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5. Dual-eligible individuals and individuals who qualify for the LIS have premium amounts due to the MA or Part D plan from a prior enrollment, and the plan offers this exception.

Once the enrollment request is complete, the plan must transmit the enrollment to CMS as outlined in § 50.8 and provide notification to the enrollee as outlined in § 50.9.

50.6 – Enrollment not Legally Valid 42 CFR §§ 422.66(b)(5)(i) and 423.36(c)(1)

There are instances when a completed enrollment can later be determined to be legally invalid. These instances may include, but are not limited to:

• An individual did not meet eligibility requirements at the time of enrollment, such as if a plan determines at a later date that the individual resides outside the plan’s service area; • An individual not authorized by State law makes an enrollment request on another’s behalf; or • The individual or their authorized representative did not intend to enroll in the plan. Evidence of lack of intent to enroll by the individual may include: o An enrollment request signed by the individual when an authorized representative should have signed for the individual; o Request by the individual for cancellation of enrollment before the effective date (refer to § 70.2 for procedures for processing cancellations); o Part C Policy: Enrolling in a supplemental insurance program immediately after enrolling in the MAO; or receiving non-emergency or non-urgent services out-of- plan immediately after the effective date of coverage under the plan.

When an enrollment is not legally valid, a cancellation of that enrollment may be necessary (refer to § 70.2 for more information). In addition, a reinstatement to the plan in which the individual was originally enrolled may occur if the invalid enrollment resulted in an individual’s disenrollment from their original plan of choice.

50.7 – Other Qualified Prescription Drug Coverage Through an Employer or Union Retiree Drug Subsidy (RDS) Plan Sponsor

CMS systems will conditionally reject Part D enrollment transactions if the individual has other qualified prescription drug coverage through an employer or union Retiree Drug Subsidy (RDS) plan.

Within 10 calendar days of receipt of the conditional rejection (transaction reply code (TRC) 127), the plan must:

1) Contact the individual to confirm the individual’s intent to enroll, and that the individual understands the implications of enrollment in a Part D plan on their employer or union coverage.