Medicare Prescription Drug Eligibility and Enrollment

This page contains enrollment and disenrollment guidance for current and future contracting Part D plan sponsors and other parties interested in the operational and regulatory aspects of Part D plan enrollment and disenrollment.

New! Addition of Race and Ethnicity Data Fields on the PDP Model Enrollment Request Form

On July 5, 2022, CMS released the “Model Individual Enrollment Request Form to Enroll in a Medicare Advantage Plan (MA) or Medicare Prescription Drug Plan (Part D), and Advance Announcement of January 2023 Software Release - Addition of Race and Ethnicity Data Fields on Enrollment Transactions” memorandum via HPMS to announce the addition of race and ethnicity data fields on the model PDP enrollment form, OMB No. 0938-1378.  These new fields are required to be included on the enrollment form; however, applicant response to these questions is optional.

Part D plans are expected to use the new form for enrollment requests received on or after January 1, 2023. The new form should be used for all enrollments after January 1, 2023.

Revisions to the Prescription Drug Plan Enrollment and Disenrollment Guidance and Individual Enrollment Request Form to Enroll in a Part D plan for CY 2021

On August 11, 2020, CMS released the “Enrollment Guidance Policy Changes and Updates and Model Medicare Advantage and Prescription Drug Plan Individual Enrollment Request Form for Contract Year 2021” memorandum via our Health Plan Management System (HPMS) to provide guidance and the new PDP model enrollment request form updates. The policy and technical changes reflect the recently published regulation changes in CMS-4190-F to include:

• The removal of enrollment prohibitions on beneficiaries with End-Stage Renal Disease (ESRD) who choose to join a Medicare Advantage (MA) plan;
• The establishment of two new Special Enrollment Periods (SEPs) for exceptional circumstances and the codification of previously adopted SEPs for exceptional conditions implemented through sub regulatory guidance; in addition, to,
• The new Model Individual Enrollment Request Form to enroll in a Part D plan, OMB No. 0938-1378; and
• Changes to the Electronic enrollment process to include new flexibility for Electronic Signatures.
   

The update to the CY 2021 guidance is now available below with the file names: CY2021 PDP Enrollment and Disenrollment Guidance.

All enrollments with an effective date on or after January 1, 2021, must be processed in accordance with the revised guidance requirements, including the new model PDP enrollment form.  Part D plans are expected to use the new model form for the 2021 plan year Annual Enrollment Period (AEP) which begins on October 15, 2020.  

Good Cause Flow Process and Frequently Asked Questions

Below are resources to help plans process good cause reinstatement requests: 

• Frequently Asked Questions
• Good Cause Triage Process Flow Chart