[Code of Federal Regulations] [Title 42, Volume 2] [Revised as of October 1, 2002] From the U.S. Government Printing Office via GPO Access [CITE: 42CFR422.74] [Page 842-845] TITLE 42--PUBLIC HEALTH HUMAN SERVICES PART 422--MEDICARE+CHOICE PROGRAM--Table of Contents Subpart B--Eligibility, Election, and Enrollment Sec. 422.74 Disenrollment by the M+C organization. (a) General rule. Except as provided in paragraphs (b) through (d) of this section, an M+C organization may not-- (1) Disenroll an individual from any M+C plan it offers; or (2) Orally or in writing, or by any action or inaction, request or encourage an individual to disenroll. (b) Basis for disenrollment--(1) Optional disenrollment. An M+C organization may disenroll an individual from an M+C plan it offers in any of the following circumstances: (i) Any monthly basic and supplementary beneficiary premiums are not paid on a timely basis, subject to the grace period for late payment established under paragraph (d)(1) of this section. (ii) The individual has engaged in disruptive behaviors specified at paragraph (d)(2) of this section. (iii) The individual provides fraudulent information on his or her election form or permits abuse of his or her enrollment card as specified in paragraph (d)(3) of this section. (2) Required disenrollment. An M+C organization must disenroll an individual from an M+C plan it offers in any of the following circumstances: (i) The individual no longer resides in the M+C plan's service area as specified under paragraph (d)(4) of this section, is no longer eligible under Sec. 422.50(a)(3)(ii), and optional continued enrollment has not been offered or elected under Sec. 422.54. (ii) The individual loses entitlement to Part A or Part B benefits as described in paragraph (d)(5) of this section. (iii) Death of the individual as described in paragraph (d)(6) of this section. (3) Plan termination or reduction of area where plan is available. (i) General rule. An M+C organization that has its contract for an M+C plan terminated, that terminates an M+C plan, or that discontinues offering the plan in any portion of the area where the plan had previously been available, must disenroll affected enrollees in accordance with the procedures for disenrollment set forth at paragraph (d)(7) of this section, unless the exception in paragraph (b)(3)(ii) of this section applies. (ii) Exception. When an M+C organization discontinues offering an M+C plan in a portion of its service area, the M+C organization may elect to offer enrollees residing in all or portions of the affected area the option to continue enrollment in an M+C plan offered by the organization, provided that there is no other M+C plan offered in the affected area at the time of the organization's election. The organization may require an enrollee who chooses to continue enrollment to [[Page 843]] agree to receive the full range of basic benefits (excluding emergency and urgently needed care) exclusively through facilities designated by the organization within the plan service area. (c) Notice requirement. If the disenrollment is for any of the reasons specified in paragraphs (b)(1), (b)(2)(i), or (b)(3) of this section (that is, other than death or loss of entitlement to Part A or Part B) the M+C organization must give the individual a written notice of the disenrollment with an explanation of why the M+C organization is planning to disenroll the individual. Notices for reasons specified in paragraphs (b)(1) through (b)(2)(i) must-- (1) Be mailed to the individual before submission of the disenrollment notice to CMS; and (2) Include an explanation of the individual's right to a hearing under the M+C organization's grievance procedures. (d) Process for disenrollment--(1) Monthly basic and supplementary premiums are not paid timely. An M+C organization may disenroll an individual from the M+C plan for failure to pay any basic and supplementary premiums under the following circumstances: (i) The M+C organization makes a reasonable effort to collect unpaid premium amounts by sending a written notice of nonpayment to the enrollee within 20 days after the date the delinquent charges were due-- (A) Alerting the individual that the premiums are delinquent; (B) Providing the individual with an explanation of the disenrollment procedures and any lock-in requirements of the M+C plan; and (C) Advising that failure to pay the premiums within the 90-day grace period will result in termination of M+C coverage; (ii) The M+C organization only disenrolls a Medicare enrollee when the organization has not received payment within 90 days after the date it has sent the notice of nonpayment to the enrollee. (iii) The M+C organization gives the individual a written notice of disenrollment that meets the requirement set forth in paragraph (c) of this section. (iv) If the enrollee fails to pay the premium for optional supplemental benefits (that is, a package of benefits that an enrollee is not required to accept), but pays the basic premium and any mandatory supplemental premium, the M+C organization has the option to discontinue the optional supplemental benefits and retain the individual as an M+C enrollee. (2) Disenrollment for disruptive behavior--(i) Basis for disenrollment.An M+C organization may disenroll an individual from the M+C plan if the individual's behavior is disruptive, unruly, abusive, or uncooperative to the extent that his or her continued enrollment in the plan seriously impairs the M+C plan's ability to furnish services to either the particular individual or other individuals enrolled in the plan. (ii) Effort to resolve the problem.The M+C organization must make a serious effort to resolve the problems presented by the individual, including the use (or attempted use) of the M+C organization's grievance procedures. The beneficiary has a right to submit any information or explanation that he or she may wish to submit to the M+C organization. (iii) Consideration of extenuating circumstances. The M+C organization must establish that the individual's behavior is not related to the use of medical services or to diminished mental capacity. (iv) Documentation. The M+C organization must document the enrollee's behavior, its own efforts to resolve any problems, and any extenuating circumstances, as described in paragraphs (d)(2)(i) through (d)(2)(iii) of this section. (v) CMS review of the M+C organization's proposed disenrollment. (A) CMS decides after reviewing the documentation submitted by the M+C organization and any information submitted by the beneficiary (which the M+C organization must forward to CMS) whether the M+C organization has met the disenrollment requirements. (B) CMS makes the decision within 20 working days after receipt of the documentation and notifies the M+C organization within 5 working days after making its decision. [[Page 844]] (vi) Effective date of disenrollment. If CMS permits an M+C organization to disenroll an individual for disruptive behavior, the termination is effective the first day of the calendar month after the month in which the M+C organization gives the individual written notice of the disenrollment that meets the requirements set forth in paragraph (c) of this section. (3) Individual commits fraud or permits abuse of enrollment card.-- (i) Basis for disenrollment. An M+C organization may disenroll the individual from an M+C plan if the individual-- (A) Knowingly provides, on the election form, fraudulent information that materially affects the individual's eligibility to enroll in the M+C plan; or (B) Intentionally permits others to use his or her enrollment card to obtain services under the M+C plan. (ii) Notice of disenrollment. The M+C organization must give the individual a written notice of the disenrollment that meets the requirements set forth in paragraph (c) of this section. (iii) Report to CMS. The M+C organization must report to CMS any disenrollment based on fraud or abuse by the individual. (4) Individual no longer resides in the M+C plan's service area. (i) Basis for disenrollment. Unless continuation of enrollment is elected under Sec. 422.54, the M+C organization must disenroll an individual if the M+C organization establishes, on the basis of a written statement from the individual or other evidence acceptable to CMS, that the individual has permanently moved out of a plan's service area. If the individual has not moved from the M+C plan's service area, but has left the plan's service area for more than 6 months, the M+C organization must disenroll the individual. (ii) Special rule. The M+C organization must disenroll an individual who is enrolled in the M+C plan, under the eligibility requirements at Sec. 422.50(a)(3)(ii) or (a)(4), if the organization establishes, on the basis of a written statement from the individual or other evidence acceptable to CMS, that the individual has permanently moved from the residence in which she or he resided at the time of enrollment in the M+C plan, to an area outside the M+C plan service area (unless continuation of enrollment is elected under Sec. 422.54). If the individual has not permanently moved from the residence in which she or he resided at the time of enrollment in the M+C plan, but has left the residence for over 6 months, the M+C organization must disenroll the individual. (iii) Notice of disenrollment. The M+C organization must give the individual a written notice of the disenrollment that meets the requirements set forth in paragraph (c) of this section. (5) Loss of entitlement to Part A or Part B benefits. If an individual is no longer entitled to Part A or Part B benefits, CMS notifies the M+C organization that the disenrollment is effective the first day of the calendar month following the last month of entitlement to Part A or Part B benefits. (6) Death of the individual. If the individual dies, disenrollment is effective the first day of the calendar month following the month of death. (7) Plan termination or area reduction. (i) When an M+C organization has its contract for an M+C plan terminated, terminates an M+C plan, or discontinues offering the plan in any portion of the area where the plan had previously been available, the M+C organization must give each affected M+C plan enrollee a written notice of the effective date of the plan termination or area reduction and a description of alternatives for obtaining benefits under the M+C program. (ii) The notice must be sent before the effective date of the plan termination or area reduction, and in the timeframes specified in Sec. 422.506(a)(2). (e) Consequences of disenrollment--(1) Disenrollment for non-payment of premiums, disruptive behavior, fraud or abuse, loss of Part A or Part B. An individual who is disenrolled under paragraph (b)(1)(i), (b)(1)(ii), (b)(1)(iii), or paragraph (b)(2)(ii) of this section is deemed to have elected original Medicare. (2) Disenrollment based on plan termination, area reduction, or individual moves out of area. (i) An individual who is disenrolled under paragraph (b)(2)(i) or (b)(3) of this section has a special election period in which to make a new [[Page 845]] election as provided in Sec. 422.62(b)(1) and (b)(2). (ii) An individual who fails to make an election during the special election period is deemed to have elected original Medicare. [63 FR 35071, June 26, 1998; 63 FR 52612, Oct. 1, 1998, as amended at 65 FR 40318, June 29, 2000]