(If you go without "creditable" drug coverage for more than 63 days, you may have to pay a late enrollment penalty for as long as you have Part D coverage.). CMS notifies the PDP sponsor within 5 working days after making its decision. (iii) Incarceration. For more information, call Customer Support. All Rights Reserved. developer resources. TTY or TDD users should call 1-877-486-2048, 24 hours a day/seven days a week; The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. (1) General rule. 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. The individual materially misrepresents information to the prescription drug plan organization regarding reimbursement for third-party coverage. Loss of the beneficiarys home or severe impact by fire, or other exceptional circumstance outside the beneficiarys control (e.g., affected individual resides in a federal disaster area), such that the individual was prevented from making arrangement for premium payment during the grace period for plan or Part D-IRMAA payment. 8 a.m.-8 p.m., weekdays (year-round) and weekends (Oct. 1March 31). Subscribe to: Changes in Title 42 :: Chapter IV :: Subchapter B :: Part 423 :: Subpart B :: Section 423.44. For all Part D - IRMAA amounts directly billed to an enrollee in accordance with 423.293(d)(2), the grace period ends with the last day of the third month after the billing month. (8) Individual is not lawfully present in the United States. Answer a few questions to help you decide. (ii) Reenrollment in the PDP. Sections 1102, 1106, 1860D-1 through 1860D-42, and 1871 of the Social Security Act (42 U.S.C. (iv) Reenrollment in the PDP. Copyright document.write(new Date().getFullYear()) 15, 2010; 76 FR 21570, Apr. 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. 1302, 1306, 1395w-101 through 1395w-152, and 1395hh). Basis of disenrollment for disruptive behavior. (a) General rule. TTY or TDD users should call 1-800-352-0778; or. The individual loses entitlement to Medicare. Having current eligibility in CMS systems. The PDP sponsor must document the enrollee's behavior, its own efforts to resolve any problems, as described in paragraph (d)(2)(iii) of this section, and any extenuating circumstances. (2) Notices for reasons specified in paragraphs (b)(1) through (b)(2)(i) and (b)(2)(iii) of this section must -, (i) Be provided to the individual before submission of the disenrollment notice to CMS; and. (ii) The PDP sponsor gives the enrollee notice of disenrollment that meets the requirements set forth in paragraph (c) of this section. 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). Comments or questions about document content can not be answered by OFR staff. (3) Extension of grace period for good cause and reinstatement. Please note, if you do choose to change your method, it may take up to three months for this change to take effect, and you will continue to be billed via the original method until your change takes effect. (vi) Extension of grace period for good cause and reinstatement. (iii) The PDP sponsor provides the individual with a grace period, that is, an opportunity to pay past due premiums in full. (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. 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. 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. (vi) The individual is not lawfully present in the United States. 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. 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. The PDP sponsor must submit this information and any documentation received by the individual to CMS. In general, enrollment is only allowed during the Annual Enrollment Period unless you recently became eligible for Medicare or qualify for a Special Enrollment Period. The Office of the Federal Register publishes documents on behalf of Federal agencies but does not have any authority over their programs. (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start': new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0], 423.44 Involuntary disenrollment from Part D coverage. You are leaving this website/app ("site"). Your Medigap issuer will remove the prescription drug coverage portion of your policy and adjust your premium. prescription drug plan (PDP) with a Medicare contract. (4) Notice of termination. (2) Orally or in writing, or by any action or inaction, request or encourage an individual to disenroll. (ii) The individual has engaged in disruptive behavior, as specified under paragraph (d)(2) of this section. The official, published CFR, is updated annually and available below under })(window,document,'script','dataLayer','GTM-WLTLTNW'); Wisconsin Physicians Service Insurance Corporation (WPS Health Insurance) is authorized by law to refuse to renew its contract with the Centers for Medicare and Medicaid Services (CMS). 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. Non-Discrimination Policy. (7) Misrepresentation of third-party reimbursement. The PDP sponsor must submit this information and any documentation received by the individual to CMS. (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. 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. The individual fails to pay any premiums or late enrollment penalty. Disenrollment is effective the first day of the month following notice by CMS that the individual is ineligible in accordance with 423.30(a)(1)(iii). S5753_PDPLP01_2110_M Last updated on 10/01/2021. The in-page Table of Contents is available only when multiple sections are being viewed. Is a U.S. citizen or lawfully present in the United States; and. You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party. (8) Individual is not lawfully present in the United States. A Special Enrollment Period is when a person, under certain circumstances, may enroll in, or disenroll from, a Medicare prescription drug plan other than during the Annual Enrollment Period. Electronic Code of Federal Regulations (e-CFR), CHAPTER IV - CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES, PART 423 - VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT. The PDP sponsor is required to provide a reasonable accommodation, as determined by CMS, for the individual in exceptional circumstances that CMS deems necessary. Calling 1-800-MEDICARE (1-800-633-4227). (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. (iv) Notification by CMS of incarceration. Individual is not lawfully present in the United States. Title 42 was last amended 7/11/2022. (3) Extension of grace period for good cause and reinstatement. One option is Adobe Reader which has a built-in screen reader. To see if you qualify for getting extra help, call: People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. (5) Individual no longer resides in the PDP service area - Basis for disenrollment. The following state regulations pages link to this page. (4) Death of the individual. (vii) Effective date of disenrollment. learn more about the process here. (iv) Documentation. (1) Optional involuntary disenrollment. CMS also may refuse to renew the contract. Termination or non-renewal of this contract may result in termination of the beneficiary's enrollment in the WPS MedicareRx Plan. (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. Health Care Service Corporation. 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. During the annual enrollment period, you may either join a stand-alone prescription drug plan or a health plan that also provides drug coverage. For all Part D - IRMAA amounts directly billed to an enrollee in accordance with 423.293(d)(2), the grace period ends with the last day of the third month after the billing month. (B) Begin on the first day of the month for which the premium is unpaid or the first day of the month following the date on which premium payment is requested, whichever is later. The PDP sponsor may request from CMS the ability to decline future enrollment by the individual. 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. A beneficiary's enrollment in the PDP may not be reinstated if the only basis for such reinstatement is a change in the individual's circumstances subsequent to the involuntary disenrollment for non-payment of premiums. Privacy Information | Eligibility, Enrollment, and Disenrollment | Appeals and Grievances | Fraud and Abuse, Espaol | Hmoob | | Deutsch | | | Ting Vit | Deitsch | | Franais | Polski | | Shqip | Tagalog | You may be able to get extra help to pay for your prescription drug premiums and costs. This new site may be offered by a vendor or an independent third party. This means that if you do not have outpatient prescription drug coverage that pays as well as, or better than, Medicare Part D, you may receive a penalty.. Customers may disenroll from a prescription drug plan during one of the election periods by doing the following: A prescription drug plan organization must disenroll an individual from a prescription drug plan in the following cases: "Disruptive behavior" is behavior that substantially impairs the prescription drug plan organization's ability to arrange or provide care to the disruptive individual or other plan customers. 70 FR 4525, Jan. 28, 2005, unless otherwise noted. (B) Begin on the first day of the month for which the premium is unpaid or the first day of the month following the date on which premium payment is requested, whichever is later. We have the right to pursue collection of the premiums you owe. If an individual is no longer eligible for Part D, CMS notifies the PDP that the disenrollment is effective the first day of the calendar month following the last month of Part D eligibility. 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? WPS MedicareRx Plan, offered by Wisconsin Physicians Service Insurance Corporation, is a (5) Individual no longer resides in the PDP service area - Basis for disenrollment. A change in residence, making the individual ineligible to be an enrollee of the prescription drug plan. If you think we have wrongfully ended your membership, you have a right to ask us to reconsider this decision by making a complaint. This content is from the eCFR and is authoritative but unofficial. 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. (iv) Notification by CMS of incarceration. (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. If you have comments or suggestions on how to improve the www.ecfr.gov website or have questions about using www.ecfr.gov, please choose the 'Website Feedback' button below. 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. 8 a.m.-8 p.m., weekdays (year-round) and weekends (Oct. 1March 31). At the time we end your membership, you may still owe us for premiums you have not paid. the individual responsible for the beneficiarys financial affairs) was unable to make timely payment due to circumstances over which you had no control and you could not reasonably have been expected to foresee. Where CMS has disenrolled an individual in accordance with paragraph (e)(1) of this section, the Part D plan sponsor must provide notice of termination in a form and manner determined by CMS. If the PDP sponsor has fulfilled the necessary requirements, CMS reviews the information and make a decision to approve or deny the request for disenrollment, including conditions on future enrollment, within 20 working days. 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. Enhanced content is provided to the user to provide additional context. (i) Definition. TTY/TDD users should call 1-877-486-2048, 24 hours a day, seven days a week. (iii) Effort to resolve the problem. (3) Loss of Part D eligiblity.
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