pay Part D-IRMAA on August 1. He contacts 1-800-MEDICARE and makes his request for reinstatement on September 29 and receives a favorable good cause determination on October 5. CMS notifies Mr. Smith that he must pay the Part D-IRMAA amount by October 31. Mr. Smith pays his Part D-IRMAA owed amount on October 25. Mr. Smith is also delinquent on his plan premiums, and the plan notifies Mr. Smith that he must pay his plan premium by October 31. Mr. Smith pays his plan premium owed amount on November 5. Because the plan received Mr. Smith’s payment for his plan premium amount after the due date, Mr. Smith may not be reinstated. (Note: If Mr. Smith had paid both his owed Part D-IRMAA and plan premiums by October 31, the plan would have had the additional five days to process the payment and he would have been reinstated.)

70.4 – Retroactive Enrollments

A retroactive enrollment is an enrollment with an effective date in the past. For example, a plan submits an enrollment transaction on March 5 with an effective date of March 1.

Occasionally, obtaining the information necessary to complete an enrollment request within the allowable time frames will extend beyond the effective date of enrollment. Plans must use the Code 61 enrollment transaction to submit the enrollment transaction directly to CMS within the Current Calendar Month (CCM) transaction processing time frame.

When a valid request for enrollment has not been communicated to CMS successfully within the required time frames in this guidance and the CCM transaction submission time frame, MA or Part D organizations are required to submit the appropriate documentation to CMS (or the RPC) for manual review and potential action. In addition, when the plan or CMS has been unable to process the enrollment in a timely manner, the following documentation must be submitted to the RPC:

• A copy of the signed completed enrollment form (the form must have been signed by the individual (or authorized representative) and received by the plan 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 plan prior to the requested effective date of coverage).

If the request for retroactive enrollment action is due to plan error, the plan must provide:

• A clear and detailed explanation supporting the requested correction; o The explanation should clearly state what the plan has communicated to the