Page 143

142 | P a g e

o Other limited exceptional conditions established by CMS (e.g., fraudulent enrollment or misleading marketing practices).

CMS approves retroactive disenrollments on a case-by-case basis. When a valid request for disenrollment has not been communicated to CMS successfully within the required time frames in this guidance and the CCM transaction submission time frame, MA or Part D organizations are required to submit the appropriate documentation to CMS (or the RPC) for manual review and potential action. This documentation would include:

• A clear and detailed explanation supporting the requested correction, including a description of what the plan has communicated to the individual throughout the period in question; • Any relevant information or documentation supporting the requested correction such as a copy of the enrollment request (or evidence of the use of another enrollment mechanism).

Organizations must submit retroactive disenrollment requests to CMS (or the RPC) for review within the time frames provided in the SOP for the RPC and the CCM transaction submission time frame. If CMS approves a request for a retroactive disenrollment, the plan must return any premium paid by the individual for any month for which CMS processed a retroactive disenrollment. In addition, CMS will recoup any capitation payment for the retroactive period.

70.6 – Retroactive Transactions for Employer/Union Group Health Plan (EGHP) Enrollees 42 CFR §§ 422.60(f), 422.66(f), 423.32(i), and 423.36(e)

When an MA or Part D plan that has both a Medicare contract and a contract with an EGHP, the MAO or Part D sponsor may arrange for the employer or union to process enrollment requests for Medicare-entitled group members who wish to enroll in an MA or Part D plan. Retroactive transactions may be necessary and provided for under this section:

• If a delay exists between the time the individual completes the enrollment request through the EGHP and when the enrollment request is received by the plan; or

• Due to errors made by the EGHP, such as failing to forward a valid enrollment or disenrollment request within required time frames.

These transactions must be submitted to CMS (or the RPC) for review within the time frames provided in the SOP for the CMS RPC and the CCM transaction submission time frame.

NOTE: Repeated errors may indicate an ongoing problem and therefore will be forwarded to the plan’s CMS Account Manager for compliance monitoring purposes. The organization’s agreement with the EGHP should include the need to meet the requirements provided in this chapter that ensure the timely submission of enrollment and disenrollment requests to avoid such errors and reduce the need for retroactivity.