Page 47

46 | P a g e

30.6.28 – SEP for contract violations 42 CFR §§ 422.62(b)(3) and 423.38(c)(8)

This SEP is for individuals who demonstrate to CMS that their MAO or Part D plan sponsor substantially violated a material provision of the plan contract in relation to the individual or materially misrepresented the plan in communications with the individual. Such violations include, but are not limited to, an MAO or Part D sponsor: • Materially misrepresenting the plan when marketing the plan. • Failing to provide the individual, on a timely basis, medically necessary services, for which benefits are available under the plan. • Failing to provide medical services in accordance with applicable quality standards.

The SEP will begin once CMS determines that a violation has occurred. Its length will depend on whether the individual immediately elects a new plan. Upon request, the individual may choose to be immediately disenrolled from the plan and be defaulted to Original Medicare or they may choose to immediately elect a new plan. If the individual does not immediately elect a new plan after the CMS determination, they have 90 calendar days to make an election.

An individual may elect another MA or Part D plan for an effective date of the first day of the month after the month the new sponsor receives the completed enrollment request. The individual may also choose an effective date of enrollment in the new plan beginning any of the three months after the month in which the sponsor receives the completed enrollment request. However, the effective date may not be earlier than the date the sponsor receives the completed enrollment request.

NOTE: On a case-by-case basis, CMS may process a retroactive disenrollment using this SEP.

30.6.29 – SEP for individuals who disenroll in connection with CMS sanction 42 CFR §§ 422.62(b)(5) and 423.38(c)(12)

This SEP allows individuals enrolled in an MA or Part D plan offered by an MAO or a Part D plan sponsor that has been sanctioned by CMS to disenroll from that plan in connection with the matter(s) that gave rise to the sanction. The SEP begins with the imposition of the sanction and ends when the sanction ends or when the individual makes an election, whichever occurs first.

Consistent with the disclosure requirements at 42 CFR §§ 422.111(g) and 423.128(f), CMS may require the MAO or Part D plan sponsor to notify current enrollees that, if the enrollees believe they are affected by the matter(s) that gave rise to the sanction, the enrollees may be eligible for an SEP. Enrollees in an MA plan offered by a sanctioned MAO may use this SEP to elect another MA plan or disenroll to original Medicare and enroll in a PDP. Enrollees in a PDP offered by a sanctioned Part D sponsor may use this SEP to elect another PDP.

30.6.30 – SEP for individuals who receive a notification of a CMS or State-initiated enrollment action 42 CFR §§ 422.60(g)(5) and 423.38(c)(10)