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Part C Policy: Enrollment requests received after a plan exceeds a CMS-approved capacity limit must be submitted to CMS within seven calendar days after a vacancy becomes available.

50.9 – Information Provided to Enrollee 42 CFR §§ 422.60(e)(3) and 423.32(d)

The plan must provide required notices in response to information received from CMS on the DTRR that provides the earliest notification.

Within 10 calendar days of the availability of a DTRR from CMS, the plan must provide written notification to the individual acknowledging that their 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.

Once the enrollment has been accepted by CMS, plans may utilize a single (“combination”) notice in place of the separate acknowledgement and confirmation notices described in §§ 50.9.1 and 50.9.2. The combination notice must be provided within seven calendar days of the availability of the DTRR. Although much of the enrollment information that the plan must provide to the enrollee must be sent prior to the effective date of coverage, some information will be sent after the effective date of coverage. An enrollee’s coverage begins on the effective date regardless of when the enrollee receives all the information the plan sends.

If the enrollment request has been denied and the plan later receives additional information from the individual substantiating their eligibility, the plan must obtain a new enrollment request from the individual in order to enroll the individual and process the enrollment with a prospective effective date.

If an individual’s enrollment request includes a request for SSA or RRB premium withhold and the enrollment transaction was processed by CMS after the monthly cut-off for payment, the plan must submit the request for premium withhold separate from the enrollment request. Plans should resubmit the request for premium withhold timely to ensure the individual can have premium withholding at the next possible effective date. Additionally, the MA or Part D plan must inform the individual that:

• If approved, their request for premium withholding will start in one to two months; • The effective date for premium withholding will not be retroactive; • They will be responsible for paying the organization directly for all premiums due from the enrollment effective date until the month in which premium withholding begins; and • Failure to pay premiums for months in which premium withholding is not yet in effect can result in disenrollment from the plan (see § 60.3.1).

50.9.1 – Prior to the Effective Date of Coverage 42 CFR §§ 422.60(e) and 423.32(d)