D.C. Mun. Regs. tit. 29, r. 29-5702

Current through Register Vol. 71, No. 44, November 1, 2024

Rule 29-5702 - DISENROLLMENT

5702.1

A beneficiary in an eligibility group enrolled on a voluntary basis (as described in § 5701.2) shall have the right to disenroll from their D-SNP upon request, for the reasons described in § 5702.5 and pursuant to the requirements under 42 CFR § 438.56.

5702.2

A D-SNP may request that a beneficiary be disenrolled from participation in the D-SNP in accordance with the requirements set forth in its contract with the Department and this section.

5702.3

Except when a beneficiary's continued enrollment in the D-SNP seriously impairs the plan's ability to furnish services to either the particular beneficiary or other beneficiaries, a D-SNP may not request disenrollment because of:

(a) An adverse change in the beneficiary's health status;

(b) The beneficiary's utilization of services;

(c) The beneficiary's diminished mental capacity; or

(d) The beneficiary's uncooperative or disruptive behavior resulting from his or her special needs.

5702.4

Disenrollment, as described in § 5702.1, shall mean a beneficiary may elect to either receive services through the FFS delivery system or to switch enrollment to a different D-SNP of their choice.

5702.5

A beneficiary may disenroll from a D-SNP, as described in § 5702.1, for the following reasons:

(a) For cause, at any time, which shall include the following:

(1) The beneficiary moves out of the D-SNP's service area;

(2) The plan does not, because of moral or religious objections, cover the service the beneficiary seeks;

(3) The beneficiary needs related services (for example, a cesarean section and a tubal ligation) to be performed at the same time; not all related services are available within the provider network; and the beneficiary's primary care provider or another provider determines that receiving the services separately would subject the enrollee to unnecessary risk; or

(4) Other reasons, including poor quality of care, lack of access to services covered under the contract, or lack of access to providers experienced in dealing with the enrollee's care needs;

(b) Without cause, at the following times:

(1) At least once per calendar quarter and during special open enrollment periods, or during Medicare's annual open enrollment period, which shall be from October 15 through December 7 each year;

(2) When the Department imposes an intermediate sanction that suspends all new enrollment, including default enrollment, into a D-SNP, as described in 42 CFR § 438.702(a)(4); and

(3) During the ninety (90) days following the date of the beneficiary's initial enrollment, or during the ninety (90) days following the date the Department sends the beneficiary notice of that enrollment, whichever is later.

5702.6

The Department must approve or disapprove disenrollment no later than the first (1st) day of the second (2nd) month following the month in which the beneficiary requests disenrollment, the D-SNP refers the request to the Department, or the D-SNP requests disenrollment of the beneficiary. Upon approval of any disenrollment, the effective date of the disenrollment shall be the first (1st) day of the month following the month in which the beneficiary requests disenrollment, the D-SNP refers the request to the Department, or the D-SNP requests disenrollment of the beneficiary.

5702.7

If the Department fails to make the determination of whether the disenrollment is approved within the timeframes specified in § 5702.6, the disenrollment shall be considered approved for the effective date that would have been established had the Department complied with § 5702.6.

5702.8

A beneficiary who is dissatisfied with the Department's denial of the beneficiary's request for voluntary disenrollment shall be entitled to request a fair hearing in accordance with the requirements set forth under § 9508 of Title 29 DCMR.

D.C. Mun. Regs. tit. 29, r. 29-5702

Final Rulemaking published at 43 DCR 4833, 4857 (September 6, 1996); repealed by Final Rulemaking published at 69 DCR 2149 (3/18/2022); amended by Final Rulemaking published at 69 DCR 11758 (9/30/2022)