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If the disruptive behavior ceases after the individual receives the advance notice and then later resumes, the plan must begin the process again. The dated copy of the advance notice sent to the individual must be provided to CMS for documentation purposes and to establish that the plan complied with 42 CFR §§ 422.74(d)(2)(iii) and 423.44(d)(2)(iii).

CMS’ Review of the Proposed Disenrollment A plan submits disenrollment requests to its CMS Account Manager. Involuntary disenrollment requests should include all information that fulfills the requirements listed in this section, as the plan bears the burden of providing the information necessary to substantiate its request. CMS will review this documentation, consulting with the appropriate clinical staff and then decide whether the plan may involuntarily disenroll the individual. CMS will not review incomplete requests that do not include all of the information described in this section.

CMS will make the decision within 20 business days after it receives all required information and will notify the plan within five business days after making its decision.

The CMS account manager will obtain CMS Central Office concurrence before approving an involuntary disenrollment. The disenrollment is effective the first day of the calendar month after the month in which the plan gives the individual a written notice of the disenrollment, or as provided by CMS.

If the request for involuntary disenrollment for disruptive behavior is approved, CMS may require the plan to provide reasonable accommodations to the individual in such exceptional circumstances that CMS deems necessary. An example of a reasonable accommodation in this context is that CMS could require the plan to delay the effective date of involuntary disenrollment to coordinate with an MA or Part D enrollment period that would provide the individual an opportunity to obtain other coverage. If necessary, CMS will establish an SEP on a case-by-case basis.

Disenrollment Notice After CMS notifies the plan of its approval of the disenrollment, the plan must provide the individual with a written notice that contains information stating the disenrollment was a result of the repeated behavior included in the Advance Notice. The written notice must include a statement that this disenrollment action was approved by CMS and meets the requirements for disenrollment due to disruptive behavior.

The plan can submit the disenrollment transaction to CMS after providing the disenrollment notice to the individual. The disenrollment is effective the first day of the calendar month after the month in which the plan gives the individual a written notice of the disenrollment, or as provided by CMS.

NOTE: For incidents of physical violence or threats of harm, the plan should engage local law enforcement to address the situation.

Any disenrollment processed for an MA enrollee under these provisions will always result in a change of enrollment to Original Medicare.