In which situation may the Medicare Advantage organization disenroll a member from an MA plan?

In which situation may the Medicare Advantage organization disenroll a member from an MA plan?

• A. Premiums are not paid on a timely basis
• B. The member relocates outside the service area
• C. The member asks to enroll in a different plan during open enrollment
• D. The MA plan changes its network rules

Answer: (A)

The situation being tested is when a Medicare Advantage organization can terminate a member’s enrollment. The key point is that ongoing premium payment is a condition of remaining enrolled in an MA plan. If the member’s monthly premium is not paid on time, the MA plan has the authority to disenroll the member after providing any required notices and opportunity to cure the nonpayment. This is a standard, allowed reason for disenrollment because it directly affects the plan’s ability to fund benefits and meet its contractual obligations with CMS. Relocating outside the service area, enrolling in a different plan during open enrollment, or changes to the plan’s network rules involve other circumstances that either remove the member from the plan by loss of eligibility (in the case of moving out of the service area) or are initiated by the member or arise from plan term changes, rather than being the plan’s unilateral action to disenroll for nonpayment. Therefore, the situation that fits the concept of the plan disenrolling a member is nonpayment of premiums on a timely basis.

The situation being tested is when a Medicare Advantage organization can terminate a member’s enrollment. The key point is that ongoing premium payment is a condition of remaining enrolled in an MA plan. If the member’s monthly premium is not paid on time, the MA plan has the authority to disenroll the member after providing any required notices and opportunity to cure the nonpayment. This is a standard, allowed reason for disenrollment because it directly affects the plan’s ability to fund benefits and meet its contractual obligations with CMS.

Relocating outside the service area, enrolling in a different plan during open enrollment, or changes to the plan’s network rules involve other circumstances that either remove the member from the plan by loss of eligibility (in the case of moving out of the service area) or are initiated by the member or arise from plan term changes, rather than being the plan’s unilateral action to disenroll for nonpayment. Therefore, the situation that fits the concept of the plan disenrolling a member is nonpayment of premiums on a timely basis.