Medicare Managed Care Eligibility and Enrollment

Medicare Managed Care Eligibility and Enrollment

This page contains information for current and future contracting Medicare Advantage (MA) organizations, other health plans, and other parties interested in the operational and regulatory aspects of Medicare health plan enrollment and disenrollment.

New! Revisions to the Programs of All-Inclusive Care for the Elderly (PACE) Enrollment and Disenrollment Guidance

On December 5, 2023, CMS released the “PACE Enrollment Guidance Updates” memorandum via our Health Plan Management System (HPMS) to provide guidance updates. Some general changes include:

  • Updates to reflect revisions resulting from final regulations published on June 3, 2019, in CMS-4168-F (Medicare and Medicaid Programs; Programs of All-Inclusive Care for the Elderly (PACE)).
  • Electronic signature option for PACE enrollment agreements.
  • Pronouns made gender neutral.

The guidance update is now available below with the file name: PACE Chapter 4 12-05-23.

Revisions to the MA and §1876 Cost Plan Enrollment and Disenrollment Guidance and Individual Enrollment Request Form for CY 2024

On August 15, 2023, CMS released the “Release of Parts C & D Enrollment and Eligibility Guidance” memorandum via our Health Plan Management System (HPMS) to provide guidance and the new MA model enrollment request form updates. The policy and technical changes reflect the recently published regulation changes in CMS-4201-F1 to include:

  • Race/Ethnicity enrollment questions added to model forms and in form fields guidance.
  • Pronouns related to “the individual/enrollee/beneficiary” made gender neutral.
  • URL updates: SSA and CMS web links have been updated to working links.
  • SEP for Individuals who Gain, Lose, or Have a Change in their Dual or LIS-Eligible Status was revised for clarity and to match the regulation at 42 CFR 423.38(c)(9).
  • Model Notice for CMS Rejection of Enrollment (Chapter 2, Exhibit 8) was revised for typo errors.
  • 4201-F1 updates:
    • NET language updated/deleted to reflect it as a permanent program.
    • Language updated for Partial/Full benefit subsidy eligible individuals to reflect changes in Federal Poverty Level.
    • Added SEP for Individuals Who Enroll in Medicare Premium-Part A or Part Busing an Exceptional Condition SEP, as described in 42 CFR Parts 406.27 and407.23.
    • Clarification of SEP for Other Exceptional Circumstances review process and possible effective dates.

The update to the CY 2024 guidance is now available below with the file names: 2024 MA Enrollment Guidance and 2024 MA Model Enrollment Form.

All enrollments with an effective date on or after January 1, 2024, must be processed in accordance with the revised guidance requirements.

Addition of Race and Ethnicity Data Fields on the MA 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 a 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 MA 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.

MA 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.

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


Page Last Modified:
03/28/2024 08:11 AM