Disenrollment process

(a) General rule. An individual may disenroll from a PDP during the periods specified in § 423.38 by enrolling in a different PDP plan, submitting a disenrollment request to the PDP in the form and manner prescribed by CMS, or filing the appropriate disenrollment request through other mechanisms as determined by CMS.

(b) Responsibilities of the PDP sponsor. The PDP sponsor must—

(1) Submit a disenrollment notice to CMS within timeframes CMS specifies;

(2) Provide the enrollee with a notice of disenrollment as CMS determines and approves; and

(3) File and retain disenrollment requests for the period specified in CMS instructions.

(4) In the case of an incomplete disenrollment request—

(ii) Notify the individual (in writing or verbally) within 10 calendar days of receipt of the disenrollment request; and

(iii) The organization must deny the request if any additional information needed to make the disenrollment request “complete” is not received within the following timeframes:

(A) For disenrollment requests received during the AEP by December 7, or within 21 calendar days of the request for additional information, whichever is later; and

(B) For disenrollment requests received during all other election periods, by the end of the month in which the disenrollment request was initially received, or within 21 calendar days of the request for additional information, whichever is later.

(c) Retroactive disenrollment. CMS may grant retroactive disenrollment in the following cases:

(1) There never was a legally valid enrollment; or

(2) A valid request for disenrollment was properly made but not processed or acted upon.

(d) Incomplete disenrollment. A disenrollment request is considered to be incomplete if the required but missing information is not received by the PDP sponsor within the timeframe specified in paragraph (b)(4)(iii) of this section.

(e) Exception for employer group health plans. (1) In cases when a PDP sponsor has both a Medicare contract and a contract with an employer, and in which the PDP sponsor arranges for the employer to process election forms for Part D eligible group members who wish to disenroll from the Medicare contract, the effective date of the election may be retroactive. Consistent with § 423.343(a), payment adjustments based on a retroactive effective date may be made for up to a 90-day period.

(2) Upon receipt of the election from the employer, the PDP sponsor must submit the disenrollment to CMS within timeframes specified by CMS.

(f) Effect of failure to submit disenrollment notice to CMS promptly. If the PDP sponsor fails to submit the correct and complete notice required in paragraph (b)(1) of this section, the PDP sponsor must reimburse CMS for any capitation payments received after the month in which payment would have ceased if the requirement had been met timely.

(g) Disenrollments requiring prior CMS approval—(1) CMS approval. Special Election Periods specified in paragraph (g)(2) of this section require CMS approval before an individual can use the SEP to make a disenrollment election. CMS approval is provided for Part D disenrollments either through the use of a CMS-operated election mechanism or through the individual's receipt of a notice which explains eligibility for the SEP and election instructions. Part D plans may not transmit disenrollment elections to CMS using the specified SEPs without prior CMS approval.

(2) Special election periods. All of the following SEPs require CMS approval prior to use:

(i) SEP for individuals who were not adequately informed of a loss of creditable prescription drug coverage, § 423.38(c)(2).

(ii) SEP for contract violation, § 423.38(c)(8).

(iii) SEP for individuals who disenroll in connection with CMS sanction, § 423.38(c)(12).

(iv) SEP for other exceptional circumstances, § 423.38(c)(36).