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Once an individual is disenrolled for failure to pay premiums: • Plan can decline re-enrollment in the plan until payment of any outstanding past due premiums is received. • Re-enrollment or enrollment in another plan must be requested during a valid election period.

Payment of past due premiums after the disenrollment date does not create an opportunity for reinstatement into the plan from which the individual was disenrolled for failure to pay premiums, except that CMS (or an entity acting on behalf of CMS) may reinstate enrollment, without interruption of coverage, if the individual demonstrates good cause and pays all of the overdue premiums within three calendar months of the disenrollment date. For more information on good cause, see § 70.3.5. Likewise, disenrollment for failure to pay premiums does not, in itself, provide the individual an SEP to enroll in a different plan.

60.3.2 – Disruptive Behavior 42 CFR §§ 422.74(d)(2), 422.74(e)(1), 423.44(b)(1)(ii), and 423.44(d)(2)

A plan may request to disenroll an individual whose behavior is disruptive. Per §§ 422.74(d)(2) and 423.44(d)(2), an enrollee is disruptive if the enrollee’s behavior substantially impairs the plan’s ability to arrange or provide for services to the individual or other plan enrollees. Circumstances that may constitute or provide evidence of disruptive behavior include:

• Contracted providers of the plan in which the individual is enrolled refuse to see or treat the individual due to their behavior or actions; • Incidents of physical violence or threats of harm that significantly impair the plan’s ability to provide services to the individual or other enrollees; • Abusive, inappropriate, or obscene language that is accompanied by an act of violence, by a threat of harm or perceived as a threat of harm by a provider, other patient, or plan employee; and • Inappropriate conduct.

Circumstances that do not constitute disruptive behavior that may substantially impair the plan’s ability to provide care include, but are not limited to:

• An individual exercising their right to pursue alternate treatment, to ignore medical advice, or to refuse a treatment regimen or diagnostic testing, even if the plan or provider disagrees with the individual’s choice; • An individual’s behavior that can be attributed to a medical or mental health condition for which they are receiving services; • Frequent calls to the plan.

The plan may disenroll an individual for disruptive behavior only after it has met the requirements of 42 CFR §§ 422.74(d)(2) and 423.44(d)(2) and has CMS’ approval. Before requesting CMS’ approval of disenrollment for disruptive behavior, the plan must make a serious effort to resolve the problems presented by the individual.