CMS Pub. 100-16, ch. mc86c17d, § 60.2

In general, CMS does not accept retroactive disenrollments. As discussed in §50.1.1 of

this chapter, voluntary disenrollment must be effective no later than the first day of the

month following receipt of the member’s written request for disenrollment, unless the

beneficiary requests a later date. If the beneficiary requests a later date, it can be no later

than the third month after the month in which CMS receives an acceptable disenrollment

request from the cost plan.

However, CMS may approve retroactive disenrollments for certain situations on a case-by-case basis. The plan should submit retroactive disenrollment requests, including

supporting evidence justifying the late disenrollment, to CMS. If CMS approves the cost

plan’s request for retroactive disenrollment, the plan must reimburse the member for any

premium paid for any month for which CMS processes a retroactive disenrollment.

The following are examples of situations where retroactive disenrollment may be

permissible. This list contains examples; it is not meant to be all-inclusive, nor does it

imply that retroactive disenrollment is assured for any circumstance:

• Systems Problems - If the beneficiary submits a proper disenrollment request,

but as a result of systems problems the disenrollment is not shown on a timely

basis in the cost plan’s and/or CMS’ records.

• Organizational Error - When the organization has not properly processed or

acted upon the member’s properly made disenrollment request. A disenrollment

request will be considered not properly processed or acted upon if the effective

date is a date other than as required in §50.1.1 of this chapter.

• Lack of Intent to Enroll - The cost plan must submit a retroactive disenrollment

request to CMS if there is evidence that the beneficiary did not intend to enroll in

the plan (e.g., the beneficiary did not realize he or she ever enrolled in a cost

plan).

Evidence that the beneficiary did not intend to enroll may include:

o Continuing supplemental (Medigap) insurance coverage after the effective

date of cost plan enrollment;

o Purchasing supplemental insurance immediately after enrolling in the

plan; or

o Making an inquiry to CMS questioning cost plan enrollment.

Payment of the plan’s premium does not necessarily indicate an informed

decision to enroll. The beneficiary may believe that he or she was purchasing a

supplemental health insurance policy. In addition, use of a plan doctor does not

necessarily indicate an understanding of the cost plan’s rules if the doctor also

treats non-cost plan members.