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! Revisions to the Prescription Drug Plan Enrollment and Disenrollment Guidance and Individual Enrollment Request Form to Enroll in a Part D plan 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 PDP 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 PDP Enrollment Guidance and 2024 PDP 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 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.
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
HPMS Announcement Memo- Race and Ethnicity (PDF)
CY 2024 Model PDP Indiv Enrollment Request Form 0938-1378 (PDF)
Good Cause FAQ 03-09-16 (PDF)
Good Cause Triage Flow Process 12-11-15 (PDF)
CY 2024 PDP Enrollment and Disenrollment Guidance (PDF)
CY 2024 HPMS Memo Enrollment Guidance Changes Final (PDF)
CY 2021 PDP Enrollment and Disenrollment Guidance (PDF)