CMS Pub. 100-16, ch. mc86c17d, § 60.2.1

Disenrollment

(Rev. 38, 10-31-03)

The cost plan must submit a retroactive disenrollment request to CMS if an employer

group fails to provide timely notification of a Medicare beneficiary’s requested

disenrollment. The CMS may process disenrollments up to 90 days retroactively. The

employer group’s notification is untimely if it does not result in a disenrollment effective

for the month following the month the request is received, or for the requested effective

date (if later).

Evidence must demonstrate that the beneficiary acted to disenroll in a timely fashion (i.e.

prospectively), but the employer group was late in providing the information to the cost

plan. Such evidence may include an election or application form signed by the

beneficiary and given to the employer group during an open enrollment season. NOTE:

The application form could be the employer group’s generic form used during its open

enrollment season for all employees and retirees.