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• Demonstrate state approval via the SMAC to continue conducting default enrollment; • Not be prohibited by CMS from accepting new enrollments; • Have a minimum overall rating from the most recently issued star ratings of at least 3 stars (or be a low enrollment contract or new MA plan as defined in 42 CFR 422.252); • Provide a description of the state’s data sharing process and agreement that the state will continue to provision prospective Medicare eligibility data to the MAO in a state policy document from the state. Examples of acceptable state policy documents include but are not limited to a SMAC, state letter, and/or a copy of the state’s completed/signed Default Enrollment Plan Application, if applicable. • Include a copy of their Advance Notice to Beneficiaries. Optional opt-out forms, telephone scripts and other supporting documentation that will be sent to prospective enrollees must be submitted to CMS for review.

Notice to individuals about default enrollment To facilitate CMS approval under § 422.66(c)(2)(ii), MAOs seeking to implement (or renew) default enrollment must include a copy of the required written notice to individuals 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. In additional to the materials required under § 422.111(b)(iii) for initial enrollments (e.g. comprehensive written statement describing cost-sharing protections an Medicare and Medicaid benefits (provided through Evidence of Coverage and Summary of Benefits)), MA organizations are required to send a written notice to identified eligible Medicaid managed care enrollees no fewer than 60 days prior to the effective date of Medicare eligibility and enrollment in the plan (MA Exhibit 39). The beneficiary notice for default enrollment must include information on:

• Whether the prospective enrollee’s primary care physician is in the D-SNP network; • The process an enrollee needs to take to access services offered under the plan; • How an enrollee can opt out of (decline) the enrollment prior to the enrollment effective date to enroll in Original Medicare or choose another Medicare Advantage plan. This must include the opportunity to contact the MAO either in writing or by telephone to a toll-free number; • The differences in premiums and cost-sharing amounts between the individual’s current Medicaid MCO and the D-SNP; • The differences in benefits between the individual’s current Medicaid MCO and 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 MAO will send the enrollment transaction to CMS at the same time that it sends the written notice to the affected individual (i.e., no fewer than 60 days prior to the enrollment effective date). Default enrollment transactions must be submitted with election code type ‘J’, enrollment source code ‘B’, 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. The MAO should not discourage declination. The organization will submit opt-out requests to CMS as enrollment cancellations. Opt-out requests received after