Medicare Advantage and Prescription Drug Plans December 28 ...

Plan Communications User Guide Appendices, Version 6.3
I.9 Disenrollment Reason Codes
Table I-7 lists the reason codes for Disenrollment.
Table I-7: Disenrollment Reason Code Table
Disenrollment
Reason Number
Disenrollment Reason Description
MARx
UI
AUTO-
DIS
PLAN
SUB’D
1 FAILURE TO PAY PREMIUMS N/A N/A N/A
2
3
RELOCATION OUT OF PLAN SERVICE AREA
(NO SPECIAL PROVISIONS)
FAILURE TO CONVERT TO RISK
PROVISIONS
N/A N/A N/A
N/A N/A N/A
4 FRAUD N/A N/A N/A
5 LOSS OF PART B ENTITLEMENT N/A Y N/A
6
LOSS OF PART A ENTITLEMENT (PLAN-
SPECIFIC)
N/A Y N/A
7 FOR CAUSE Y N/A N/A
8 REPORT OF DEATH N/A Y N/A
9
10
11
12
13
TERMINATION OF CONTRACT (CMS-
INITIATED)
TERMINATION OF
CONTRACT/PBP/SEGMENT (PLAN
WITHDRAWAL)
VOLUNTARY DISENROLLMENT THROUGH
PLAN
VOLUNTARY DISENROLLMENT THROUGH
DISTRICT OFFICE
DISENROLLMENT BECAUSE OF
ENROLLMENT IN ANOTHER PLAN
N/A Y N/A
N/A Y N/A
Y N/A Y
N/A N/A N/A
N/A Y N/A
14 RETROACTIVE N/A N/A N/A
15 TERMINATED IN ERROR BY CMS SYSTEM N/A N/A N/A
16
17
END OF SCC CONDITIONAL ENROLLMENT
PERIOD
BENE DOES NOT MEET AGE CRITERION
(PLAN-SPECIFIC)
N/A N/A N/A
N/A N/A N/A
18 ROLLOVER N/A Y N/A
19 TERMINATED BY SSA DISTRICT OFFICE N/A N/A N/A
20 INVALID ENROLLMENT WITH ESRD N/A Y N/A
21
22
23
CANNOT TRAVEL/POOR HEALTH/TO
HMO/PLAN DOCTORS
SPOUSE IS NO LONGER MEMBER OF
HMO/PLAN
COULDN'T USE MEDICARE CARD TO SEE
OTHER PLAN
N/A N/A N/A
N/A N/A N/A
N/A N/A N/A
December 28, 2012 I-108 Disenrollment Reason Codes