Medicare Advantage and Prescription Drug Plans December 28 ...

Plan Communications User Guide Appendices, Version 6.3
Disenrollment
Reason Number
Disenrollment Reason Description
MARx
UI
AUTO-
DIS
PLAN
SUB’D
57 BENEFICIARY HOSPICE PERIOD RECEIVED N/A Y N/A
59 INVALID ENROLLMENT WITH HOSPICE N/A Y N/A
60
BENEFICIARY LIVES IN USA LESS THAN
183 DAYS A YEAR
N/A N/A N/A
61 LOSS OF PART D ELIGIBILITY N/A Y N/A
62
PART D DISENROLLMENT DUE TO FAILURE
TO PAY IRMAA
N/A Y N/A
63** MMP OPT-OUT AFTER ENROLLED Y Y Y
64** LOSS OF DEMONSTRATION ELIGIBILITY Y Y Y
88 CONVERSION N/A N/A N/A
90
ENROLLMENT CANCELLED DUE TO
BENEFICIARY MERGE
N/A Y N/A
91 FAILURE TO PAY PREMIUMS Y N/A Y
92 RELOCATION OUT OF PLAN SERVICE AREA Y N/A Y
93
LOST SPECIFIC PLAN ELIGIBILITY (SNP
ONLY)
Y N/A Y
99 OTHER (NOT SUPPLIED BY BENE) N/A N/A Y*
*Plan cannot submit 99; it is assigned as a default value by the system only.
**Only valid for MMP Disenrollments, Disenrollment Cancellations or Enrollment Cancellations.
December 28, 2012 I-110 Disenrollment Reason Codes