Page 18

17 | P a g e

Part C Policy: There are limited exceptions to the requirement for an individual to permanently reside in the plan’s service area while continuing enrollment in the plan. These exceptions are optional for the MAO to offer:

• Enrollee Affected by Service Area Reduction: An enrollee may remain in the MA plan following a service area reduction (SAR) if: the individual permanently resided in the service area of the plan at the time the SAR goes into effect; and there is no other MA plan offered in the area at that time. • Enrollee Moves into Continuation Area: Consistent with § 422.54, an enrollee may remain in the MA local plan when they permanently move into a geographic area designated by the MAO as a continuation area. For more information on continuation areas, see § 20.3.1.

20.3.1 – Continuation Areas 42 CFR §§ 422.50 and 422.54

With CMS approval, an MAO may establish continuation areas, separate and apart from an MA local plan’s service area. See Chapter 11 of the Medicare Managed Care Manual regarding CMS approval of continuation areas.

If an MAO wants to offer a continuation of enrollment option under one or more of its MA local plans, it must obtain CMS’ approval of the continuation area and make the option available to all enrollees of the MA local plan who make a permanent move to the continuation area. An MAO may require enrollees to give advance notice of their intent to use the continuation of enrollment option. If the MAO has this requirement, it must fully describe the required notification process in enrollee materials. In addition, the MAO must describe the continuation of enrollment option to all enrollees of the MA local plan, including those who reside in the continuation area.

Enrollees may choose to continue enrollment with the MA local plan only if they have permanently moved from the service area into the continuation area. An enrollee who permanently moves from the service area into the continuation area and does not choose the continuation of enrollment option must be disenrolled. Procedures for continuation of enrollment are in § 70.7.

20.4 – U.S. Citizenship or Lawful Presence 42 CFR §§ 422.50 and 423.30

An individual is eligible to enroll in a plan if they are a United States citizen or lawfully present in the United States, as determined pursuant to 8 CFR § 1.3. CMS will notify the plan if the individual is not eligible to enroll on this basis at the time of enrollment and the plan must deny an enrollment request if CMS has provided such a notice.

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