CMS Pub. 100-16, ch. mc86c17d, § 20

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 individual’s 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 employer’s health benefits plan (or that of a

spouse). If the individual enrolls in a cost plan and continues enrollment in his/her (or

their spouse’s) employer health benefits plan, then coordination of benefits rules apply.