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50 – Enrollment Processing 42 CFR §§ 422.50(a)(3), 422.60, 423.30, and 423.32

An MAO or Part D sponsor (except for MAOs that have reached a CMS-approved capacity limit) must accept without restriction, enrollment requests from individuals who are eligible to elect a plan offered by the organization during a valid election period. Accepting the enrollment request means that the organization must process it and determine eligibility for enrollment.

The initial step in processing an enrollment begins with the acceptance of an enrollment request from the individual or the individual’s authorized representative and ends with the plan communicating, in writing, whether the individual’s enrollment request has been accepted or denied by the plan or by CMS, in accordance with MA and Part D regulations, as explained in CMS guidance. As outlined below and further explained in §§ 50.1–50.5, processing the enrollment includes:

An MAO may specify a capacity limit for one or all of the MA plans it offers and reserve spaces for individual and employer or union group commercial members who are converting from a commercial product to an MA product at the time the member becomes eligible (i.e., conversion enrollments). When an MA plan is closed due to a capacity limit, the MA plan must remain closed to all prospective enrollees (with the exception of reserved vacancies) until space becomes available. All requests from MAOs for a capacity limit should be submitted to the CMS Regional Office account manager.

Plans may not delay processing enrollment requests unless the individual’s enrollment request is being placed on a waiting list (as described in § 50.10.1).

The following should also be considered when processing an enrollment:

• Permanent Residence Information – The plan must obtain the individual’s permanent residence address to determine that they reside within the plan’s service area. If an individual puts a Post Office Box as their place of residence, the plan must consider the enrollment election incomplete and must contact the individual to determine the place of permanent residence. If an individual wants to join a plan but has no permanent residence, a Post Office Box, an address of a shelter or clinic, or the address where they receive mail (e.g., social security checks) may be considered their permanent residence address. If the applicant claims permanent residency in two or more states, or if there is a dispute over where the individual permanently resides, the plan should consult the State law in which the plan operates and determine whether the applicant is considered a resident of the State, see § 20.3.

Individuals for whom the Batch Eligibility Query (BEQ) or MARx online query (M232 screen) reflects an incarcerated status, that individual is considered to reside outside the service area and are, therefore, not eligible to enroll.

• Entitlement Information and Medicare Number – Following the procedures outlined in the CMS Plan Communications User Guide (PCUG), plans must verify Medicare