CMS Pub. 100-18, ch. 12, App. IV

MA organizations and PDP sponsors may submit individual waiver/modification requests at

any time to CMS. The Applicant should submit these additional waiver/modification requests

to their Account Manager.

These requests must be identified as requests for additional waivers/modifications and must

fully address the following items:

• Specific provisions of existing statutory, regulatory, and/or CMS policy requirement(s)

the entity is requesting to be waived/modified (identify the specific requirement (e.g.,

“42 CFR 422.66,” or “Pub. 100-16, Medicare Managed Care Manual chapter 2,

section 40.4, ”) and whether you are requesting a waiver or a modification of these

requirements);

• How the particular requirements hinder the design of, the offering of, or the enrollment

in, the employer-sponsored group plan;

• Detailed description of the waiver/modification requested including how the

waiver/modification will remedy the impediment (i.e., hindrance) to the design of, the

offering of, or the enrollment in, the employer-sponsored group plan;

• Other details specific to the particular waiver/modification that would assist CMS in

the evaluation of the request; and

• Contact information (contract number, name, position, phone, fax and email address)

of the person who is available to answer inquiries about the waiver/modification

request.