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10 – Definitions and Acronyms

10.1 – Definitions The following definitions relate to topics addressed in this guidance.

Applicable Integrated Plan (AIP) – A type of integrated D-SNP defined in 42 CFR § 422.561 and Chapter 16-B.

Application Date – The date the completed enrollment request is initially received by the plan. Plans must use this date in the appropriate field when submitting enrollment transactions to CMS.

At-risk Beneficiary – A Part D eligible individual who is identified using clinical guidelines, not an exempted beneficiary, and 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), or an individual with respect to whom a plan received notice upon enrollment that the beneficiary was identified as an at-risk beneficiary under the plan in which the beneficiary was most recently enrolled and such identification had not been terminated upon disenrollment.

Authorized Representative – An individual who is legally able to act on behalf of the beneficiary, as allowed by applicable state laws, in order to execute an enrollment or disenrollment request. A representative may be appointed by the individual (consistent with the standards under applicable law) or may be authorized under law without a specific or explicit appointment.

Cancellation of Enrollment Request – An action initiated by the individual to cancel an enrollment request. To be valid, the cancellation request must be received by the plan before the enrollment effective date.

Chronic condition special needs plan (C-SNPs) – A type of SNP that restricts enrollment to MA eligible individuals who have one or more severe or disabling chronic conditions, as defined under 42 CFR § 422.2, including restricting enrollment based on the multiple commonly co- morbid and clinically linked condition groupings specified in 42 CFR § 422.4(a)(1)(iv).

Continuation Area – An additional area outside a Medicare Advantage local plan’s service area within which the MAO furnishes or arranges for furnishing of services to the MA plan’s enrollees.

Conversions – The action of converting individuals who are enrolled in a health plan offered by the MAO the month immediately before entitlement to Medicare Parts A and B into an MA plan offered by the same organization.

Denial of Enrollment Request – An action taken by the plan when it determines that an individual is not eligible to make an enrollment request, or the individual did not provide the information required to complete the enrollment request in a timely fashion, and does not submit