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Favorable Determinations If the plan makes a favorable determination and there are past due premium amounts owed to the plan, the plan should notify the individual of this decision within three business days of making the determination. If the plan offers immediate payment options, such as payment by credit card via phone, it may provide the notification verbally; however, if the individual does not complete the payment at that time, the plan should issue a written notice to ensure that the individual has the information necessary to pay the owed amounts. This notice should include:

• Amount owed (i.e., the premiums owed at the time of disenrollment), • Date by which payment must be received for reinstatement (i.e., last day of the third month following the disenrollment effective date), • Where to send payment, and/or • All payment options available, such as credit card or direct withdrawal from a bank account, if offered by the plan.

If, at the time the plan makes a favorable determination, there are no amounts owed to the plan for past due premiums, the plan should notify the individual of this decision either verbally or in writing within three business days of making the determination. If verbal notification is attempted but unsuccessful, a written notice should be provided. Verbal notification must be documented by the plan to meet CMS’ RPC reinstatement submission requirements.

Reinstatements for good cause are considered complete when the plan receives a TRC 287 (Enrollment Reinstated) from CMS.

Plans have additional time beyond the deadline (i.e., three months from the disenrollment effective date) to verify payment by the bank and credit the payment to the individual’s account with the plan. To provide adequate protections for individuals who make timely payment of their owed amounts, plans have five calendar days beyond the payment deadline to process the payment and submit the reinstatement request to the CMS RPC.

An individual may not be reinstated in cases where:

• The individual pays all plan premiums owed but does not receive a favorable good cause determination. • The individual receives a favorable good cause determination but does not pay the plan premiums owed within three months of the disenrollment effective date.

In both of the circumstances above, the plan may re-enroll the individual for a prospective enrollment effective date at the individual’s request only if the individual has a valid election period (i.e., AEP, SEP, etc.)—see §§ 30 and 50.

Example 1: Mr. Smith is disenrolled for failure to pay plan premiums on April 1 (after the plan’s required grace period expired). Mr. Smith contacts the plan and makes his request for reinstatement on April 15 and receives a favorable good cause determination on April 23. On April 21, the plan notifies Mr. Smith of the amount that he must pay by June 30 in order to be reinstated