CMS Pub. 100-16, ch. mc86c17d, § 40.1

The cost plan must use a CMS approved enrollment form that complies with the

following guidelines on structure and content. A model CMS enrollment form is

provided as Exhibit 1 at the end of this chapter.

The enrollment form should include a statement acknowledging that premium and

copayment amounts were stated to the enrollee and may be found in the subscriber

agreement or other documents, as well as statements indicating that the enrollee:

• Agrees to abide by the cost plan membership rules as outlined in the material

provided to the enrollee;

• Authorizes the plan to disclose and exchange necessary information with CMS;

• Understands that he or she may receive medical services from non-network

providers, but will be liable for deductibles, coinsurance, and charges not covered

by Medicare;

• Understands that enrollment in the plan automatically disenrolls him/her from any

other cost plan or Medicare+Choice plan in which he or she is enrolled; and

• Knows the proposed effective date of coverage, which is the date he/she should

begin receiving care through the plan.

The cost plan must obtain the applicant’s signature and the date. If the applicant

inadvertently fails to include the date of signature on the form, then the date of receipt

stamped by the cost plan may serve as the signature date on the form.