US · guidance
CMS Pub. 100-16, ch. mc86c17d, § 50.3.3
Disenrollment for Cause
A cost plan has the right to initiate procedures to disenroll a Medicare member if his/her
behavior is disruptive, unruly, abusive, or uncooperative to the point that his or her
continuing membership seriously impairs the ability to furnish services to either him/her
or other members. The cost plan must ascertain that the enrollee’s behavior is not related
to the use of medical services or to mental illness. The cost plan may not initiate
disenrollment because the beneficiary exercises his or her option to make treatment
decisions with which the cost plan disagrees, e.g. refuses aggressive treatment for cancer.
Before beginning the disenrollment for cause process, the plan must make a serious effort
to resolve the problem presented by the member. It must inform the member that his/her
continued behavior may result in termination of membership in the organization. If the
problem cannot be resolved, the plan must give the member written notice of its intent to
request disenrollment for cause. In this notice, explain the member’s right to a hearing
under the organization’s grievance procedures.
History
(Rev. 38, 10-31-03)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
10645de6dfb7bf250d505b8403d073972122824d3c2f4a821ca63d4357e31e1e
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