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There may be situations in addition to those listed above that result in a favorable good cause determination. If an individual presents a circumstance which is not captured in the listed examples, it must meet standards at §§ 422.74(d)(1)(v)(C) and/or 423.44(d)(1)(vi) and (e) of being outside of the individual’s control or unexpected such that the individual could not have reasonably foreseen its occurrence, and this circumstance must be the cause for the nonpayment of plan premiums or Part D-IRMAA. CMS expects circumstances constituting good cause to be rare.

Examples of circumstances that do not constitute good cause include:

• Allegation that bills or warning notices were not received due to unreported change of address or because the individual was out of town for personal non/emergency reasons, such as a vacation; • Authorized representative did not pay timely on the individual’s behalf; • Lack of understanding of the ramifications of not paying plan premiums or Part D- IRMAA; • Could not afford to pay premiums during the grace period; or • Need for prescription medicines or other plan services.

For examples of cases for favorable and unfavorable good cause determinations, see Appendix 4.

For the purpose of determining good cause for enrollees with authorized representatives, the criteria for both favorable and unfavorable determinations apply as though the authorized representative is the enrollee.

In addition, good cause determinations are not organization determinations related to coverage and, therefore, are not appealable, see 42 CFR §§ 422 and 423, subpart M. However, an individual has the right to file a grievance against the plan related to the involuntary disenrollment.

NOTE: Requests for reinstatement for good cause related to nonpayment of plan premiums and/or Part D-IRMAA are not considered complaints against the plan; therefore, these types of Complaint Tracking Module (CTM) cases are excluded from tracking for the purposes of plan ratings.

70.3.5.1 – Process for Good Cause Determinations for Nonpayment of Plan Premiums

Pursuant to 42 CFR §§ 422.74(d)(1)(v) and/or 423.44(d)(1)(vi), plans process good cause determinations for failure to pay premiums.

When an individual initially contacts the plan following disenrollment for failure to pay plan premiums and indicates that they “have a good reason for not having paid the premiums”, the plan must: