(ii) Basis of disenrollment for disruptive behavior. A change in residence, making the individual ineligible to be an enrollee of the prescription drug plan. All Rights Reserved. This web site is designed for the current versions of The PDP sponsor must disenroll affected enrollees in accordance with the procedures for disenrollment set forth at 423.507 through 423.510. In addition, some sites may require you to agree to their terms of use and privacy policy. Those who qualify will not be subject to the coverage gap or a late enrollment penalty. You can contact us if you need additional information regarding the number of appeals and grievances filed by our customers. Once an individual is disenrolled from the PDP for misrepresentation of third party reimbursement, the PDP sponsor has the option to decline future enrollment by the individual in any of its PDPs for a period of time CMS specifies. Enrollment in WPS MedicareRx (iv) Notification by CMS of incarceration. We have the right to pursue collection of the premiums you owe. (iv) Documentation. If you enroll in a Medicare plan that includes Medicare prescription drugs or any MA-coordinated care (HMO or PPO) plan, you will be automatically disenrolled from the HMO, PPO, or MA PFFS Plan if you enroll in a PDP. Privacy Information | Eligibility, Enrollment, and Disenrollment | Appeals and Grievances | Fraud and Abuse, Espaol | Hmoob | | Deutsch | | | Ting Vit | Deitsch | | Franais | Polski | | Shqip | Tagalog | (i) If CMS determines an individual has materially misrepresented information to the PDP sponsor as described under 423.44(b)(2)(v), the termination is effective the first day of the calendar month after the month in which the PDP sponsor gives the individual written notice of the disenrollment that meets the requirements set forth in paragraph (c) of this section. When CMS notifies the PDP of the disenrollment due to the individual being incarcerated and not residing in the service area of the PDP as per 423.4, disenrollment is effective the first of the month following the start of incarceration, unless otherwise specified by CMS. At the time we end your membership, you may still owe us for premiums you have not paid. The individual must establish by a credible statement that failure to pay premiums within the initial grace period was due to circumstances for which the individual had no control, or which the individual could not reasonably have been expected to foresee. The official, published CFR, is updated annually and available below under Plan depends on contract renewal. Blue Cross and Blue Shield of New Mexico (BCBSNM) must disenroll a person from Blue Cross MedicareRx in these cases: Not sure what you need? (2) Required involuntary disenrollment. The PDP sponsor must make a serious effort to resolve the problems presented by the individual, including providing reasonable accommodations, as determined by CMS, for individuals with mental or cognitive conditions, including mental illness, Alzheimers disease, and developmental disabilities. Sections 1102, 1106, 1860D-1 through 1860D-42, and 1871 of the Social Security Act (42 U.S.C. (2) Orally or in writing, or by any action or inaction, request or encourage an individual to disenroll. (i) When a PDP contract terminates as provided in 423.507 through 423.510, the PDP sponsor must give each affected PDP enrollee notice of the effective date of the plan termination and a description of alternatives for obtaining prescription drug coverage under Part D, as specified by CMS. The PDP sponsor is required to provide a reasonable accommodation, as determined by CMS, for the individual in exceptional circumstances that CMS deems necessary. If the individual has not moved from the PDP service area, but has been absent from the service area for more than 12 consecutive months, the PDP sponsor must disenroll the individual from the plan effective on the first day of the 13th month after the individual left the service area. This is called a Reinstatement for Good Cause. Learn more about the eCFR, its status, and the editorial process. new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0], The individual enrolls in a different Medicare Advantage, Medicare Advantage Prescription Drug plan or stand-alone Medicare Prescription Drug plan. The PDP sponsor is required to provide a reasonable accommodation, as determined by CMS, for the individual in exceptional circumstances that CMS deems necessary. Examples of such circumstances may include: receiving benefits from both Medicare and Medicaid; changing living situations (such as moving out of state or into a long-term care facility); losing creditable coverage from an employer or other plan sponsor; or losing coverage because a plan no longer offers Medicare prescription drug coverage. (i) When a PDP contract terminates as provided in 423.507 through 423.510, the PDP sponsor must give each affected PDP enrollee notice of the effective date of the plan termination and a description of alternatives for obtaining prescription drug coverage under Part D, as specified by CMS. CMS reserves the right to deny a request from a fallback prescription drug plan as defined in 423.855 to disenroll an individual for disruptive behavior.
During the annual enrollment period, you may either join a stand-alone prescription drug plan or a health plan that also provides drug coverage. A PDP enrollee is disruptive if his or her behavior substantially impairs the plans ability to arrange or provide for services to the individual or other plan members. A PDP sponsor may disenroll an individual from a PDP it offers in any of the following circumstances: (i) Any monthly premium is not paid on a timely basis, as specified under paragraph (d)(1) of this section; or. (vii) Effective date of disenrollment. (vi) Extension of grace period for good cause and reinstatement. S5753_PDPLP01_2110_M Last updated on 10/01/2021. If we end your membership with the plan because you did not pay your premiums, and you don't currently have prescription drug coverage, then you may not be able to receive Part D coverage until the following year if you enroll in a new plan during the annual enrollment period. (vi) Exception for fallback prescription drug plans. The PDP sponsor may request from CMS the ability to decline future enrollment by the individual. You are using an unsupported browser. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. Many people are eligible for these savings and don't even know it. Title 42 was last amended 7/11/2022. After a grace period and notice of termination has been provided in accordance with paragraphs (e)(2) and (4) of this section, the effective date of disenrollment is the first day following the last day of the initial grace period. (2) Initial grace period. (1) Except as specified in paragraph (d)(1)(iv) of this section, a PDP sponsor may disenroll an individual from the PDP for failure to pay any monthly premium under the following circumstances: (i) The PDP sponsor can demonstrate to CMS that it made reasonable efforts to collect the unpaid premium amount. (iii) Incarceration. CMS reserves the right to deny a request from a fallback prescription drug plan as defined in 423.855 to disenroll an individual for disruptive behavior. (iii) Incarceration. The individual intentionally misrepresents information to BCBSNM regarding reimbursement for third-party coverage. (ii) The PDP sponsor gives the enrollee notice of disenrollment that meets the requirements set forth in paragraph (c) of this section. If an individual is disenrolled from the PDP for failure to pay monthly PDP premiums, the PDP sponsor has the option to decline future enrollment by the individual in any of its PDPs until the individual has paid any past premiums due to the PDP sponsor. If you move out of the service area, your disenrollment is considered voluntary. When an individual is disenrolled for failure to pay the plan premium, CMS (or a third party to which CMS has assigned this responsibility, such as a Part D sponsor) may reinstate enrollment in the PDP, without interruption of coverage, if the individual shows good cause for failure to pay within the initial grace period, and pays all overdue premiums within 3 calendar months after the disenrollment date. This document is available in the following developer friendly formats: Information and documentation can be found in our CMS also may refuse to renew the contract. (ii) Include an explanation of the individual's right to file a grievance under the PDP's grievance procedures. An individual cannot be considered disruptive if the behavior is related to the use of medical services or compliance (or noncompliance) with medical advice or treatment. 423.44 Involuntary disenrollment from Part D coverage. Enhanced content is provided to the user to provide additional context. Most PDF readers are a free download. (8) Individual is not lawfully present in the United States. CMS will disenroll individuals who fail to pay the Part D income related monthly adjustment amount (Part D - IRMAA) specified in 423.286(d)(4) and 423.293(d) of this part. (ii) Basis of disenrollment for disruptive behavior. (iv) Notification by CMS of incarceration. (ii) The PDP sponsor gives the enrollee notice of disenrollment that meets the requirements set forth in paragraph (c) of this section. The prescription drug plan contract is terminated or the Prescription Drug Plan organization discontinues offering a prescription drug plan in any portion of the area where it had previously been available. TTY users should call 1-877-486-2048. (ii) The individual loses eligibility for Part D. (iv) The PDP sponsor's contract is terminated by CMS or by a PDP or through mutual consent. 1302, 1306, 1395w-101 through 1395w-152, and 1395hh). An individual cannot be considered disruptive if the behavior is related to the use of medical services or compliance (or noncompliance) with medical advice or treatment. If you qualify for a Special Enrollment Period, you may be eligible to leave the plan at other times of the year.
(7) Misrepresentation of third-party reimbursement. For more information about this Extra Help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, seven days per week. (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start': You may be enrolled in only one Part D plan at a time. (4) Notice of termination. (iv) Documentation. Get started, Prescription Drug Estimator & Pharmacy Finder. The eCFR is displayed with paragraphs split and indented to follow the hierarchy of the document. You can learn more about the process (v) A PDP sponsor may not disenroll an individual who had monthly premiums withheld per 423.293(a) and (e) of this part or who is in premium withhold status, as defined by CMS. Calling 1-800-MEDICARE (1-800-633-4227). Individual & Family HMO/POS Health Plans, Marketing Materials/Reporting (Employer Reports), WPS Health Insurance and WPS Health Plan Employer Enrollment, WPS Health Insurance and WPS Health Plan Reporting (Employer Reports), WPS Administrative Services (ASO) Powered by Auxiant, Medicare MAC J5, MAC J8, and J5 National Part A, Wisconsin Medicare Prescription Drug Plans, Medication Therapy Management (MTM) Program, Eligibility, Enrollment, and Disenrollment, Espaol | Hmoob | | Deutsch | | | Ting Vit | Deitsch | | Franais | Polski | | Shqip | Tagalog. In addition, the PDP sponsor must inform the individual of the right to use the PDP's grievance procedures.
Health Care Service Corporation. A PDP enrollee is disruptive if his or her behavior substantially impairs the plans ability to arrange or provide for services to the individual or other plan members. CMS reviews the information submitted by the PDP sponsor and any information submitted by the individual (which the PDP sponsor has submitted to CMS) to determine if the PDP sponsor has fulfilled the requirements to request disenrollment for disruptive behavior. Except as provided in paragraphs (b) through (d) of this section, a PDP sponsor may not -, (1) Involuntarily disenroll an individual from any PDP it offers; or. To view this file, you may need to install a PDF reader program. (i) The PDP must disenroll an individual if the individual notifies the PDP that he or she has permanently moved out of the PDP service area. We must also explain how you can make a complaint about our decision to end your membership. If you had an emergency circumstance that was out of your control and it caused you to not be able to pay your premiums within our grace period, you can ask WPS to reconsider this decision and reinstate your enrollment in the plan. Please note, reinstatement of enrollment for Good Cause is provided only in rare circumstances in which you or your authorized representative (i.e. When an individual is disenrolled for failing to pay the Part D - IRMAA within the initial grace period specified in paragraph (e)(2) of this section, CMS (or an entity acting on behalf of CMS) may reinstate enrollment, without interruption of coverage, if the individual shows good cause as specified in 423.44(d)(1)(vi), pays all Part D - IRMAA arrearages, and any overdue premiums due the Part D plan sponsor within 3 calendar months after the disenrollment date. The Blue Cross MedicareRx contract is terminated or BCBSNM discontinues offering Blue Cross MedicareRx in any portion of the area where it had previously been available. Contact your local agent or call us at 1-800-731-0459 (TTY: 711) Prior Authorization/Utilization Management, Medicare Coverage Determination, Appeals and Grievances, Blue Cross Medicare Advantage Dual Care Plus (SNP), Blue Cross Medicare Advantage Dual Care (HMO SNP). File is in portable document format (PDF). (4) Notice of termination. The individual has a right to submit any information or explanation that he or she may wish to the PDP. (d) Process for disenrollment - (1) Except as specified in paragraph (d)(1)(iv) of this section, a PDP sponsor may disenroll an individual from the PDP for failure to pay any monthly premium under the following circumstances: (i) The PDP sponsor can demonstrate to CMS that it made reasonable efforts to collect the unpaid premium amount. If you think we have wrongfully ended your membership, you have a right to ask us to reconsider this decision by making a complaint. 70 FR 4525, Jan. 28, 2005, unless otherwise noted. This is imposed when a beneficiary fails to maintain creditable prescription drug coverage for a period of 63 days or more following the last day of an individual's initial enrollment in a Part D plan. Having current eligibility in CMS systems. 8 a.m.-8 p.m., weekdays (year-round) and weekends (Oct. 1March 31). learn more about the process here. (1) Optional involuntary disenrollment. You must provide a signed written notice to Blue Cross MedicareRx (or, if enrolled through your employer group, the employer group must provide Blue Cross MedicareRx with the request to disenroll you). (iii) The PDP sponsor provides the individual with a grace period, that is, an opportunity to pay past due premiums in full. No matter the reason, we are never allowed to ask you to leave the plan because of your health.
