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In addition to the information collected in the request, all enrollment mechanisms must include the applicant’s acknowledgement of the following:

MA Part D Required to keep Part A and Part B Required to keep Part A or Part B, or both Consent to the disclosure and exchange of information between the U.S. Department of Health and Human Services (HHS), its designees and the MA or Part D plan; information may be used to track enrollment and other purposes, as allowed under federal law and regulations Can be enrolled in only one MA or Part D plan—and that enrollment automatically disenrolls the individual from any other MA or Part D plan (see § 20.1 for exceptions) The information provided in the enrollment request is correct; intentionally falsifying information will result in disenrollment Their signature indicates an understanding of the enrollment application, and that (if applicable) authorized representatives have legal authority to complete the enrollment request Benefits and services (excluding hospice and kidney acquisition costs for transplants) must be obtained from the plan in order to be covered as Medicare benefits

The plan premium amount is not required to be displayed or disclosed on the enrollment mechanism unless it is part of the plan name. Plans may include the premium amount on the enrollment mechanism if they choose to do so, but they must do so consistently for all Plan Benefit Packages (PBPs) listed on the enrollment mechanism.

For enrollment between PBPs under the same parent organization, the plan may limit the data to be collected from the applicant to data it does not already have. However, the plan must obtain the following data to complete and process the enrollment:

▪ Minimal personal data sufficient for the plan to correctly identify the enrollee and their information within its systems; ▪ The applicant’s Medicare number; ▪ The name of the plan selected for enrollment; ▪ A statement requesting preferred language or alternate format preference (applicant response not required; does not affect enrollment if not completed); ▪ The applicant’s signature or attestation of intent to enroll, or, as applicable, from an authorized representative acting on the individual’s behalf, and contact information; and, ▪ Any other data the plan does not already have in its records that is necessary to meet the requirements in Appendix 2.