Medicare Managed Care Manual 
Chapter 17, Subchapter D 
Medicare Cost Plan  
Enrollment and Disenrollment Instructions 
(Rev. 38, 10-31-03) 
 
Table of Contents 
10 - Definitions 
10.1 - General Requirements 
20  Eligibility for Enrollment in a Medicare Cost Plan 
20.1  Conversion Enrollments 
20.2 - End Stage Renal Disease 
20.2.1  Background on ESRD Entitlement 
20.2.2 - Exceptions to Eligibility Rule for Individuals with ESRD 
20.3 - Hospice 
30  Enrollment Periods and Effective Date of Enrollment 
30.1  General Open Enrollment Requirements 
30.1.1  Waivers for Open Enrollment 
30.1.2  Determining Enrollment Availability for Medicare Beneficiaries 
30.1.3  Utilization Adjustment Factor 
30.1.4  Reserved Vacancies 
30.1.5  Special Requirements When Reaching Capacity 
30.2  Effective Date of Enrollment in Cost Plans 
30.2.1  Cost Plan Enrollment Effective Date Option 1 
30.2.2  Cost Plan Enrollment Effective Date Option 2 
40 - Enrollment Procedures 
40.1  Format of Enrollment Forms 
40.2 Verifying Enrollment Information 
40.2.1  Who May Complete a Cost Plan Enrollment Form  40.2.2  When the Enrollment Form Has Missing or Erroneous 
Information 
40.3 - ESRD and Enrollment 
40.4 - Processing Applications 
40.4.1  Information Provided to the Beneficiary 
40.5  Cost Plan Denial of Enrollment 
40.6  Transmission of Enrollments to CMS 
40.7  Re-enrollment 
50  Disenrollments 
50.1  Voluntary Disenrollments 
50.1.1 - Effective Date of Voluntary Disenrollment 
50.2  Required Involuntary Disenrollments 
50.2.1  Permanent Move Out of the Plans Service Area 
50.2.1.1 - Retention of Members Who Temporarily Leave the 
Plans Service Area 
50.2.2  Death 
50.2.3  Loss of Entitlement to Part B 
50.2.4  Plan Termination/Non-Renewal or Reduction of Plan Service 
Area 
50.3  Other Involuntary Disenrollments 
50.3.1  Failure to Pay Premium 
50.3.2  Fraud in Enrollment or Abuse of Membership Cards 
50.3.3  Disenrollment for Cause 
50.3.3.1  Proposed Notice for Disenrollment for Cause 
50.3.3.2  Regional Office Review of Disenrollment for Cause 
50.3.3.3  Effective Date of Disenrollments for Cause 
60 - Post-Enrollment/Disenrollment Activities 
60.1  Retroactive Enrollments 
60.1.1 Enrollment Retroactive to Date of Initial Medicare Entitlement 
60.1.2  Errors in Social Security Administration (SSA) Records and/or 
CMS Medicare Entitlement Data 
60.2  Retroactive Disenrollment 
60.2.1  Failure of Employer Group to Notify Plan of Requested 
Disenrollment  60.3 - Multiple Transactions 
60.4  Storage of Enrollment Forms 
Appendix 1: Summary of Exhibits 
Exhibit 1:  Model Individual Enrollment Form (3 Pages) 
Exhibit 2:  Model Notice to Acknowledge Receipt of Completed Enrollment Form 
Exhibit 3:  Model Notice to Request Information 
Exhibit 4:  Model Notice to Confirm Enrollment 
Exhibit 5:  Model Notice for Denial of Enrollment 
Exhibit 6:  Model Notice to Send Out Disenrollment Form 
Exhibit 6a:  Model Disenrollment Form 
Exhibit 7:  Model Notice to Acknowledge Receipt of Members Voluntary Disenrollment 
Request 
Exhibit 8:  Model Notice to Confirm Voluntary Disenrollment Identified Through Reply 
Listing 
Exhibit 9: Model Notice of Disenrollment Due to Death 
Exhibit 10:  Model Notice of Disenrollment Due to Loss of Medicare Part B 
Exhibit 11:  Model Capacity Waiver Calculation Worksheet 
Exhibit 12:  Model for Closing Enrollment 
 
10 - Definitions 
(Rev. 38, 10-31-03) 
Conversions - For individuals who are enrolled in a health plan offered by the managed 
care organization the month immediately before the month of their entitlement to 
Medicare Parts A and B, or Part B only, their enrollment in a cost plan offered by the 
same organization is referred to as a conversion from commercial status to Medicare 
cost enrollee status.  The effective date of conversion enrollments is the first of the month 
of initial Medicare entitlement.  
Evidence of Medicare Part A and/or Part B Coverage  Acceptable forms of evidence 
are:  
1.   A Medicare card;  
2.   Social Security Administration (SSA) award notice;  
3.   A Railroad Retirement Board (RRB) letter of verification;   4.   A statement from SSA or RRB verifying the individuals entitlement to Medicare 
Part A and enrollment in Part B;  
5.   Verification of Medicare Part A and Part B through one of CMSs systems, 
including CMS data available through CMS subcontractors; or  
6.   For individuals enrolling when they first become entitled to Medicare, an SSA 
application for Medicare Part A and/or B showing the effective date for both 
Medicare Parts A and B or Part B only.   
Evidence of Permanent Residence - A permanent residence is normally the enrollees 
primary residence.  A Medicare Cost organization may request additional information 
such as voters registration records, drivers license records, tax records, or utility bills to 
verify the primary residence. Such records must establish the permanent residence 
address, and not the mailing address, of the individual.  
Involuntary Disenrollment - Refers to when a Medicare Cost organization, as opposed 
to the member, initiates disenrollment from the plan. Procedures regarding involuntary 
disenrollment are found in 50.2 of this chapter.  
Medicare +Choice Organization (M+C organization) - Refer to Chapter 1 (General 
Administration of the Managed Care/Medicare+Choice Program) of the Medicare 
Managed Care Manual for a definition of a M+C organization. 
10.1 - General Requirements  
(Rev. 38, 10-31-03) 
Cost contracts generally are limited to existing contractors, who had a cost contract in 
place before the date of enactment of the Balanced Budget Act of 1997.   The only 
exception to this rule is for entities that currently have an HCPP contract under 
1833(a)(1)(A) of the Social Security Act (the Act), and wish to convert to a 1876 cost 
contract.  In order for an HCPP to contract CMS under a cost contract, the entity must 
meet certain qualifying conditions as outlined in 42 CFR 417, Subpart J.  One of these 
qualifying conditions requires the entity to demonstrate an ability to enroll members and 
to sustain a membership that ensures effective, efficient and economical care to the plans 
Medicare enrollees.  Meeting these requirements is also a condition for continuing to 
contract with CMS as an existing cost contractor. 
Operating experience and enrollment requirements are minimum standards.  In addition 
to the plan demonstrating the ability to enroll members, these enrollment levels are 
necessary to provide a reasonable basis for CMS to establish payment rates for the plan.  20  Eligibility for Enrollment in a Medicare Cost Plan 
(Rev. 38, 10-31-03) 
In general, an individual is eligible to enroll in a cost plan by meeting each of the 
following requirements. A cost plan that is accepting new members must enroll any 
Medicare beneficiary who: 
  Is entitled to benefits under Medicare Part A and enrolled in Medicare Part B, or 
is enrolled in Medicare Part B only; 
  Permanently resides within the service area of the cost plan (see exception in 
20.1 for persons converting to Medicare Part A and/or Part B who are living 
outside the service area at the time of enrollment); 
  Completes and signs the application form used to enroll members during the 
enrollment period and provides all the information required to process the 
enrollment; and 
  Agrees to abide by the membership rules disclosed during the enrollment process. 
A cost plan must deny enrollment if: 
  The beneficiary has been medically determined to have End Stage Renal Disease 
(ESRD) prior to applying for enrollment (with some exceptions; see 20.2). 
In addition, a cost plan is permitted to deny enrollment if CMS has granted a waiver or 
limitation of the open enrollment requirement (see 30.1.1), and that limit has been 
reached. 
A cost plan may choose to wait for the individuals payment of the plan premium, 
including any premiums or cost sharing due the organization for a prior enrollment, 
before processing the enrollment.  
The organization may not deny enrollment to a Medicare beneficiary who continues to 
work and who is enrolled in his or her employers health benefits plan (or that of a 
spouse).  If the individual enrolls in a cost plan and continues enrollment in his/her (or 
their spouses) employer health benefits plan, then coordination of benefits rules apply. 
20.1  Conversion Enrollments  
(Rev. 38, 10-31-03) 
The cost plan must accept as a Medicare member any individual who was enrolled in the 
organization during the month immediately before the month in which he or she became 
entitled to both Medicare Parts A and B, or Part B only.  The application of this provision 
to individuals with ESRD is discussed in 20.2.2.   The cost plan has the option to also allow individuals who are newly entitled to Medicare 
Parts A and/or B to elect the cost plan upon conversion even if they reside outside the 
service area.  The cost plan must apply its choice of this option consistently for all 
individuals. These members will be known as out-of-area members. This option applies 
both to individual members and employer group members of the cost plan. 
20.2 - End Stage Renal Disease 
(Rev. 38, 10-31-03) 
Generally, an individual is not eligible to enroll in a cost plan if he or she has been 
medically determined to have ESRD (see exceptions described under 20.2.2).  End 
Stage Renal Disease (ESRD) is defined as that stage of kidney impairment that appears 
irreversible and permanent, and requires a regular course of dialysis or a kidney 
transplant to maintain life.   
An individual who receives a transplant that restores kidney function and no longer 
requires a regular course of dialysis to maintain life is no longer considered to have 
ESRD for purposes of cost plan eligibility.  The individual may elect to enroll in a cost 
plan if he or she meets the other applicable eligibility requirements indicated in 20. If a 
beneficiary is only eligible for Medicare on the basis of ESRD (i.e., not based on 
disability or age), he or she would only be permitted to remain enrolled in a cost plan 
during his or her remaining months of Medicare eligibility.  See 40.3 for additional 
information. 
The cost plan is permitted to ask whether the beneficiary has ESRD at the time of 
application.  This question is permissible since the law does not permit a person with 
ESRD to join a cost plan. If the applicant answers yes to the question of whether he or 
she requires regular maintenance dialysis, the plan can deny enrollment after ensuring the 
beneficiary is not eligible for one of the exceptions listed in 20.2.2.  The CMS will 
reject the enrollment if Medicare records indicate the applicant has ESRD. 
20.2.1  Background on ESRD Entitlement 
(Rev. 38, 10-31-03) 
When an individual files for Medicare based upon ESRD, entitlement can begin:  
  The first day of the third month after the month dialysis begins (i.e., the first day 
of the fourth month of dialysis);  
  The first day of the month dialysis began if the individual trains for self-dialysis;  
  The month an individual is admitted to a hospital for a kidney transplant or for 
health care services needed before a transplant if the transplant takes place in the 
same month or within the 2 following months;     Up to 12 months prior to the month of filing (if dialysis began more than 12 
months before); or 
  Prospectively.  
The Medicare entitlement date is usually the month an individual is hospitalized for a 
transplant or 3 months after the month the individual begins dialysis (i.e., the first day of 
the fourth month of dialysis). For example, if an individual begins dialysis in January, 
Medicare entitlement is effective April 1. 
There are individuals who are approved to perform self-dialysis. If an individual is 
approved for self-dialysis, the Social Security Administration (SSA) will waive the 3-
month waiting period to begin Medicare entitlement. In cases of self-dialysis, Medicare 
entitlement is effective the month dialysis begins, rather than the customary 3 months 
from the month the individual begins dialysis. 
20.2.2 - Exceptions to Eligibility Rule for Individuals with ESRD 
(Rev. 38, 10-31-03) 
  Conversion:  Individuals who developed ESRD while a member of a health plan 
offered by an organization and who are converting to Medicare Parts A and B, or 
Part B only, may enroll in a cost plan in the same organization (within the same 
state, with exceptions) at the time of conversion.  The individuals must meet all 
other cost plan eligibility requirements and must fill out an enrollment form to 
enroll. 
If a Medicare entitlement determination is made retroactively, an individual has 
not been provided the opportunity to elect a cost plan at the time of their 
conversion. Therefore, these individuals will be allowed to prospectively elect a 
cost plan offered by the organization, as long as they were in a health plan offered 
by the same organization the month before their entitlement to Parts A and B, or 
Part B only, developed ESRD while a member of that health plan, and are still 
enrolled in that health plan. This would also be allowed in cases when there is an 
administrative delay and the entitlement determination is not made timely. For 
example, an individual who performs self-dialysis will have his/her entitlement 
date adjusted to begin at the time of dialysis, rather than the customary third 
month after the month dialysis begins. 
  If the individual was first medically determined to have ESRD after the date on 
which the enrollment form was signed but before the effective date of coverage, 
he can still enroll in that cost plan 
  An individual who develops ESRD while enrolled in a cost plan may continue to 
be enrolled that cost plan.  This also can apply to an individual who developed 
ESRD while enrolled with the organization offering the cost plan, even if the  individual was not enrolled under the cost contract, and it is not a conversion 
situation. 
  An individual with ESRD who is a member of a cost plan may enroll in other 
plans offered by that organization (within the same state, with exceptions) 
  An individual who receives a kidney transplant and who no longer requires a 
regular course of dialysis to maintain life is not considered to have ESRD for 
purposes of cost plan eligibility (see 40.3 for additional instructions). 
20.3 - Hospice  
(Rev. 38, 10-31-03) 
When it is determined that a current member of the cost plan has a terminal illness and 
life expectancy is 6 months or less, he or she may elect to receive care through a 
Medicare-certified hospice.  If the current member elects hospice care, he or she must 
waive the right to receive treatment for the terminal condition and related conditions 
from any provider other than the hospice and the attending physician. The individual 
cannot be disenrolled merely because he or she has elected hospice care. 
The beneficiary remains in the cost plan as long as he or she continues payment of the 
plan premium.  This means that the cost plan must provide those services that have not 
been waived, e.g., the cost plan must continue providing services unrelated to the 
terminal condition that the cost plan provides or authorizes.  The cost plan must also 
continue to provide services unrelated to the terminal condition under the same 
conditions that would apply to a member who has not elected hospice (the member 
continues to be responsible for normal plan cost sharing for these services), and any 
supplemental benefits for which the beneficiary has paid. 
Upon revocation of the hospice election, the cost plan must immediately reinstate the 
beneficiarys full enrollment. 
30  Enrollment Periods and Effective Date of Enrollment  
(Rev. 38, 10-31-03) 
30.1  General Open Enrollment Requirements  
(Rev. 38, 10-31-03) 
The general requirements for open enrollment are that the cost plan: 
  Hold an annual open enrollment period of at least 30 or more consecutive days for 
Medicare beneficiaries;    Publicize its upcoming enrollment period in appropriate media throughout the 
service area (this requirement does not apply for Cost Plans that are continuously 
open for enrollment); and 
  Enroll Medicare beneficiaries on a first come, first serve basis. 
If the organization has met the 30-day requirement through a longer enrollment period or 
through continuous open enrollment and it decides to close enrollment, the plan must 
notify CMS and the general public 30 days in advance of the new limitations on its open 
enrollment process (refer to Exhibit 12). 
If the organization has both a cost contract and a Medicare+Choice contract in the same 
service area, it may not enroll new individuals in the cost plan (42 CFR 422.501(b)(4)).  
In this case, the cost plan would not be able to retain its Medicare+Choice contract if it 
were to accept new enrollments in the cost plan at any time of the year.  In this instance 
only, CMS will not enforce the cost plans obligation to open enrollment.  The cost plan 
must always accept requests for disenrollment. 
If a cost plan is closed for enrollment, then it is closed to all individuals in the entire plan 
service area for enrollment. When a cost plan re-opens after being closed, there is no 
requirement for the cost plan to notify the general public. However, the cost plan should 
notify CMS when this occurs. If this occurs, the plan would no longer be able to offer a 
Medicare+Choice contract in the area. 
30.1.1  Waivers for Open Enrollment 
(Rev. 38, 10-31-03) 
The organization may obtain a waiver of the open enrollment requirements under one of 
the following two conditions  (1) Non-representative enrollment, and (2) Limited 
capacity. 
Non-Representative Enrollment 
An open enrollment period will result in a membership substantially non-representative 
of the population in the geographic area.  In this case, the organization may request a 
selection restriction in writing at least 90 days before the proposed open enrollment 
period.  The organization must provide statistical data that an open enrollment period 
would cause a particular membership subgroup to exceed its proportion of the geographic 
area by at least 10 percent.  A subgroup is defined as a class of Medicare beneficiaries 
based on factors such as age, sex, or other factors that CMS determines significantly 
affects health care utilization. The organization may not limit enrollment unless and until 
CMS approves the selection policy.  If the organization submits insufficient data to make 
a decision, CMS will deny the request.  Limited Capacity 
The organization does not have capacity for additional members, or the organization must 
limit enrollment to a certain number of members.  The organization must estimate 
whether it would reach capacity during its next open enrollment period, and would 
therefore need a CMS-approved capacity waiver. 
The following sections describe criteria and procedures for capacity waiver applications. 
 An organization must submit all required information to its Regional Office at least (and 
preferably more than) 90 days prior to the open enrollment period for Medicare 
beneficiaries.  The CMS will make every attempt to notify the organization of its 
decision at least 60 days in advance of the enrollment period.  If the waiver is granted, it 
remains in effect for one year only. 
30.1.2  Determining Enrollment Availability for Medicare Beneficiaries  
(Rev. 38, 10-31-03) 
The cost plan must verify to CMS the number of vacancies open to Medicare 
beneficiaries during the open enrollment period.  If there are conditions or factors that the 
organization believes are pertinent to determining its enrollment availability for Medicare 
beneficiaries, it should submit this information to CMS.  Utilizing a worksheet (Exhibit 
11), the plan will determine enrollment availability by: 
1.   Establishing present capacity; 
2.   Obtaining current Medicare, Medicaid, and commercial enrollment numbers; 
3.   Adjusting these enrollment numbers by the following figures: 
i.   Reserved vacancies  add to commercial enrollment the number of 
members the plan expects to enroll from its existing group contracts and 
from anticipated new group contracts (see 30.1.5); 
ii.   Subtract expected age-ins (commercial members of the plan who will 
convert to Medicare status upon becoming eligible for Medicare) from the 
commercial enrollment total and add to the Medicare enrollment numbers 
for a new Medicare enrollment total; and 
iii.  Multiply the new Medicare enrollment total by the organizations 
Medicare utilization factor (see 30.1.4) to obtain an adjusted Medicare 
enrollment total. 
4.   Subtracting the adjusted commercial enrollment total and the adjusted Medicare 
enrollment total from the organizations capacity.  The remainder determines the 
number of vacancies available for open enrollment  These vacancies must be filled with Medicare beneficiaries up to the point where further 
enrollment would be substantially non-representative of the population in the geographic 
area. 
30.1.3  Utilization Adjustment Factor 
(Rev. 38, 10-31-03) 
The CMS recognizes the greater intensity of services and frequency of health care 
utilization among Medicare beneficiaries than among commercial membership.  Since 
there is no one-to-one equivalence between Medicare and commercial members in this 
respect, a utilization adjustment factor is incorporated in calculating enrollment capacity. 
 The utilization adjustment factor represents the number of commercial members the 
organization could serve for every one Medicare member served over the course of the 
contract year. The organization also provides backup documentation and discussion of 
the methodology employed in the calculations.  For example, if the data show that 
Medicare utilization is three times that of commercial members, the capacity for new 
commercial members is three times what it would be for new Medicare members.  
Therefore, if the available capacity is for 3,000 additional commercial members in the 
next contract period, and the organization anticipates filling 1,500 of those slots with 
commercial members, the remaining 1,500 slots must be divided by three.  That is, full 
capacity is reached if the organization enrolls 500 Medicare members in addition to the 
1,500 commercial members, based on a ratio of one Medicare vacancy to every three 
commercial vacancies. 
30.1.4  Reserved Vacancies  
(Rev. 38, 10-31-03) 
Reserved vacancies are those set aside for members of anticipated new group contracts or 
for anticipated new members of an existing group contract when these group enrollment 
periods are held after the cost plan open enrollment period. 
If open enrollment(s) for one or more of the organizations group contracts is scheduled 
after the organizations cost plan open enrollment period, the plan should set aside a 
reasonable number of slots or vacancies for anticipated new members from these groups. 
 These reserved vacancies should also be used to determine the enrollment availability 
for Medicare beneficiaries as described in 20.1. 
Because these reserved vacancies limit the available spaces for Medicare members, CMS 
must approve the organizations use and number of reserved vacancies. Therefore, 
reserved vacancies are included in the calculations outlined in 30.1.5 and on the 
worksheet shown in Exhibit 12. Reserved vacancies not used within a reasonable time 
after the group contract enrollment period has begun must be released and made available 
to Medicare beneficiaries.  30.1.5  Special Requirements When Reaching Capacity  
(Rev. 38, 10-31-03) 
If an organization reaches capacity during open enrollment and it has a CMS approved 
waiver, it has two options:  It can refuse further enrollments or continue accepting 
applications and place them on a waiting list.  For example, if the organization opts to 
continue accepting applications, it must place all prospective members who wish to wait 
for an opening on the waiting list in chronological order.  As vacancies occur, the plan 
should contact the beneficiary, and enroll him or her after ensuring he or she still wants 
the plan to honor the application. 
30.2  Effective Date of Enrollment in Cost Plans  
(Rev. 38, 10-31-03) 
A Medicare cost plan may choose between the following two Enrollment Effective date 
options:  
1.  Cost Plan Enrollment Effective Date Option 1:  Follow the traditional cost plan 
effective date rules found below as Enrollment Effective Date Option 1 (30.2.1) 
- OR - 
2.  Cost plan Enrollment Effective Date Option 2:  Follow the effective date policy 
for enrollment outlined below as Enrollment Effective Date Option 2 (30.2.2). 
The CMS will assume the organization will follow Cost Plan Enrollment Effective Date 
Option 1 unless the organization notifies (or has notified) the appropriate CMS Regional 
Office and includes this change in the policies and procedures provided to CMS.  
Organizations offering Medicare cost plans will be expected to follow the chosen 
enrollment effective date option throughout the contract year.  The CMS may permit an 
organization to change its enrollment effective date option during a contract year by 
special request for good cause. 
If the organization plans to change its selection of enrollment effective date options for a 
new contract year, it must notify the appropriate CMS Regional Office. 
30.2.1  Cost Plan Enrollment Effective Date Option 1  
(Rev. 38, 10-31-03) 
A Medicare beneficiarys enrollment begins on the first day of the month in which his or 
her membership in the cost plan is effective, as shown on CMS records.  The effective 
month of coverage may not be earlier than the first month after, or later than the third 
month after, the month in which the enrollment information is correctly submitted to and  received by CMS.  The CMS may approve a later effective date if requested by the plan 
and the beneficiary. 
Enrollment cannot be effective prior to the date entitlement to Medicare Part A and Part 
B, or Part B only begins. 
The cost plan is responsible for submitting accurate and timely records to CMS for new 
enrollments.  The CMS is responsible for promptly supplying written verification of the 
individuals acceptance (or rejection) in the plan. Generally, CMS does not accept 
records received after the monthly cut-off date for submission of records (as announced 
by CMS periodically), or that are incomplete or incorrect. 
Enrollment Effective Date Example: 
The CMS monthly cut-off date for the submission of records is August 14, 
2002.  A cost plan enrollment application form that is received on 
August 12, 2002, could have an effective date of enrollment of 
September 1, October 1, or November 1, 2002. 
If the same cost plan enrollment application form was received on 
August 15, 2002, (i.e., after the cut-off date for the submission of records) 
it could have an effective date of enrollment of October 1, November 1, or 
December 1, 2002. 
If the cost plan has informed a beneficiary that his/her enrollment in the plan is effective 
on a certain date, but then submits an incorrect enrollment record to CMS, the plan must 
honor its contract with the individual and begin providing coverage on the stated date.  If 
the plan provides services to the member before it can submit the correct enrollment 
information, the plan may still receive Medicare fee-for-service payments for any 
services it renders. In order for the cost plan to receive direct payments for physician and 
supplier services from a Medicare carrier, the cost plan must have a third party billing 
number, or it can have the physician or supplier directly bill the FFS program. 
Additionally, if the cost plan collects or has waived collection of a premium from the 
beneficiary which covers the deductible and coinsurance for Medicare covered services 
for the originally designated month of enrollment, the cost plan is financially responsible 
for Medicare deductibles and coinsurance amounts not paid by carriers and 
intermediaries on pre-enrollment claims for services obtained in network or for 
emergency or urgently needed care.  The Medicare beneficiary is liable for any services 
for which the cost plan has no financial responsibility under the terms of its Medicare 
contract.  30.2.2  Cost Plan Enrollment Effective Date Option 2 
(Rev. 38, 10-31-03) 
Cost plans who choose this option will follow the following rules:  
1.   First of the Next Month: Enrollments will be effective the first day of the month 
after the month the cost plan receives an enrollment form. The cost plan must be 
open to accept such enrollments.  
2.   November 15 through December 31 of every year: Enrollments received 
during this time period will be effective January 1 of the following year (except as 
noted below).  
(NOTE: Enrollments made between November 15 and November 30 may be 
effective December 1 or January 1.  The cost plan must allow the individual to 
choose the effective date.  If no choice is made, January 1 will be the effective 
date.)  
3.  Enrollment Prior to entitlement: Individuals may enroll in a cost plan during the 
three months immediately before the individuals entitlement to Medicare Part A 
and/or Part B.  The enrollment will be effective the first day of the month of 
entitlement to Medicare Part A and/or Part B.  
Employer group members only: Cost plans that have contracted with an employer 
group may offer beneficiaries enrolling through an employer group effective dates of up 
to three months after the month in which the cost plan receives the enrollment form. 
However, the effective date may NOT be earlier than the date the cost plan receives the 
enrollment form; retroactive transactions are not allowed.  
40 - Enrollment Procedures  
(Rev. 38, 10-31-03) 
The enrollment form is a portion of the cost plans contract with the beneficiary.  There 
are several requirements regarding the exchange of information between the plan and the 
prospective member during the application process.  There are also requirements 
regarding who may complete the application form. 
40.1  Format of Enrollment Forms  
(Rev. 38, 10-31-03) 
The cost plan must use a CMS approved enrollment form that complies with the 
following guidelines on structure and content.  A model CMS enrollment form is 
provided as Exhibit 1 at the end of this chapter.  The enrollment form should include a statement acknowledging that premium and 
copayment amounts were stated to the enrollee and may be found in the subscriber 
agreement or other documents, as well as statements indicating that the enrollee: 
  Agrees to abide by the cost plan membership rules as outlined in the material 
provided to the enrollee; 
  Authorizes the plan to disclose and exchange necessary information with CMS; 
  Understands that he or she may receive medical services from non-network 
providers, but will be liable for deductibles, coinsurance, and charges not covered 
by Medicare; 
  Understands that enrollment in the plan automatically disenrolls him/her from any 
other cost plan or Medicare+Choice plan in which he or she is enrolled; and 
  Knows the proposed effective date of coverage, which is the date he/she should 
begin receiving care through the plan. 
The cost plan must obtain the applicants signature and the date.  If the applicant 
inadvertently fails to include the date of signature on the form, then the date of receipt 
stamped by the cost plan may serve as the signature date on the form. 
40.2 Verifying Enrollment Information  
(Rev. 38, 10-31-03) 
Whether Medicare beneficiaries are enrolled during a face-to-face interview or by mail, 
the plan should verify all information.  If the enrollment application is being completed 
in person, the applicants Medicare card should be used to verify the spelling of his or her 
name and to confirm the correct recording of sex, Health Insurance Claim Number 
(HICN), and the beneficiarys type of entitlement, i.e. whether entitled to both Parts A 
and B, or Part B only.  The plan must obtain the applicants permanent residence address 
and verify that he/she resides within the service contract area.  If enrollment assistance is 
given by telephone, a back-up system should be established for verifying this 
information.  For example, some cost plans direct staff responsible for recording 
enrollment information to call the applicant and double-check the information. 
While desirable, it is not necessary for an individual to prove Medicare Part A 
entitlement and/or Part B enrollment at the time he/she completes the enrollment form, 
i.e., the cost plan organization may not deny the enrollment if the individual does not 
have the evidence when filling out the enrollment form or does not include it with the 
form when he/she mails it to the organization.  40.2.1  Who May Complete a Cost Plan Enrollment Form  
(Rev. 38, 10-31-03) 
A Medicare beneficiary is generally the only person who may execute a valid cost plan 
enrollment form.  However, another individual would be the appropriate party to execute 
an enrollment application if a court has designated him or her as the proper party to take 
such actions on behalf of the beneficiary.  The CMS will recognize State laws that 
authorize persons to take such actions on behalf of a beneficiary.  Persons authorized 
under State law may be court appointed legal guardians or persons having durable power 
of attorney for health care decisions, provided they have the authority to act for the 
beneficiary in this capacity. 
If a Medicare beneficiary is unable to sign an enrollment form, or disenrollment request, 
due to reasons such as physical limitations or illiteracy, state law would again govern 
whether another individual may execute the form on behalf of the beneficiary.  Usually, a 
court-appointed guardian is authorized to act on the beneficiarys behalf.  If there is 
uncertainty regarding whether another person may sign for a beneficiary, cost plan 
organizations should check State laws regarding the authority of persons to sign for and 
make health care treatment decisions for other persons. 
Where cost plan organizations are aware that an individual has a representative payee 
designated by the SSA to handle the individuals finances, the cost plan should contact 
the representative payee to determine his or her legal relationship to the beneficiary, and 
to ascertain whether he or she is the appropriate person, under state law, to complete the 
individuals membership application. 
When someone other than the beneficiary completes the application or submits the 
disenrollment request, the plan must retain documentation showing how the 
determination was made that another entity or person was legally authorized to enroll the 
Medicare beneficiary. 
If the cost plan receives an enrollment form that was signed more than 30 calendar days 
prior to the organizations receipt of the form, the plan is encouraged to contact the 
individual to confirm intent to enroll prior to processing the enrollment, and to advise the 
beneficiary of the upcoming effective date. 
40.2.2  When the Enrollment Form Has Missing or Erroneous 
Information  
(Rev. 38, 10-31-03) 
When the cost plan receives an enrollment form that cannot be processed because it has 
missing (or erroneous) information, it should contact the individual by telephone to 
obtain the information necessary, and document all efforts to obtain the information 
needed.  The cost plan may also send a letter asking for information to facilitate the 
enrollment (see Exhibit 3).  If the individual does not respond within 30 days of the  request for additional information, the cost plan must deny the enrollment, and should 
send the appropriate notice to the individual (Exhibit 5) within the 7 business days 
following this denial. 
40.3 - ESRD and Enrollment  
(Rev. 38, 10-31-03) 
Please refer to 20.2 of this chapter for information on when a beneficiary with ESRD 
may be eligible to enroll in a cost plan. 
If a cost plan is aware that an individual electing a plan has received a kidney transplant 
(e.g., the individual informs the cost plan this has occurred), then the plan should request 
that the individual submit medical documentation that he or she no longer has ESRD (i.e., 
a letter from the physician that states the individual has received a kidney transplant and 
no longer requires a regular course of dialysis to maintain life). Upon receipt of this 
documentation, the cost plan should enroll the beneficiary. 
If an individual indicates on the enrollment form that he or she does not have ESRD but 
the cost plan receives a reply listing containing a code 45 or code 15 rejection (an 
explanation of reply listing codes is contained in Chapter 19), the cost plan should 
investigate further to determine whether the individual is eligible to enroll. To determine 
eligibility, the cost plan should contact the individual and request medical 
documentation. Contact can be made orally, in which case the cost plan must document 
the contact and retain the documentation in its records. 
If the cost plan learns that the individual has received a kidney transplant which has 
restored kidney function and that the individual no longer requires a regular course of 
dialysis to maintain life, then the individual must be permitted to enroll in the plan if 
other applicable eligibility requirements are met. When this occurs, the cost plan must 
contact its RO to override the system rejection. The following documentation must be 
submitted to the RO: 
1.  Evidence of contact with the individual after the system rejection, including the 
individuals explanation for rejection (i.e., successful transplant) and medical 
documentation, i.e., a letter from the physician that documents that the individual 
has received a transplant that has restored kidney function. 
2.   A copy of the Reply Listing or, if using the services of a CMS subcontractor, a 
report indicating the cost plans attempts to enroll the individual and the resulting 
rejection. 
Once received and approved, the Regional Office will override the enrollment rejection 
for the individual.  40.4 - Processing Applications 
(Rev. 38, 10-31-03) 
The cost plan must maintain a system for receiving, controlling and processing 
applications for membership in which it: 
  Date-stamps each application with the date the form was received;  
  Ensures that each beneficiary who enrolls (whether previously a member of the 
organization or not) receives a signed and dated copy of the application form; 
  Processes applications from beneficiaries in chronological order by received date; 
  Notifies the beneficiary in writing of the cost plans acceptance or denial of 
his/her application no later than 30 calendar days following the date the 
application was received; 
  If the application is accepted, the plan must inform the beneficiary of the 
proposed effective date of coverage (see Exhibit 2); 
  If the application is denied, the plan must provide the applicant with a written 
explanation of the reason for denial (see Exhibit 5 and additional detail in 40.5 
of this chapter); and 
  Contacts the beneficiary if additional information is needed to process the 
enrollment (see Exhibit 3 and additional information in 40.2.2). 
For Cost Plans that have obtained a capacity waiver: 
  Places the application on a waiting list as described in 30.1.5 of this chapter, and 
provides the beneficiary with an explanation of procedures to follow as vacancies 
occur, and 
  Fills vacancies occurring during an enrollment period in chronological order, 
beginning with the earliest dated application on the list. 
Once the plan receives a reply listing report from CMS indicating whether the 
individuals enrollment has been accepted or rejected, the plan should send written 
notification to the beneficiary that CMS accepted or rejected his/her enrollment 
application.  (See Exhibit 4 and Exhibit 6.) 
40.4.1  Information Provided to the Beneficiary  
(Rev. 38, 10-31-03) 
During the enrollment process, the cost plan must provide the enrollee with all the 
necessary information about being a member of the cost plan, including the plan rules  and the members rights and responsibilities. The cost plan must ensure that the enrollee 
is provided with the following: 
  A description of the charges for which the beneficiary is liable, e.g. any 
premiums, coinsurances, fees, or other amounts.  For a high option, amounts 
attributable to the Medicare deductible and coinsurance should be explained in 
detail. 
  An explanation of the beneficiarys authorization for the disclosure and exchange 
of necessary information between the cost plan and CMS that is generally 
included on the application form. 
  A copy of the signed and dated enrollment form, if the individual does not already 
have a copy of the form. 
  A letter acknowledging receipt of the completed enrollment form and showing the 
effective date of coverage (Exhibit 2). 
  Following receipt of the confirmation of enrollment from CMS promptly (within 
14-30 calendar days) notify the enrollee in writing of the effective date of 
enrollment and send a CMS-approved evidence of coverage that describes M+C 
organization rules, including benefits and enrollee rights and responsibilities (42 
CFR 417.436). 
40.5  Cost Plan Denial of Enrollment  
(Rev. 38, 10-31-03) 
A cost plan must deny an enrollment based on its own determination of the ineligibility 
of the individual to enroll in the plan. 
Cost plan denials occur before the organization has transmitted the enrollment to CMS. 
For example, it may be obvious that the individual is not eligible to elect the plan due to 
place of permanent residence, or that the cost plan is closed for enrollment, etc.  This up-
front denial determination should be made in a timely manner, but no later than 30 
calendar days from the date the organization received the enrollment form. 
Notice Requirement - The organization must send written notice of the denial to the 
individual that includes an explanation of the reason for denial (Exhibit 5). This notice 
should be sent no later than 30 calendar days from the date the organization received the 
enrollment form. 
If the cost plan is following the procedures in 40.2.2 of this chapter to request additional 
information from a beneficiary, the denial notice should be sent within 7 business days of 
the denial determination made when the request for additional information period 
expires.  40.6  Transmission of Enrollments to CMS  
(Rev. 38, 10-31-03) 
Within 30 days of the date of the organizations receipt of the completed enrollment 
form, the plan must transmit information necessary to add the beneficiary to CMS 
records.  In the case of applications that are accepted when the cost plan enrollment is at 
a capacity limit, it must transmit the information by the earliest plan data due date after a 
vacancy has become available.  However, if a current commercial plan member is 
converting to Medicare enrollment status, the plan must submit the enrollment 
information no earlier than the third plan data due date, but no later than the first plan 
data due date, prior to the individuals Medicare entitlement date. 
40.7  Re-enrollment  
(Rev. 38, 10-31-03) 
Some members may disenroll but then wish to re-enroll at a later time.  The cost plan 
must enroll these members following standard enrollment procedures, i.e. the member 
must meet the requirements of 20 and reapply during an open enrollment period.  If 
there is a waiting list, the former member must be placed on a waiting list with other 
applicants.  New applications from former plan enrollees must be processed in 
chronological order with all other applications, i.e.; the former member cannot be 
enrolled ahead of other applicants. 
A cost plan may choose to wait for the individuals payment of the plan premium, 
including any premiums or cost sharing due the organization for a prior enrollment, 
before processing the enrollment.  See 20 of this chapter. 
50  Disenrollments  
(Rev. 38, 10-31-03) 
Cost plans must submit disenrollments to CMS no later than the systems cut-off date of 
the month for which disenrollment is requested. Disenrollment requests can be submitted 
up to 90 days prospectively. 
Except as provided for in this section, a cost plan may not, either orally or in writing, or 
by any action or inaction, request or encourage a member to disenroll. 
50.1  Voluntary Disenrollments  
(Rev. 38, 10-31-03) 
A Medicare beneficiary may disenroll at any time by mailing, hand delivering, or faxing 
a signed and dated written notice to the plan, SSA, or the Railroad Retirement Board (if 
the member is an annuitant). If the member is unable to sign the disenrollment request,  his or her legal representative must do so (refer to 40.2.1 for more details on who may 
sign forms).  The CMS systems will generate an automatic disenrollment if a beneficiary 
elects another cost plan or Medicare+Choice plan without first disenrolling from the 
current health plan.  
If a member verbally requests disenrollment from the cost plan, the plan must instruct 
him or her to make the request in writing.  The plan may send a disenrollment form to the 
member upon request (see Exhibits 6 and Exhibit 6a).  
The liability of CMS to make monthly payments on the beneficiarys behalf ends with 
the close of the last month of membership specified by the beneficiary, with the 
exception that the last month of payment may not be earlier than the month in which the 
beneficiary requested disenrollment. However, if the Regional Office has reason to 
review the disenrollment request, the last month of CMS liability may not follow this 
guideline, e.g. if the member moved out of the service area and the Regional Office 
grants an earlier disenrollment date. 
50.1.1 - Effective Date of Voluntary Disenrollment  
(Rev. 38, 10-31-03) 
The disenrollment must be effective no later than the first day of the month following 
receipt of the members written request for disenrollment, unless the member requests a 
later date.  The plan must date stamp the disenrollment request upon initial receipt.  If the 
member requests a later effective date, it can be no later than the third month after the 
month in which CMS receives an acceptable disenrollment request from the cost plan.  
The cost plan must provide the member with a copy of his/her request for termination of 
enrollment (Exhibit 7 may be used if desired).  The CMS encourages cost plans to 
provide the beneficiary with a final letter once the disenrollment has been confirmed and 
should send this notice within 7 business days of the availability of the reply listing 
(Exhibit 8). 
If the plan learns of the disenrollment through the CMS Reply Listing Report rather than 
by written request, the cost plan is strongly encouraged to provide the beneficiary with a 
final letter within 7 business days of the availability of the reply listing (see Exhibit 8). 
50.2  Required Involuntary Disenrollments  
(Rev. 38, 10-31-03) 
The cost plan must disenroll a member from the plan in the following cases: 
  A permanent change in residence out of the plans service area (50.2.1), or a 
temporary absence from the plans service area for more than 90 consecutive days 
(except as described in 50.2.1.1);    Death of the member (50.2.2); 
  Members loss of entitlement to Medicare Part B (50.2.3); and 
  Termination or non-renewal of the cost plans contract (50.2.4). 
50.2.1  Permanent Move Out of the Plans Service Area  
(Rev. 38, 10-31-03) 
A beneficiary must be disenrolled if he or she permanently moves out of the plans 
service area and does not voluntarily disenroll.  The plan must initiate disenrollment as 
soon as it becomes aware that the beneficiary has permanently moved outside the service 
area.  An uninterrupted absence of more than 90 days is deemed to be a permanent move 
(see the exception in 50.2.1.1).  A written statement from the beneficiary or other 
reasonable evidence establishes that the beneficiary has moved out of the service area.  
Even if the beneficiary has not informed the plan of his or her new address, the plan must 
attempt to provide the beneficiary written notice of enrollment termination.  The CMS 
encourages the plan to send final confirmation of disenrollment to the member. 
50.2.1.1 - Retention of Members Who Temporarily Leave the Plans 
Service Area  
(Rev. 38, 10-31-03) 
Cost plans are allowed to retain a Medicare member under either of the two options 
described below if the member leaves the plans service area for an extended absence. 
An extended absence is one that is over 90 days, but not more than 1 year, and where the 
member intends to return to the service area within the 1 year period.  The extended 
absence option is available only to members remaining in the United States. 
Option 1  General Retention Option 
The cost plan may choose to cover all out-of-area routine services for anyone who leaves 
the service area for an extended absence.  If the plan offers such a service, it must advise 
all members of its availability. When an individual who has taken advantage of this 
policy returns to the service area, he or she must resume obtaining medical services 
through network providers in order for services to be covered in full. However, the 
member can still elect to obtain services from non-network providers, but he or she will 
be responsible for any applicable Medicare coinsurance and deductibles. If the member 
elects to obtain care from non-network providers, those providers can submit bills to 
Original Medicare for payment consideration. 
The cost plan may place restrictions on the services received out-of-area for individuals 
who take advantage of the extended absence option, as long as the Medicare beneficiary 
agrees to the restrictions and the full scope of contracted benefits is available to the 
member in the extended service area.  Possible restrictions on services include obtaining  medical care through designated providers or requiring prior authorization.  Non-
designated providers or those seen without prior authorization (where required) would 
submit bills to Original Medicare. 
Additionally, the cost plan remains financially liable for emergency and out-of-area 
urgently needed services. 
Option 2  Retention of Enrollment With Services Provided Through Affiliated 
Organization 
If the cost plan is affiliated with another organization (by common ownership or control, 
or written agreement), the plan may make the extended absence option available only to 
members who move to the affiliates service area during an extended absence.  The 
members must agree to obtain services exclusively through the affiliated organization.  
The cost plan may retain such individuals as Medicare members of its plan for up to one 
year.  This option must be made available to anyone moving to the affiliated 
organizations service area during an extended absence, and all plan members must be 
advised of the availability of this service. 
Also, the cost plan is financially responsible for emergency and out of area urgently 
needed services.  For this extended absence option, urgently needed services obtained 
while temporarily absent from the geographic area and needed while the member is 
present in the affiliate organizations service area are the responsibility of the affiliate 
organization responsible for providing services to the member during the extended 
absence. 
The CMS approves extended absence options as part of the cost plans initial Medicare 
application, or as such options are developed.  The CMS also reviews marketing 
materials and membership rules to ensure that the options are clearly explained and 
beneficiaries are advised of the distinction between authorized and unauthorized out-of-
plan service use. 
If a plan wants to offer an extended absence option, CMS suggests that the cost plan have 
the individual sign an agreement which states any restrictions on services imposed, where 
and how to obtain services, and how billing is accomplished.  
Supplemental benefits for which the member is paying a premium may be discontinued 
upon his or her leaving the service area, as long as the member is not required to continue 
paying the premium or portion of a premium that corresponds to these services. 
If a member takes advantage of the extended absence option, but fails to return to the 
service area within one year, the plan must disenroll him or her effective the first day of 
the month following the 1 year anniversary date of the original departure from the service 
area. The plan should notify the beneficiary regarding the upcoming disenrollment before 
it occurs.   50.2.2  Death  
(Rev. 38, 10-31-03) 
The CMS will disenroll deceased members effective the month immediately following 
the month of death and notify the cost plan that the member has expired.  Monthly 
interim per capita payments end with that month.  The plan should send a notice to the 
member or his or her estate so that any disenrollment due to an erroneous report of death 
can be corrected as soon as possible (Exhibit 9).  
50.2.3  Loss of Entitlement to Part B 
(Rev. 38, 10-31-03) 
The member is disenrolled by CMS the month immediately following the month that 
enrollment in Part B ends.  Monthly interim per capita payments made on behalf of the 
beneficiary terminate effective the month immediately following the last month of 
entitlement to benefits under Part B.  The plan should send a notice to the member so that 
any disenrollment due to erroneous information can be corrected as soon as possible 
(Exhibit 10). The beneficiary may remain a member of the organization if a non-
Medicare option is available. 
If a member loses entitlement to benefits under Part A, but remains entitled to benefits 
under Part B, he or she remains a member of the cost plan.  The member is entitled to 
receive and have payment made for Part B services only, beginning with the month 
immediately following the last month of his/her entitlement to Part A. The cost plan may 
offer all or partial Medicare Part A benefits.  
50.2.4  Plan Termination/Non-Renewal or Reduction of Plan Service 
Area  
(Rev. 38, 10-31-03) 
A cost plan must disenroll members from its plan if the contract is terminated, if the 
organization discontinues offering the plan, or if the plan does not renew in any portion 
of the area where it had previously been available.  
A member who is disenrolled from a cost plan under these provisions is allowed to 
choose another cost plan or an M+C plan (if one is available and he/she meets applicable 
eligibility requirements), or original Medicare.  If no other choice is made, the individual 
will automatically return to Original Medicare by default. 
Notice Requirements:  In most cases, the plan terminating the contract must send a 
written notice to all Medicare members enrolled in the organization at least 60 days 
before the effective date.  However, if CMS initiates a termination, it notifies members 
30 days before the effective date.  The notice must be reviewed by CMS prior to issuance.  The plan must submit the 
proposed notices for review in sufficient time to meet all deadlines, and provide final 
copies of the notices sent to beneficiaries to the CMS Regional Office Plan Manager. 
The termination, non-renewal, or partial non-renewal of a contract between the plan and 
CMS, whether by mutual consent or by unilateral action of either party, ends the liability 
of CMS to make monthly interim per capita payments on behalf of Medicare 
beneficiaries.  The CMS liability ends effective the first day of the month following the 
last month the contract is in effect.  
If the cost plan defaults on its contract with CMS prior to the close of the contract year 
due to bankruptcy or other reasons, CMS will establish the month in which interim per 
capita payments end for all enrolled Medicare beneficiaries. The CMS will notify the cost 
plan and all affected Medicare enrollees in writing as soon as practical. 
50.3  Other Involuntary Disenrollments  
(Rev. 38, 10-31-03) 
50.3.1  Failure to Pay Premium  
(Rev. 38, 10-31-03) 
Cost plans have the following options when a member does not pay his/her basic monthly 
premium.  The cost plan should outline its policy in its policy and procedures and apply 
the option chosen consistently among all members. 
1.   Do nothing, i.e., allow the member to remain enrolled in the same premium plan; 
or  
2.   Disenroll the member after proper notice. 
The cost plan may disenroll a Medicare beneficiary who fails to pay his/her basic 
monthly premiums, or other charges imposed by the cost plan for Medicare deductible 
and coinsurance amounts for which he or she is liable.  However, the cost plan must 
demonstrate to CMS that a reasonable effort was made to collect the unpaid amount and 
that the plan gave the beneficiary written notice of disenrollment before notifying CMS.  
Since it is possible that the beneficiary believes that nonpayment of premiums is a way to 
disenroll, the cost plan may wish to include in its payment reminder notices an 
explanation of the proper way to disenroll.  The CMS will consider the cost plan to have 
demonstrated reasonable effort in collecting unpaid premiums if the plan mails a notice 
of disenrollment for nonpayment of premium to the beneficiary at least 20 days before 
the effective date of disenrollment.  This allows 5 days for mailing time and 15 days for 
the beneficiary to act on the notice.  Disenrollment for nonpayment of premium will be 
effective as of the last day of the month in which the 20-day period expires.  The plan 
should include an explanation of the members rights to a hearing under its grievance  procedures.  The cost plan may not notify CMS until after the plan has notified the 
beneficiary. 
NOTE:  If the member fails to pay the premium for optional supplemental benefits, but 
pays the premium for the basic benefits, the cost plan may not disenroll him or her.  The 
cost plan may discontinue the optional benefits, but may not disenroll the member. 
50.3.2  Fraud in Enrollment or Abuse of Membership Cards 
(Rev. 38, 10-31-03) 
A Medicare beneficiary may be disenrolled if he/she commits fraud in connection with 
his or her enrollment or permits abuse of the membership card, e.g., the beneficiary 
knowingly provides fraudulent information on the application form, which materially 
affects eligibility for enrollment, or a Medicare beneficiary permits others to use his/her 
membership card to receive services.  This category includes any abuse relating to cost 
plan membership or the Medicare program. 
In the case of fraud or abuse, the plan must send the beneficiary written notice of 
termination prior to submission of the disenrollment notice to CMS.  The plan must 
include an explanation of the members rights to a hearing under grievance procedures 
established by the organization, and also notify the RO so that the Office of the Inspector 
General may initiate its own investigation of the alleged fraud or abuse.  
50.3.3  Disenrollment for Cause 
(Rev. 38, 10-31-03) 
A cost plan has the right to initiate procedures to disenroll a Medicare member if his/her 
behavior is disruptive, unruly, abusive, or uncooperative to the point that his or her 
continuing membership seriously impairs the ability to furnish services to either him/her 
or other members.  The cost plan must ascertain that the enrollees behavior is not related 
to the use of medical services or to mental illness. The cost plan may not initiate 
disenrollment because the beneficiary exercises his or her option to make treatment 
decisions with which the cost plan disagrees, e.g. refuses aggressive treatment for cancer. 
Before beginning the disenrollment for cause process, the plan must make a serious effort 
to resolve the problem presented by the member.  It must inform the member that his/her 
continued behavior may result in termination of membership in the organization.  If the 
problem cannot be resolved, the plan must give the member written notice of its intent to 
request disenrollment for cause.  In this notice, explain the members right to a hearing 
under the organizations grievance procedures.  50.3.3.1  Proposed Notice for Disenrollment for Cause 
(Rev. 38, 10-31-03) 
Once the grievance process has been completed or the member has chosen not to use this 
process, the cost plan must submit a proposed disenrollment notice to the Regional Office 
stating reasons for the termination of enrollment and the proposed effective date.  Also, 
the cost plan must summarize the case and submit documentation to the Regional Office, 
including: 
  The reason that the plan is requesting disenrollment for cause; 
  A summary of plan efforts to explain these issues to the member and the other 
types of options presented before disenrollment was considered; 
  A description of the members age, diagnosis, mental status, functional status, and 
social support system; and 
  Separate statements from primary providers describing their experiences with the 
member. 
50.3.3.2  Regional Office Review of Disenrollment for Cause 
(Rev. 38, 10-31-03) 
The Regional Office will review the cost plans request based on the documentation 
submitted and make a decision within 20 business days of receipt of complete 
documentation.  The Regional Office will notify the plan within 5 business days after the 
decision is made. 
When the cost plan receives the decision it must inform the enrollee of the determination. 
 If membership is being terminated, the cost plan must send a notice that contains the 
reason for disenrollment, the effective date of termination, and a statement that this 
action was approved by CMS. 
50.3.3.3  Effective Date of Disenrollments for Cause 
(Rev. 38, 10-31-03) 
If CMS permits a cost plan to disenroll a member for cause, the disenrollment takes 
effect on the first day of the calendar month after the month in which the plan serves 
written notice of termination to the member and the grievance period has expired.  The 
liability of CMS to make payments ends on that date.  The cost plan must retain copies of 
its documentation, the proposed disenrollment notice, the approval letter from CMS, and 
the notice to the beneficiary in its files for verification purposes.   60 - Post-Enrollment/Disenrollment Activities 
(Rev. 38, 10-31-03) 
60.1  Retroactive Enrollments 
(Rev. 38, 10-31-03) 
In general, retroactive enrollments are not accepted by CMS.  If the cost plan has 
informed a beneficiary that his/her enrollment in the plan is effective on a certain date, 
but then submits an incorrect enrollment record to CMS, the plan must honor its contract 
with the individual and begin providing coverage on the stated date.  If the plan provides 
services to the member before it can submit the correct enrollment information, the plan 
may still receive Medicare fee-for-service (FFS) payments for any services it renders. In 
order for the cost plan to receive direct payments for physician and supplier services from 
a Medicare carrier, the cost plan must have a third party billing number. 
Each month, CMS will make an interim per capita payment to the plan based on the 
number of members enrolled in the plan.  At the end of the contract period, the plan must 
submit a Cost Settlement Report to CMS (please see Chapter 17-Subchapter A, 20.2, of 
the Medicare Managed Care Manual for further details on the Report). The report will 
allow the cost plan to report any underpayments or overpayments due. 
However, there are situations where CMS may make an exception. CMS will review 
these situations on a case-by-case basis and will generally only grant exceptions for 
incorrect entitlement data or other types of CMS systems problems.  
60.1.1 Enrollment Retroactive to Date of Initial Medicare Entitlement 
(Rev. 38, 10-31-03) 
The effective date of membership as a Medicare beneficiary is the month in which the 
individual becomes entitled to benefits under Medicare Part A and is enrolled in 
Medicare Part B, or enrolled in Medicare Part B only if: 
  The individual enrolls in Part B of Medicare and applies to the cost plan prior to 
the month in which he/she is entitled to part B of Medicare; or 
  The individual is a member of the cost plan organization prior to his/her 
entitlement to Medicare benefits and applies to the cost plan prior to the month of 
entitlement. 
Some beneficiaries may not have a record of entitlement to Part B established in the data 
system at CMS until after the actual date of first entitlement.  In such cases, CMS will 
take action to correct the effective date retroactively.  60.1.2  Errors in Social Security Administration (SSA) Records and/or 
CMS Medicare Entitlement Data 
(Rev. 38, 10-31-03) 
In some instances, problems may occur that are related to SSA and/or CMS systems.  The 
cost plan may request a retroactive enrollment when SSA/CMS systems problems delay 
processing of applications.  These include:  
1.  Application rejection when Part B entitlement is not reflected on Medicare 
records prior to the first month of entitlement (due to possible lag time when a 
beneficiary enrolls during a special enrollment period instead of the initial 
enrollment period); 
2.  HIC number changes; 
3.  Erroneous death notifications; 
4.  Problems with posting of Medicare Part B premiums; or 
5.  Any other SSA/CMS systems issue that may cause the Medicare entitlement data 
to be incorrect or missing or that may result in an erroneous enrollment rejection 
The cost plan should submit requests for review of such cases to CMS. 
60.2  Retroactive Disenrollment 
(Rev. 38, 10-31-03) 
In general, CMS does not accept retroactive disenrollments.  As discussed in 50.1.1 of 
this chapter, voluntary disenrollment must be effective no later than the first day of the 
month following receipt of the members written request for disenrollment, unless the 
beneficiary requests a later date.  If the beneficiary requests a later date, it can be no later 
than the third month after the month in which CMS receives an acceptable disenrollment 
request from the cost plan. 
However, CMS may approve retroactive disenrollments for certain situations on a case-
by-case basis.  The plan should submit retroactive disenrollment requests, including 
supporting evidence justifying the late disenrollment, to CMS.  If CMS approves the cost 
plans request for retroactive disenrollment, the plan must reimburse the member for any 
premium paid for any month for which CMS processes a retroactive disenrollment. 
The following are examples of situations where retroactive disenrollment may be 
permissible.  This list contains examples; it is not meant to be all-inclusive, nor does it 
imply that retroactive disenrollment is assured for any circumstance:    Systems Problems - If the beneficiary submits a proper disenrollment request, 
but as a result of systems problems the disenrollment is not shown on a timely 
basis in the cost plans and/or CMS records. 
  Organizational Error - When the organization has not properly processed or 
acted upon the members properly made disenrollment request.  A disenrollment 
request will be considered not properly processed or acted upon if the effective 
date is a date other than as required in 50.1.1 of this chapter. 
  Lack of Intent to Enroll - The cost plan must submit a retroactive disenrollment 
request to CMS if there is evidence that the beneficiary did not intend to enroll in 
the plan (e.g., the beneficiary did not realize he or she ever enrolled in a cost 
plan). 
Evidence that the beneficiary did not intend to enroll may include: 
o  Continuing supplemental (Medigap) insurance coverage after the effective 
date of cost plan enrollment; 
o  Purchasing supplemental insurance immediately after enrolling in the 
plan; or 
o  Making an inquiry to CMS questioning cost plan enrollment. 
Payment of the plans premium does not necessarily indicate an informed 
decision to enroll.  The beneficiary may believe that he or she was purchasing a 
supplemental health insurance policy.  In addition, use of a plan doctor does not 
necessarily indicate an understanding of the cost plans rules if the doctor also 
treats non-cost plan members. 
60.2.1  Failure of Employer Group to Notify Plan of Requested 
Disenrollment 
(Rev. 38, 10-31-03) 
The cost plan must submit a retroactive disenrollment request to CMS if an employer 
group fails to provide timely notification of a Medicare beneficiarys requested 
disenrollment.  The CMS may process disenrollments up to 90 days retroactively.  The 
employer groups notification is untimely if it does not result in a disenrollment effective 
for the month following the month the request is received, or for the requested effective 
date (if later). 
Evidence must demonstrate that the beneficiary acted to disenroll in a timely fashion (i.e. 
prospectively), but the employer group was late in providing the information to the cost 
plan.  Such evidence may include an election or application form signed by the 
beneficiary and given to the employer group during an open enrollment season.  NOTE:   The application form could be the employer groups generic form used during its open 
enrollment season for all employees and retirees. 
60.3 - Multiple Transactions 
(Rev. 38, 10-31-03) 
Multiple transactions occur when CMS receives more than one enrollment transaction for 
the same individual with the same effective date in the same reporting period. An 
individual may not be enrolled in more than one M+C, cost, or HCPP plan at any given 
time. Generally, the last enrollment action the beneficiary makes during the month will 
be accepted as the plan the individual intends to enroll in.  The CMS will accept the 
enrollment action based upon the date that the enrollment application was signed.  If the 
beneficiary does not date the enrollment form, the date the enrollment form was received 
by the cost plan will be used as the default date. 
If an individual elects more than one plan for the same effective date and with the same 
signature date, an assumption cannot be made as to which plan the individual truly 
intended to be enrolled in.  Therefore, if multiple transactions are received for the same 
effective date with the same application signature date, they will all be rejected.  The 
reply listings will show rejections for these types of multiple transactions. 
In these cases, the beneficiarys enrollment will remain with Original Medicare or with 
the Medicare health plan in which the beneficiary was enrolled before he/she applied to 
the plans that received the multiple transaction rejections.  
Upon availability of the reply listing from CMS showing a rejection for a multiple 
transaction, the cost plan should contact the individual to determine in which plan the 
individual wishes to enroll. Once the individual has chosen one plan, he/she must either 
fill out and sign another enrollment form or send written notice of his/her intent to enroll 
in the plan.  The cost plan may transmit the information to CMS using the appropriate 
effective date as described in 30. 
Generally, given the use of signature date to determine the intended election, retroactive 
enrollments will not be processed for multiple transactions that reject because the 
elections were signed on the same day. 
EXAMPLE  
  Two Medicare managed care plans receive completed enrollment forms from one 
individual on May 11 for a June 1 effective date.  The form received by cost plan 
#1 was signed on May 4th and the form received by cost plan #2 was signed on 
May 10.  Both cost plans submit enrollment transactions, including the applicable 
signature date.  The enrollment in cost plan #2 will be the transaction that is  accepted and will be effective on June 1.  Both plans receive the appropriate reply 
on the reply listing. 
  Two Medicare managed care plans receive completed enrollment forms from one 
individual on August 13 for an October 1 effective date.  Both enrollment forms 
were signed on August 8, and were transmitted by the August cutoff date.  Both 
enrollments will be rejected.  The individual must complete a new enrollment 
form to enroll in either plan.  
60.4  Storage of Enrollment Forms 
(Rev. 38, 10-31-03) 
The cost plan must retain enrollment forms while beneficiaries are members of the plan 
and for one year after disenrollment. 
It is appropriate to allow for storage on microfilm or by other technologies, such as 
optical scanning, as long as all forms and associated documents stored in this manner are 
legible, including the signature, and easily accessible by reviewers.  Appendix 1: Summary of Exhibits 
(Rev. 38, 10-31-03) 
This information provides a summary of the model notices and forms referenced in this chapter. 
For exact details on requirements and any applicable time frames, refer to the appropriate 
sections within this Chapter.   
Please refer to Chapter 17 for information on cost plan marketing material review. 
Exhibit  Notice  Section  Required ?  Timeframe  
1  Enrollment Form   40.1  Yes  N/A 
 
2  Acknowledgment of Receipt  40.4,  < 30 days from the date the 
 
of Enrollment Form   form was received 
40.4.1  Yes 
3  Request for Information   40.2.2  No  N/A 
4  Confirmation of Enrollment   40.4.1  Yes  Within 14-30 days from 
receipt of CMS confirmation 
5  Cost Plan Denial of  40.2.2  Yes 7 business days following 
 
Enrollment   denial made when additional 
information request period 
ends 
 
    40.5   Within 30 days of date of 
receipt
6 & 6a  Sending Out Disenrollment  50.1  No  N/A 
Form & Disenrollment 
Form  
7  Acknowledgment of Receipt  50.1.1  No 1   
of Voluntary Disenrollment 
Request from Member  
8  Notice to Confirm  50.1.1  No  Encouraged to send within 7 
                                                 
1 However, the cost plan must provide the member with a copy of his/her disenrollment request.  Exhibit  Notice  Section  Required ?  Timeframe  
Voluntary Disenrollment  days of the availability of the 
Following Receipt of Reply  reply listing 
Listing 
9  Notice of Disenrollment  50.2.2  No  N/A 
Due To Death 
10  Notice of Disenrollment  50.2.3  No  N/A 
Due To Loss of Part B 
11  Capacity Waiver  30.1.1,  N/A  N/A 
Calculation Worksheet  30.1.2 
  Exhibit 1:  Model Individual Enrollment Form (3 Pages) 
(Rev. 38, 10-31-03) 
(Health Plan Name)  
 
<include plan options for enrollee to choose from, including premium amounts for each> 
                                                        
Enrollment effective date:__________________ (please indicate your requested effective date) 
 
Your Name (exactly as it appears on your Medicare Card): 
                                     ___________________________________________  
First        Middle       Last 
Date of Birth (month/day/year):  ______________              Male___   Female ___ 
Permanent Residence Address: 
_________________________________________________________________ 
Number, Street, Apartment # 
                 __ ___                                                            ________  
City        County     State    Zip Code 
Telephone Number:                    _______________   
Area Code  Number 
Mailing Address (if different from permanent address): 
_________________________________________________________________ 
Number, Street, Apartment # 
                 __ ___                                                            ________  
City        County     State    Zip Code 
 
Name of person to contact in case of emergency [Optional field]__________________ 
Phone Number:[Optional field]____________Relationship to You [Optional field]____________ 
  [Optional field] Please check one of the boxes below if you would prefer us to send you information 
in a language other than English: 
______Language A (e.g., Chinese)  ______Language B (e.g., Spanish) 
 
Medicare Information:   Medicare Health Insurance 
Social Security Act 
Please fill in these blanks so they match what 
appears your Medicare card. You need to fill     Name of Beneficiary:   
this out, or you can attach a copy of your 
   Medicare Claim Number    Sex 
Medicare card or your Letter of Verification 
from the Social Security Administration or          -           -                        ____   
Railroad Retirement Board.  
   Is Entitled To      Effective Date 
Your enrollment form cannot be processed       Hospital Insurance (Part A)   ___________   
without this information. 
     Medical Insurance (Part B)  ____________ 
 
Please read and answer these questions: 
1.  Are you currently enrolled in another Medicare health plan?  By enrolling in (Health Plan), you 
will be canceling your membership in your current plan.    
Yes _______      No______ 
2.  Do you have insurance through your spouses employer? 
Yes                           No_______                     
If yes, Employer Name:  _____________________ 
Address:  _________________________________ 
City/State/Zip:  _____________________________ 
Policyholder Name:  ________________________ 
Policy Number: ___________________ 
3.  Do you have End Stage Renal Disease (ESRD)? ESRD is permanent kidney failure and  requires 
regular kidney dialysis or a transplant to sustain life. 
Yes                           No _____ 
(Note: You cannot enroll in this plan if you have ESRD, unless you are already enrolled in <name 
of plan organization> as a non-Medicare member and you developed ESRD while a member of 
<name of plan organization> or unless you have had a successful kidney transplant and no longer  require dialysis.  Please attach a note or records from your doctor showing you no longer need 
dialysis or have had a successful kidney transplant.) 
4.  By enrolling in this plan, I authorize: 
a)  The Centers for Medicare & Medicaid Services to furnish information to the plan 
confirming my entitlement to Medicare Hospital Insurance Benefits (Part A) and/or 
Supplementary Medical Insurance Benefits (Part B); and, 
b)  The plans providers, clinics, or anyone else with medical or other relevant information 
about me to give CMS or CMS agents the information needed to run the Medicare 
program. 
Yes                           No _____ 
5.  I understand that it is my responsibility to tell the plan before I permanently  move or leave the 
service area for more than 90 consecutive days, and that my absence means that the plan may take 
action to disenroll me and return me to traditional Medicare coverage. 
Yes                           No _____ 
6.  I understand that the plan will send me written notification of the effective date of my enrollment. 
7.   I understand that once my enrollment is effective, in order for [name of plan] to fully cover my 
medical services (except for emergency or urgently-needed services), they must be provided or 
arranged by the plan.  If I obtain services not provided or arranged by the plan, I will be 
responsible for all Medicare deductibles and coinsurance, as well as any additional charges as 
prescribed by the Medicare program. I may also be liable for any charges not covered by 
Medicare.  
Signature: 
I understand that my signature on this application means that I have read and understand 
the contents of this application.  Please read your Evidence of Coverage document to know 
what rules you must follow in order to receive coverage with this health plan. 
Your Signature*                                                                 Date: ___________         
*If the individual cannot sign, a court-appointed Legal Guardian or person with Durable Power of 
Attorney for Health Care (DPAHC), if authorized by state law; or another person who is 
authorized by State law, must sign the following line. Attach a copy of proof of Legal 
Guardianship, DPAHC, or proof of authorization by state law. 
Signature                                                                            Date: ___________         
  Exhibit 2:  Model Notice to Acknowledge Receipt of Completed Enrollment 
Form 
(Rev. 38, 10-31-03) 
Referenced in section(s):  40.5 
 
Dear <Name of Member>: 
Thank you for filling out a form to enroll in <Plan name>.  Starting <effective date>, you must 
see your <Plan> doctor(s) for your health care in order for the plan to fully cover your medical 
services. You may obtain medical services not provided or arranged by [name of 
plan/organization], but you will be responsible for payment of all Medicare deductibles and 
coinsurance, as well as any additional charges as prescribed by the Medicare program. Optional 
language: This letter can serve as evidence of insurance until you receive your membership 
card from us. You should show this letter to your doctor when you go to your doctor 
appointments until you receive your membership card.  
All enrollment forms must be reviewed by the Centers for Medicare & Medicaid Services 
(CMS), the federal agency that administers the Medicare program.  We will send your 
enrollment form to CMS, and a final review of the enrollment form will be performed.  When 
CMS finishes its review, we will send you a letter to confirm your enrollment with <Plan>. 
However, you can begin using <Plan> doctors prior to receiving the confirmation letter. You 
should begin using <Plan> doctors on <effective date>. Also, you should not cancel any 
Medigap/Medicare Select or supplemental insurance that you have until we send you the letter. 
You must have Medicare Part B (Medical Insurance) to be a member of <name of plan>. If you 
do not have Medicare Part B, we will bill you for any health care you receive from us, and 
neither Medicare nor <name of plan> will pay for those services.  Also, if you have End Stage 
Renal Disease (ESRD), you may not be able to enroll in <Plan>, and you may be billed for 
Medicare deductibles and coinsurance for any health care you received.   
If you have any questions, please call our Member Services Department at <phone number>.  
TTY users should call <TDD/TTY number>.  We are open {insert days/hours of operation and, 
if different, TTY/TDD hours of operation}.   Thank you.  Exhibit 3:  Model Notice to Request Information 
(Rev. 38, 10-31-03) 
Referenced in section(s):  40.2.2 
Dear <Name of Beneficiary>: 
 
Thank you for your application to <Plan>. We cannot process your application until we receive 
the following things from you: 
              Proof of Medicare Part B coverage.  
You can send us a copy of your Medicare card or a letter from Social Security 
or the Railroad Retirement Board as evidence of your Medicare coverage.  
              A copy of the legal document that authorizes another person to act on your behalf. 
              Other:  
You will need to send this information to <Plan and address> by <date - 30 days from date letter 
provided to the beneficiary>.  If you cannot send this information by <date listed above>, we 
will have to deny your request to enroll in our plan.  However, if you wish to apply at a later 
date, you may complete another application and provide the information necessary to process 
your request. 
If you have any questions, please call our Member Services Department at <phone number>.   
TTY users should call <TTY/TDD number>.  We are open {insert days/hours of operation and, 
if different, TTY/TDD hours of operation}.   Thank you.  Exhibit 4:  Model Notice to Confirm Enrollment  
(Rev. 38, 10-31-03) 
Referenced in section(s):  40.3 
Dear <Name of Member>: 
This letter is to tell you that the Centers for Medicare & Medicaid Services (CMS), the federal 
agency that administers Medicare, has approved your enrollment in <Plan>, beginning <effective 
date>. You must see your <Plan> doctor(s) for your health care in order for the plan to fully 
cover your medical services. If you obtain medical care from a non-network provider, you will 
be responsible for deductibles, coinsurance, or charges for services not covered by Medicare. 
As we explained in an earlier letter, you may cancel any Medigap or supplemental insurance that 
you have now that we have confirmed your enrollment.  Before canceling any supplemental 
insurance, be sure to determine if it is more beneficial to keep additional coverage. 
Please feel free to call our Member Services at <phone number>.  TTY users should call 
<TTY/TDD number>.  We are open {insert days/hours of operation and, if different, TTY/TDD 
hours of operation}.   Thank you. 
  Exhibit 5:  Model Notice for Denial of Enrollment 
(Rev. 38, 10-31-03) 
Referenced in section(s):  40.5, 40.5.1 
 
Dear <Name of Beneficiary>: 
Thank you for applying for membership in <Plan>. We cannot accept your application for 
enrollment in <Plan> because: 
1.  _____ You do not have Medicare Part B 
2.  _____ You have End Stage Renal Disease (ESRD) 
3.  _____ Your permanent residence is outside of our service area.  
4.  _____ We did not receive the information we requested from you within 30 days of our 
request. 
If any of the above items are checked, and our information is correct, then you may be billed for 
any services you received.   
If our information is incorrect, or if you have any questions, please call us at <phone number>. 
TTY users should call <TTY/TDD number>.  We are open {insert days/hours of operation and, 
if different, TTY/TDD hours of operation}.   Thank you. 
  Exhibit 6:  Model Notice to Send Out Disenrollment Form 
(Rev. 38, 10-31-03) 
Referenced in section(s):  50.1 
Dear <Name of Member>: 
Attached is the disenrollment form you requested. Please complete the entire form, sign it, and 
return it to us in the enclosed envelope, or mail it to your local Social Security Office or Railroad 
Retirement Board Office. You can also fax it to us, as long as the signature and date are 
readable. Our fax number is <fax number>. You can also disenroll by calling 1-800-MEDICARE 
or <TTY/TDD number> for the hearing impaired. 
If you are joining another Medicare managed care plan, it is not necessary for you to complete 
the enclosed disenrollment form.  You will be automatically disenrolled from <name of plan> if 
you submit an enrollment application for a new Medicare managed care plan.  
We will mail a copy of the disenrollment form back to you with the date of your disenrollment 
written on the form.  
If you need assistance, please call us at <phone number>.  TTY users should call <TTY/TDD 
number>.  We are open {insert days/hours of operation and, if different, TTY/TDD hours of 
operation}.   Thank you. 
 
Attachment  Exhibit 6a:  Model Disenrollment Form 
(Rev. 38, 10-31-03) 
Referenced in section:  50.1 
DATE 
(Please Print in Ink) 
MEMBERS NAME  ___________________________________________________________ 
First        Middle   Last 
ADDRESS                  ___________________________________________________________ 
      City        State    Zip Code  County 
TELEPHONE   (        ) ______________________ 
MALE _________  FEMALE __________  DATE OF BIRTH __________ 
MEDICARE # __________________ 
DISENROLLMENT RESPONSIBILITIES: Please carefully read and complete the following 
information before signing and dating this disenrollment form: 
Note: 
If you want to return to Original Medicare (also known as the Medicare fee-for-service 
program), then you must complete this disenrollment form.   
If you want to join another HMO immediately following termination from (Health Plan), then 
you do not need to complete this form. Once you enroll in another HMO, your current 
membership in <health plan> will automatically be cancelled.  We will notify you of the 
effective date of your disenrollment after we have received this form from you.  
Disenrollment from the (health plan) will be effective on the first day of the month after the 
month (health plan) receives the written request (unless you request a later date of 
disenrollment).  For example, if you complete this form and submit it to (health plan) on April 
30, the last day of the month, your disenrollment will be effective the next day, May 1st.  If you 
are requesting a later date, disenrollment cannot take place later than the third month after which 
you submit a completed disenrollment request to (health plan). Therefore, if you submit this 
form on April 30, the latest disenrollment date possible would be July 1. 
Requested disenrollment date: _______________ 
____________________________________  ________ 
Your Signature          Date 
____________________________________  ________ 
Your Guardians Signature        Date  Exhibit 7:  Model Notice to Acknowledge Receipt of Members Voluntary 
Disenrollment Request  
(Rev. 38, 10-31-03) 
Referenced in section(s):  50.1.1 
Dear <Name of Beneficiary>: 
We received your request to disenroll from <Health Plan> and you will be disenrolled effective 
<date.> Beginning <effective date>, <Health Plan> will not cover any health care you receive.  
A copy of your disenrollment request is enclosed. 
If you have any questions, please call us at <phone number>. TTY users should call <TTY/TDD 
number>.  We are open {insert days/hours of operation and, if different, TTY/TDD hours of 
operation}.  
Enclosure  Exhibit 8:  Model Notice to Confirm Voluntary Disenrollment Identified 
Through Reply Listing  
(Rev. 38, 10-31-03) 
Referenced in section(s):  50.1.1 
Dear <Name of Beneficiary>: 
This is to confirm your disenrollment from <Health Plan>. This disenrollment began <effective 
date>, and <Health Plan> will not cover any health care you receive after that date. Please note 
that you may want to tell your doctors that if they need to send Medicare claims, you just 
disenrolled from <Health Plan> and there may be a short delay in having your records updated.  
If you think you did not disenroll from <Health Plan>, and you want to remain a member of our 
plan, please call us right away at <phone number>.  TTY users should call <TTY/TDD number>. 
 We are open {insert days/hours of operation and, if different, TTY/TDD hours of operation}.   
Thank you. 
  Exhibit 9: Model Notice of Disenrollment Due to Death 
(Rev. 38, 10-31-03) 
Referenced in section(s):  50.2.2 
 
Note: Address letter To The Estate of <Members Name> or To <Members Name> 
 
To The Estate of <Members Name> (or To <Members Name>): 
The Centers for Medicare & Medicaid Services, the federal agency that administers the Medicare 
program, has notified us of the death of <Members Name>.  Please accept our condolences. 
<Members name>s coverage in <name of health plan> has ended as of <effective date>. If 
membership premiums were paid for any month after <effective date>, we will refund the Estate 
within 30 days of this letter. 
If this information is wrong, please call us at <phone number>. TTY users should call 
<TTY/TDD number>.  We are open {insert days/hours of operation and, if different, TTY/TDD 
hours of operation}.   Thank you.  Exhibit 10:  Model Notice of Disenrollment Due to Loss of Medicare Part B 
(Rev. 38, 10-31-03) 
Referenced in section:  50.2.3 
Dear <Members Name>: 
The Centers for Medicare & Medicaid Services, the federal agency that administers the Medicare 
program, has notified us that your Medicare Part B coverage has ended.  Without Medicare Part 
B enrollment, you cannot continue your membership in <name of plan health plan>.  Therefore, 
your coverage in <name of health plan> has ended as of <effective date>. If you paid plan 
premiums for any month after <effective date>, we will send you a refund within 30 days of this 
letter. 
If this information is incorrect, please contact us immediately at <phone number>. TTY users 
should call <TTY/TDD number>.  We are open {insert days/hours of operation and, if different, 
TTY/TDD hours of operation}.    Thank you.  Exhibit 11:  Model Capacity Waiver Calculation Worksheet 
(Rev. 38, 10-31-03) 
 
1  Start with total capacity for the year that the waiver is requested  (i.e., how  ________ 
many slots are available for both commercial and Medicare. 
2  Current total (Medicare/Medicaid and commercial) membership, excluding  ________ 
estimated number of age-ins (i.e., non-Medicare enrollees of your plan 
who will convert to Medicare status during the period for which you are 
seeking a capacity waiver). 
3  Projected new Medicaid-only and commercial individual or group members.  ________ 
4  Add steps (2) and (3) and subtract result form step (1) above to determine  ________ 
remaining slots available. 
5  Divide the figure in step (4) above by the utilization factor or factors from  ________ 
the most recent ACR to determine available slots for Medicare enrollees. 
Use an inpatient factor and ambulatory factor, or both.  However, if both are 
used, the data must be shown separately for each one, or show an acceptable 
methodology for combining the factors. 
6  The resultant figure is the initial number of available Medicare slots.  ________ 
7  Enter estimated Medicare enrollment from age-ins.(Current members  ________ 
excluded from (2) above. 
8  Subtract step (7) from step (6).  The result is the total number of slots  ________ 
available to individual Medicare members.  Exhibit 12:  Model for Closing Enrollment 
(Rev. 38, 10-31-03) 
Model A: Closing Enrollment for Partial Month(s) 
[Insert name of health plan] PUBLIC NOTICE 
As of [insert date] [health plan] will no longer offer continuous open enrollment under its 
contract with the Centers for Medicare & Medicaid Services for [insert plan name] in [insert 
service area]. 
Instead, [insert name of health plan] will offer open enrollment for all eligible individuals from 
the [insert date] to the [insert date] of each month. 
Current members of [insert name of plan] are not affected by this change. For information 
regarding this notice, call [insert name of M+C organization] at [insert phone number]. TTY 
users should call [insert number].  We are open [insert days and hours of operation]. 
Model B: Closing Enrollment for Whole Month(s) 
[Insert name of health plan] PUBLIC NOTICE 
As of [insert date] [insert name of health] will no longer offer open enrollment under its contract 
with the Centers for Medicare & Medicaid Services [insert plan name] in [insert service area]. 
Current members of [insert name of plan] are not affected by this change. For information 
regarding this notice, call [insert name of M+C organization] at [insert phone number]. TTY 
users should call [insert number].  We are open [insert days and hours of operation]. 
Model C: Closing Enrollment for Capacity Reasons 
[Insert name of health plan] PUBLIC NOTICE 
As of [insert date], [insert name of health plan] will no longer accept enrollment under its 
contract with the Centers for Medicaid & Medicaid Services [insert plan name] in [insert service 
area]. 
[insert plan] has been approved for a capacity limit by the Centers for Medicare & Medicaid 
Services. A capacity limit allows a health plan to limit enrollment once a specific number of 
members joins the plan. This is based in part on the accessibility and availability of providers to 
provide services to members of the plan. 
Current members of [insert name of plan] are not affected by this change. For information 
regarding this notice, call [insert name of M+C organization] at [insert phone number]. TTY 
users should call [insert number].  We are open [insert days and hours of operation].