CMS Pub. 100-16, ch. mc86c17d, § 30.1.1

The organization may obtain a waiver of the open enrollment requirements under one of

the following two conditions – (1) Non-representative enrollment, and (2) Limited

capacity.

Non-Representative Enrollment

An open enrollment period will result in a membership substantially non-representative

of the population in the geographic area. In this case, the organization may request a

selection restriction in writing at least 90 days before the proposed open enrollment

period. The organization must provide statistical data that an open enrollment period

would cause a particular membership subgroup to exceed its proportion of the geographic

area by at least 10 percent. A subgroup is defined as a class of Medicare beneficiaries

based on factors such as age, sex, or other factors that CMS determines significantly

affects health care utilization. The organization may not limit enrollment unless and until

CMS approves the selection policy. If the organization submits insufficient data to make

a decision, CMS will deny the request.

Limited Capacity

The organization does not have capacity for additional members, or the organization must

limit enrollment to a certain number of members. The organization must estimate

whether it would reach capacity during its next open enrollment period, and would

therefore need a CMS-approved capacity waiver.

The following sections describe criteria and procedures for capacity waiver applications.

An organization must submit all required information to its Regional Office at least (and

preferably more than) 90 days prior to the open enrollment period for Medicare

beneficiaries. The CMS will make every attempt to notify the organization of its

decision at least 60 days in advance of the enrollment period. If the waiver is granted, it

remains in effect for one year only.