Enrollment Process

(1) Applications. (a) Applications shall be made available through the Plan, through Elder Affairs and at locations frequented by potential Applicants. (b) A toll-free telephone number shall be available to provide Enrollment assistance and to take requests for applications, and the telephone number shall conspicuously appear on applications and other written materials regarding the Plan. (c) The Plan shall publicize that assistance with the application process is available to Applicants with limited English proficiency. (d) The Applicant or the Applicant's designee must complete the application and attest that all information submitted in the application is true to the best of his or her knowledge and belief. (e) An application may be submitted by mail or any other acceptable method as determined by the Plan. (2) Applicant Information. (a) The Applicant must furnish his or her name, address and other information as specified by the Plan. The Plan may require verification of any eligibility requirement as deemed reasonable by the Plan. (b) Residency. 1. As a condition of eligibility, an Applicant or Member must: a. live in the Commonwealth with the intent to remain permanently or for an indefinite period; and b. whenever absent, intend to return to the Commonwealth. 2. An Applicant must attest on the application to his or her residence in the Commonwealth. 3. Verification of residence may be required if there is conflicting or contradictory information regarding the Applicant's or Member's declared place of residence. In the event such information is required, residency shall be verified by the Applicant or Member by the submission of such documentation as deemed reasonable by the Plan. (c) Medicare Eligibility. As a condition of enrollment in the Plan, all Applicants who may qualify for the Low-income Subsidy shall apply for that subsidy or certify to the Plan that they are ineligible because their resources exceed the limit established by the Social Security Administration. If authorized by the Applicant, the Plan may apply for the Low-income subsidy on his or her behalf. To receive covered benefits in the Plan, all Applicants who are eligible for Medicare must be enrolled in a Medicare Part D Plan or Creditable Coverage Plan. (d) MassHealth. As a condition of enrollment in the Plan, all Applicants who may qualify for the MassHealth Buy-in or MassHealth Senior Buy-in, as those coverages are defined in 130 CMR 519.000: MassHealth: Coverage Types, shall apply for those programs or certify to the Plan that they are ineligible because their resources exceed the limit established by MassHealth. (3) Age and Disability Status. (a) An Applicant under 651 CMR 15.04(1)(a) must: 1. have reached his or her 65 birthday by the Effective Date of Coverage; and th 2. attest to his or her age in the application. (b) An Applicant under 651 CMR 15.04(1)(b) younger than 65 years old must: 1. verify disability status by submitting one of the following: a. a current Social Security Administration (SSA) award letter for Social Security Disability Income (SSDI) or Supplemental Security Income (SSI) benefits; b. a copy of the Applicant's Medicare card; c. a certificate of blindness from the Massachusetts Commission for the Blind; d. a copy of the determination of disability from MassHealth or CommonHealth; or e. written verification of SSDI or SSI benefits signed by an authorized Social Security Claims Representative on Social Security letterhead. 2. attest that he or she does not work more than 40 hours per month; and, 3. provide documentation consistent with 651 CMR 15.06(5) to verify that Applicant's Gross Annual Household income is not more than 188% of the Federal Poverty Level. (4) Membership Categories. (a) The Plan will establish Membership Categories based on Members' eligibility for Medicare Part D coverage, Gross Annual Household Income, and eligibility for the Medicare Low-income Subsidy. The Plan will annually define the specific benefit levels available to members in each category, including applicable Enrollment Fees, Co-payments, Deductibles, Supplemental Assistance, and Annual Out-of-pocket Spending Limits. Applicants eligible under 651 CMR 15.04(1)(a) must submit financial information pursuant to 651 CMR 15.06(5). NON-TEXT PAGE (b) Applicants determined to be eligible shall be enrolled into the Plan in the applicable Membership Category. (c) An Applicant or Member who has been determined by the Plan to be potentially eligible for the Low-income Subsidy, but who has not applied for or cooperated in the submission of an application for the Low-income Subsidy, may be temporarily classified in a Membership Category which offers no supplemental assistance for Premiums, and the lowest supplemental assistance for Co-payments and Deductibles. (d) A Member may at any time request in writing a Membership Category change by submitting financial information in accordance with 651 CMR 15.06(5). The Plan shall render a determination regarding the category change request after reviewing the Member's submitted financial information. The effective date of an approved category change is the first calendar day of the month following the date such a request is submitted to the Plan. A Member will not receive any refund for, or adjustment to, Premiums billed before a Member's request for a category change is submitted to the Plan. (5) Income. (a) All Applicants must submit the following documentation of their income, as must all Applicants and Spouses who live together in the same housing unit: 1. The most recently filed federal income tax return(s) and documentation of current Social Security income; or 2. If the Applicant or his or her Spouse did not file a federal income tax return within the two years prior to application, easily obtainable means of income verification as approved by the Plan and indicated in the Plan's application materials. (6) Eligibility Determination. (a) Written notification shall be mailed to each Applicant or his or her authorized representative regarding the Plan's determination of eligibility for enrollment in the Plan, in the applicable Membership Category, and the Applicant's Effective Date of Coverage, if applicable. (b) The Plan shall only consider completed applications. The Plan shall approve and enroll new Members on the first calendar day of each month. (c) An Applicant shall be notified in writing by the Plan regarding the determination of eligibility within 40 Business Days after receipt of a completed application. (d) Application Review. 1. Eligible Applicants. a. The Plan shall determine whether an Applicant meets eligibility criteria and shall enroll new Members in the Plan at the appropriate Membership Category according to his or her Gross Annual Household Income. b. The Plan shall mail written notice to each Applicant or his or her authorized representative regarding the Plan's determination of eligibility for enrollment in the Plan, the Effective Date of Coverage, the Applicable Membership Category, any applicable Enrollment Fee, Co-payments, and Deductibles. 2. Ineligible Applicants. The Plan shall mail written notice to all Applicants or their authorized representatives determined to be ineligible for the Plan, including a summary of the determination, the reasons for the determination and the regulatory and/or legal citations supporting the determination. 3. Incomplete Applications. a. If an Applicant fails to provide information necessary for the determination of eligibility, the Plan shall mail written notification to the Applicant or his or her authorized representative within 15 Business Days from the receipt of the application regarding all outstanding information and/or documents that must be submitted in order to determine eligibility and be given the opportunity to complete or amend the application. b. If an Applicant fails to provide all outstanding information and/or documents necessary for the determination of eligibility within 60 days of a written notification as set forth in 651 CMR 15.06(6)(d)3.a., the Applicant shall be determined to be ineligible for the Plan. c. In the event that the Secretary closes Enrollment, the Plan may suspend all processing of incomplete applications and/or modify timelines for notification or action on incomplete applications until the Secretary has made a determination to re-open Enrollment.