Medicare Prescription Drug Eligibility and Enrollment

Guidance Update for 2017

NEW! On August 15, 2016, CMS issued an HPMS memo as an addendum to previously released revisions to the CY 2017 enrollment guidance.  This update includes clarifications to the definition of Application Date for the Online Enrollment Center.

On May 20, 2016, CMS issued an HPMS memo establishing flexibility in notification requirements for a favorable good cause determination. CMS revised the guidance to no longer require written notification of a favorable good cause determination if the Part D plan sponsor is successful in providing this information verbally, either when the individual has already paid all the owed amounts or when the individual pays the owed amounts in full at the time he or she receives the verbal notification. In addition, CMS developed a new model notice consonant with this policy to assist Part D plan sponsors when an individual receives a favorable determination and has already paid the amount required for reinstatement.

Part D plan sponsors must process all enrollments with an effective date on or after January 1, 2017, in accordance with these revisions.

Good Cause Flow Process and Frequently Asked Questions

On March 9, 2016, CMS appended the Frequently Asked Questions to specifically define who is authorized to act on behalf of a former member to process good cause requests. In addition, this document highlights operational procedures for submitting reinstatement requests to the RPC under the good cause process. Additional questions will be added to the FAQs, as necessary.

On November 18, 2015, CMS hosted a Part C and Part D User Call to respond to questions and clarify policies outlined in guidance.  As a result of that call, CMS is providing some additional resources to help plan sponsors prepare and implement the operational changes for processing good cause reinstatement requests: 

• Frequently Asked Questions
• Good Cause Triage Process Flow Chart

As plan sponsors begin to process good cause requests, they are encouraged to submit feedback and questions. CMS will add additional questions to the FAQ document, as necessary.

CMS Notice to Individuals Enrolled in Plans with Fewer Than Three Stars for Three or More Consecutive Years

CMS will further the goals of facilitating beneficiary enrollment into higher quality plans by issuing notices to individuals enrolled in plans with fewer than three stars for three consecutive years. The notices inform enrollees of an opportunity to contact CMS to request a special enrollment period (SEP) to move into a higher quality plan. Plans are not able to effectuate enrollments for this one-time SEP; all requests must come into CMS via 1-800-MEDICARE by the beneficiary and will be handled on a case-by-case basis. Spanish and English notices are  mailed to current members in October. Copies of the notices are available below.