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70.6.1 – EGHP Retroactive Enrollments 42 CFR §§ 422.66(f), 422.308(f)(2), 423.32(i), and 423.343(a)

Retroactive EGHP enrollment transactions are based on the need to make the enrollment record consistent with the individual’s election decision or with the effective dates that are reflected in the regulation. These transactions may be submitted only for enrollment requests that were completed by an individual prior to the enrollment effective date but were delayed in being submitted by the employer or union to the MA or Part D plan. The effective date of EGHP enrollments may be retroactive up to, but may not exceed, 90 days (consistent with retroactive payment adjustments per §§ 422.308(f)(2) and 423.343(a)) from the date the organization received the request from the employer or union group.

Example: For EGHPs, an effective date of March 1, February 1, or January 1 would reflect 30, 60 and 90 days of retroactivity, respectively. Therefore, if a completed EGHP enrollment request was received by the MA or Part D organization on March 5, the retroactive effective date could be January 1, February 1, or March 1, as long as the enrollment request was completed prior to the respective effective date.

Retroactive enrollments may not be processed unless the individual certifies that the MA or Part D organization (or EGHP/union) provided them with the explanation of enrollee rights disclosure statement as specified in 42 CFR § 422.111 at the time of enrollment. Refer to the Medicare Advantage and Prescription Drug Plan Communications User Guide (PCUG) for more information.

70.6.2 – EGHP Retroactive Disenrollments 42 CFR §§ 422.66(f), 422.308(f)(2), 423.36(e), and 423.343(a)

The MA or Part D organization submits a retroactive disenrollment request to CMS (or the RPC) if an EGHP fails to provide the organization with timely notification of an individual’s requested disenrollment and action is needed to make the enrollment record consistent with the individual’s election decision or with the effective dates that are reflected in the regulation. The EGHP notification is considered untimely if it does not result in a disenrollment effective for the month following the month the request is received, or for the requested effective date (if later).

CMS may process disenrollments up to 90 days retroactively to conform to the adjustments in payment described under 42 CFR §§ 422.308(f)(2) and 423.343(a).

Similar to retroactive disenrollment for non-EGHPs, the plan must submit a disenrollment notice (i.e., documentation) to CMS (or the RPC) demonstrating that the individual acted to disenroll in a timely fashion (i.e., prospectively), but that the EGHP was late in providing the information to the MA or Part D organization (see § 70.5). Such documentation may include:

• An enrollment form for a different MA or Part D plan signed by the individual and given to the EGHP during an open enrollment season.