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Generally, plans deny an enrollment when:

• An individual is determined ineligible to enroll in the plan (see § 20 on eligibility criteria) or, • The individual fails to provide the information within the required time frames outlined in § 50.3.

The plan must send notice of the denial to the individual that includes an explanation of the reason for denial (see MA Exhibit 7 or Part D Exhibit 6). This notice must be sent within 10 calendar days of either: 1) receipt of the enrollment request, or 2) expiration of the time frame for receipt of requested additional information.

Example 1: The plan receives an enrollment request from an individual on November 7 and determines on that same day that the individual is ineligible due to place of residence. The plan should send notice of denial within 10 calendar days from November 7.

Example 2: The plan receives an enrollment form on November 7 from an individual, identifies the enrollment form as incomplete, and notifies the individual of the need for additional information on November 10. The individual does not submit the information by December 1 (as required under § 50.3), which means the organization must deny the enrollment. The organization should send notice of denial within 10 calendar days from December 1.

Example 3: The plan receives an enrollment request from an individual on January 7 and is unable to determine, through direct contact with the individual or the individual’s authorized representative, that the individual has a valid enrollment period available. The organization should send notice of denial within 10 calendar days from January 7.

50.5 – When the Enrollment Request is Complete

An enrollment request is considered complete when:

1. The enrollment request/mechanism is completed and signed by the individual or their authorized representative within required time frames (see Appendix 2);

2. Evidence of entitlement to Medicare Part A and/or enrollment in Medicare Part B is obtained by the plan;

3. If applicable, an attestation of an authorized representative’s authority to make the enrollment request is obtained (refer to § 50.1).

4. For Special Needs Plans (SNP), SNP eligibility is verified, as outlined in § 20.8.4. Chronic condition SNPs (C-SNP) that utilize a pre-enrollment qualification assessment tool will consider the enrollment request to be complete upon receipt of the completed tool.