Medicare Advantage Eligibility

Involuntary Disenrollment for Medicare Advantage Plan

A client may be involuntarily disenrolled from Medicare Advantage Plan under the following conditions (which are described in the following sections):

Change in residence outside the plan’s service area or temporary absence for more than 6 consecutive months

The Eligibility Coordinator (EC) will document receipt of a verbal request for disenrollment and will document and stamp the date of receipt on written requests.

When an enrollee or legal representative contacts Community Health Plan with an address change that is outside the service area, the EC will determine the effective date of disenrollment and then mail to the enrollee a Disenrollment Due to Permanent Move letter. The EC will transmit a Disenrollment Transaction to CMS.

When Community Health Plan receives an enrollee’s address change from a source other than the enrollee or the enrollee's representative, the EC cannot disenroll until the enrollee or enrollee's representative has confirmed that this out-of-area move is permanent or that six months have passed. The EC will call the enrollee to verify the address change.

If the EC cannot contact the enrollee by a telephone call, the EC will mail the enrollee a Verification of Change in Address letter. If the EC does not receive a response to written attempts from the EC to confirm a permanent out-of-area move by the beginning of the sixth month after sending the letter, the EC will mail to the enrollee an Upcoming Disenrollment Due to Out of Area Over 6 Months letter. The EC will determine the disenrollment effective date and send a Disenrollment Transaction to CMS. When the reply is received from CMS, a Final Confirmation of Disenrollment Due to Out of Area for 6 Months letter will be sent to the enrollee.

Loss of entitlement to Washington State Medicaid

If an enrollee is in a Special Needs Plan and is no longer eligible with Medicaid, the EC will mail the enrollee a Disenrollment from the Special Needs Plan Due to Loss of Medicaid letter. However, the enrollee will be enrolled in the MA-PD plan and given the option of disenrolling or moving to the MA Only plan.

Loss of entitlement to Medicare Part A or loss of enrollment in Part B

When the EC receives a CMS Reply Listing that indicates an enrollee has lost Medicare Part A or Part B benefits, the EC will mail to the enrollee a Disenrollment Due to Loss of Part A or Part B Coverage letter. If an enrollee then contacts us regarding an erroneous disenrollment, the EC will use the Enrollment Reinstatement procedure.

Enrollee is deceased

When the EC receives a CMS Reply Listing that indicates an enrollee is deceased, the EC will mail a Disenrollment Due to Death letter to the estate of the enrollee. If an enrollee then contacts us regarding an erroneous disenrollment, the EC will use the Enrollment Reinstatement procedure.

Disruptive behavior

When the EC determines that an enrollee exhibits behavior that substantially impairs Community Health Plan’s ability to arrange or provide care to the disruptive individual or other plan enrollees, the EC will assess the situation. The EC will determine if the enrollee's behavior may be related to the use of medical services or diminished mental capacity. If it is not, the EC will try to resolve the issue with the enrollee and document his or her efforts. The EC will call the Regional Office to discuss the issue with the CMS Plan Manager. If the CMS Plan Manager advises Community Health Plan to proceed with disenrolling the enrollee, the EC will mail to the enrollee a Warning of Potential Disenrollment Due to Disruptive Behavior letter and will work to resolve the issues and document all efforts to do so.

If the disruptive behavior does not end after the EC sends the letter, the EC will mail the enrollee an Intent to Disenroll letter. Then, the EC will send a disenrollment request to CMS with all of the required documentation about the disruptive behavior. Within 20 business days of receiving the documentation, CMS will decide to approve or deny the disenrollment request and CMS will notify Community Health Plan of the decision to approve or deny the disenrollment request.

If the Disenrollment request was denied by CMS, we will send a letter to the enrollee and enrollment will continue.

If the Disenrollment request was approved by CMS, the EC will determine the effective date of disenrollment and mail to the enrollee a Disenrollment for Disruptive Behavior letter. We will then transmit a Disenrollment Transaction to CMS.

Fraud and abuse

Examples of fraud and abuse are when an enrollee:

  • Submits fraudulent information on an enrollment form; or
  • Allows another person to use his or her enrollment card to obtain services or a prescription drug.

When Community Health Plan receives information that an enrollee has committed fraud and abuse, the EC will call the Regional Office to discuss the issue with the CMS Plan Manager. If the CMS Plan Manager advises Community Health Plan should disenroll the enrollee, the EC will determine the effective date of disenrollment and send a Disenrollment for Fraud and Abuse letter to the enrollee. The EC will then send a Disenrollment Transaction to CMS. At this time the EC will send all supporting documentation to the Inspector General in the CMS Regional Office, and to Community Health Plan’s Compliance Officer.

Contract termination

If Community Health Plan determines not to renew its contract with CMS, the EC will mail to the enrollee a Contract Non-Renewal letter at least 90 calendar days before the effective date of the nonrenewal.

If Community Health Plan receives a contract termination from CMS, the EC will mail to the enrollee a Contract Termination by CMS letter at least 30 calendar days before the effective date of termination.

If we receive a contract termination from CMS for immediate termination, the EC will mail a notice of termination to the affected enrollees. CMS establishes the special election period that will be used in the notice of termination.

If Community Health Plan terminates the contract with CMS due to CMS substantially not carrying out the terms of its contract, enrollees will be sent the Contract Termination by Community Health Plan letter 60 days prior to the effective date of termination.

Involuntary Disenrollment Documents: