| Date: | December 7, 1999 |
| Subject: | Data Elements Required to Complete the Medicare+Choice (M+C) Enrollment Forms |
| Effective Date: | January 1, 2000 |
QUESTION:
Section 1.0 of OPL 99.100 defines an enrollment as being complete when, among the other items listed in section 1.0, the enrollment form is signed by the beneficiary or legal representative and all necessary elements on the form are completed. Exactly which elements on the enrollment form must be completed in order for the enrollment form to be considered complete? Should an M+C organization (M+CO) deny the enrollment if the "necessary elements" are not completed?
The definition of a completed election is found in section 1.0 of OPL 99.100 and states that an enrollment is complete when the enrollment form is signed by the beneficiary or legal representative and all necessary elements on the form are completed. (NOTE: There are additional requirements for a completed enrollment. For a thorough definition of a "completed election," refer to section 1.0 of OPL 99.100.)
Given the definition of a completed election, an M+CO must ensure that specific data elements, including the signature, are filled in on the enrollment form in order to consider the enrollment complete. These specific data elements are known as the "necessary elements" mentioned above.
The following grid lists all the data elements that are contained in Exhibits 1, 2, and/or 3 in OPL 99.100, i.e., the model enrollment forms. All data elements with a "Yes" in the "Required before enrollment complete" column are necessary in order for the enrollment to be considered complete.
If the M+CO receives an enrollment form that contains all "necessary elements," the M+CO must consider the enrollment form complete even if all other data elements on the enrollment form are not filled out.
| Data Element | Required before Element Complete? | OPL 99.100 Exhibit # in which data element appears |
|
| 1 | Data Element | Yes | 1, 2, 3 |
| 2 | Effective Date of Coverage | No1 | 1, 2, 3 |
| 3 | Beneficiary Name | Yes | 1,2,3 |
| 4 | Beneficiary Medicare Number | Yes | 1,2,3 |
| 5 | Beneficiary Date of Birth | Yes | 1,2 |
| 6 | Beneficiary Sex | Yes | 1,2 |
| 7 | Permanent Residence Address | Yes | 1,2,3 |
| 8 | Mailing Address | No | 1,2,3 |
| 9 | Beneficiary Telephone Number | No | 1,2,3 |
| 10 | Name of Person to Contact in Emergency, including Phone Number and Relationship to Beneficiary (Optional Field) | No | 1,2 |
| 11 | Language Preference (Optional Field) | No | 1,2 |
| 12 | Annotation of Whether Beneficiary is Retiree, including Retirement Date and Name of Retiree (if not the Beneficiary) | No | 2 |
| 13 | Question of Whether Spouse or Dependents are Covered Under the Plan and, if Applicable, Name of Spouse or Dependents | No | 2 |
| 14 | Medicare Information Contined on Sample Medicare Card, or Copy of Card | No2 | 1,2 |
| 15 | M+C Plan/Product Choice | Yes | 1,2 |
| 16 | M+C Product/Premium Choice | Yes | 3 |
| 17 | Question of Whether Beneficiary is Currently a Member of the Plan and, if Yes, Request fo Plan Identification Number | No | 2 |
| 18 | Name of Chosen Primary Care Physician, Clinic, or Health Center (Optional Field) | No | 1,2,3 |
| 19 | Beneficiary Signature and/or Beneficiary Representative Signature | Yes | 1,2,3 |
| 20 | Signature and Relationship of any Individual Who Helped Beneficiary Fill Out Form (If Applicable) | Yes | 1,2,3 |
| 21 | Date of Signatures | No3 | 1,2,3 |
| 22 | Response to Question 1 on Page 3 ("Please Read and Answer These Questions") | Yes | 1,2 |
| 23 | Response to Questions 2 - 5 on Page 3 ("Please Read and Answer These Questions") | Yes | 1,2 |
| 24 | Initials/Annotation Next to All Statements on Page 4 ("Please Read These Sentences and Put Your Initials Next to Them") | Yes4 | 1,2 |
| 25 | Employer Name and Group Number | Yes | 2 |
| 26 | Question of Which M+C Plan/Premium of which the Beneficiary is Currently a Member and to Which M+C Plan/Premium the Beneficiary is Changing | Yes | 3 |
If an M+CO has received HCFA approval for an enrollment form that contains data elements in addition to those listed above, it must not consider an enrollment incomplete if the additional data elements are not completed on the form.
If an M+CO receives an enrollment form that does not have all necessary elements completed, it must not deny the enrollment. Instead, the enrollment is considered incomplete and the M+CO must follow the procedures outlined in section 4.1.1 of OPL 99.100, "When the enrollment form is incomplete," in order to complete the enrollment. Where possible, the M+CO should check available systems for information to complete an enrollment before requiring the beneficiary to provide the missing information. For example, if a beneficiary failed to fill out the "sex" field on the enrollment, the M+CO could obtain this information via available systems rather than request the information from the beneficiary.
Contact: HCFA Regional Office Managed Care Staff.
This OPL was prepared by the Center for Beneficiary Services.
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Last Updated December 7, 1999
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