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CMS recognizes that in many instances, plans request disenrollment after a pattern of disruptive behavior emerges. Under federal law, a serious effort to resolve the individual’s issues means that the plan is expected to:

• Work with the individual to address concerns, seek solutions to meet the individual’s needs, and continue to provide services to the individual; • Provide a reasonable amount of time for the individual to demonstrate the ability to act appropriately, with efforts taken prior to submitting any requests for involuntary disenrollment to CMS; • Inform the individual of their inappropriate behavior and consequences of this behavior in writing at the time such behavior occurs, including the member’s right to file a grievance so that the individual is provided fair notice of the behavior to correct; and • Determine on a case-by-case basis if a reasonable amount of time has passed for the individual to show improvement prior to submitting a request for involuntary disenrollment. Generally, this should be based on the frequency of receipt of services, the frequency of the continued inappropriate behavior, and the severity of the continued action.

CMS reviews and approves all involuntary disenrollment requests for disruptive behavior on a case-by-case basis considering all of the facts and circumstances. Plans must submit documentation of the specific case to CMS for review. The plan’s request for involuntary disenrollment for disruptive behavior should include:

• Specifics of the disruptive behavior, including dates, locations, and actions; • Explanation of how the individual’s disruptive behavior has impacted the plan’s ability to arrange for or provide services to the individual or other enrollees of the plan; • Enrollee information, including diagnosis, mental status, functional status, and any other relevant information related to the individual’s condition or ability to access services (e.g., unable to transport oneself to provider facilities, etc.); • Statements and supporting documentation of the plan’s serious efforts to resolve the problem with the individual; and • Statements and supporting documentation that the plan provided the individual with appropriate notice of the inappropriate behavior, the consequences of the continued disruptive behavior, and the rights for the member to file a grievance. • Statements of the plan’s effort to provide reasonable accommodations for enrollees with disabilities in accordance with the Americans with Disabilities Act (if applicable); • Any written statements (email or letter) from the plan or providers describing their experiences with the individual (and refusal to see or treat the individual) and a description of any extenuating circumstances cited under 42 CFR §§ 422.74(d)(2)(iii) and (iv) or 423.44(d)(2)(iii) and (iv); • Any information provided by the individual related to the behavior that demonstrates their issues with the plan (e.g., complaints, statements).

Advance Notice The Advance Notice notifies the individual of the adverse impact of their behavior and provides the individual an opportunity to cease the inappropriate behavior and remain enrolled in the plan.