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I did not pay my plan premiums and was disenrolled from my Medicare Part D plan. What is the "good cause" that I must show to be reinstated in my plan?


In general, you must show that your failure to make timely premium payments was due to unique, unusual, or unexpected circumstances over which you had no control and could not reasonably have been expected to foresee - and such an event most likely will never occur again.

Before being disenrolled for non-payment of your premiums . . .
As a first step, if you receive a written notification that you have not paid your Medicare plan premium (or IRMAA payment), telephone your Medicare plan’s Member Services department immediately (the toll-free number is on your Member ID and most printed plan documents) and arrange to make the payments.  If you need more assistance, ask to speak with a Member Services supervisor or call a Medicare representative at 1-800-Medicare (1-800-633-4227).

After you have been disenrolled for non-payment of your premiums . . .
If you find that you have already been disenrolled from your Medicare plan, for failure to pay your monthly premiums, you can still contact your plan’s Member Services department within 60 days of the disenrollment and, if you can show “good cause” for why your Medicare plan premium was not paid, ask to pay the unpaid premiums and be reinstated in the plan (see the "Tip" below - and be sure to mention that you wish to show "good cause" for reinstatement).

Important:  You (or your authorized representative) must contact your Medicare plan within 60 days of the disenrollment effective date if you wish to be reinstated for "good cause".


What is considered "good cause"?

Good cause is when the disenrolled person has "an unusual or unexpected situation that prevented them from making arrangements to pay the premium timely" and this situation is unlikely to happen again.

As noted by the Centers for Medicare and Medicaid Services (CMS) in the Medicare Manuals:

"Generally, these circumstances constitute good cause:
  • A serious illness, institutionalization and/or hospitalization of the member or his or her authorized representative (i.e. the individual responsible for the member’s financial affairs), that lasted for a significant portion of the grace period for plan premium or Part D-IRMAA payment;

  • Prolonged illness that is not chronic in nature, a serious (unexpected) complication to a chronic condition or rapid deterioration of the health of the member, a spouse, another person living in the same household, person providing caregiver services to the member, or the member’s authorized representative (i.e., the individual responsible for the member’s financial affairs) that occurs during the grace period for the plan premium or Part D-IRMAA payment;

  • Recent death of a spouse, immediate family member, person living in the same household, or person providing caregiver services to the member, or the member’s authorized representative (i.e., the individual responsible for the member’s financial affairs);

  • Home was severely damaged by a fire, natural disaster or other unexpected event, such that the member or the member’s authorized representative was prevented from making arrangement for payment during the grace period for plan premium or Part D-IRMAA;

  • An extreme weather-related, public safety or other unforeseen event declared as a Federal or state level of emergency prevented premium payment at any point during the plan premium or Part D-IRMAA grace period. For example, the member’s bank or U.S. Post Office closes for a significant portion of the grace period; or

  • For disenrollments effectuated by CMS for failure to pay Part D-IRMAA, Federal government error (i.e., CMS, SSA or RRB) caused the payment to be incorrect or late, and the member was unaware of the error or unable to take action prior to the disenrollment effective date.
There may be situations in addition to those listed above that result in favorable good cause determinations. If an individual presents a circumstance which is not captured in the listed examples, it must meet the regulatory standards of being outside of the member’s control or unexpected such that the member could not have reasonably foreseen its occurrence, and this circumstance must be the cause for the non-payment of plan premiums or Part D-IRMAA. CMS expects non-listed circumstances will be rare." [emphasis added]


Tip:  You will need to ask for "Good Cause" reinstatement and clearly explain why your situation fits into the "Good Cause" exception.

As noted above "Good Cause" is an unforeseeable, emergency situation where you had no control over paying your premium and no time to arrange for premium payments.

Before speaking with your plan or a Medicare representative, please take some time to organize your thoughts about why you had "good cause" not to pay your plan premiums and, if you telephone your Medicare plan, choose your words carefully as you are only allowed to make one "good cause" reinstatement request in a 60-day period.

As noted by Medicare, "an individual requesting reinstatement indicates that he had no unusual or unexpected circumstance that caused the nonpayment of premiums and the plan determines that he does not qualify for his case to be reviewed under good cause. The plan is expected to clearly communicate that the individual’s request will not be reviewed because the situation does not meet the criteria (e.g., not unusual or unexpected). The individual remains disenrolled and may not make another request for good cause during the same 60-day period following the involuntary disenrollment."

Important:  If you telephone your Medicare plan's Member Services department (use the toll-free number found on your Member ID card) about being disenrolled from your Medicare plan for non-payment of your monthly premium, you will need to clearly ask the Medicare plan representative for "good cause" reinstated.


Are you also eligible for Medicaid or the Low-Income Subsidy?

If you are a Medicare beneficiary who is eligible for Medicaid or the Low-Income Subsidy or Medicare Part D Extra Help program please tell this to your Medicare plan.


What is NOT considered "Good Cause"?

Remember, just saying that you didn't receive a premium bill or notice because you moved and didn't inform your Medicare plan will not be considered the "good cause" necessary for reinstatement - even if you have repaid your past unpaid premiums.

For more guidance, the CMS Medicare Manual also provides:

"Examples of circumstances that do not constitute good cause include:
  • Allegation that bills or warning notices were not received due to unreported change of address, out of town for vacation, visiting out of town family, etc;

  • Authorized representative did not pay timely on member’s behalf;

  • Lack of understanding of the ramifications of not paying plan premiums or Part D-IRMAA;

  • Could not afford to pay premiums during the grace period [The inability to afford premiums or failure to make timely payment by a member or an authorized representative alone is not grounds for a favorable good cause determination and reinstatement.];

  • Need for prescription medicines or other plan services." [emphasis added]

Can I appeal a non-favorable "good cause" determination?

No.
   If your "good cause" request for reinstate into your Medicare plan for failure to pay your premiums is denied, you do not have the right to appeal the negative decision.  But, you can wait 60 days and make another "good cause" request or file a grievance against your plan.

As noted by the CMS Medicare manual: "good cause determinations are not coverage determinations related to coverage and, therefore, are not appealable.  (See 42 CFR 423, subpart M.)  An individual may not make more than one reinstatement request for good cause in the same 60-day period following disenrollment, including instances in which the initial request resulted in an unfavorable determination.  However, an individual has the right to file a grievance against the plan related to the involuntary disenrollment."


And remember ... "Good Cause" is not enough - you must repay your premiums (or IRMAA payment) - within a certain time!

Even if you have an acceptable good cause reason why you were not able to make your monthly premium payments or IRMAA payments - you will not be reinstated (or re-enrolled) into your Medicare Part D plan unless you also repay the unpaid premiums within the fixed time (for example, 3-months).

The CMS Medicare Manuals also state:

"Reinstatement for good cause, pursuant to 42 CFR § 423.44(d)(1)(vi), will occur when:

1. The individual requests reinstatement within 60 days of disenrollment effective date;

2. The individual has been determined to meet the criteria specified below (i.e., receives a favorable determination); and

3. (a) Within three (3) months of disenrollment for nonpayment of plan premiums, the individual pays in full the plan premiums owed at the time he or she was disenrolled; or (b) Within three (3) months of disenrollment for nonpayment of Part D-IRMAA, the individual pays in full the Part D-IRMAA amounts and any plan premiums owed at the time he or she was disenrolled."


A few more Medicare examples of "Good Cause" reinstatement - or not . . .

The appendix of the same CMS Medicare Manual also provided a few examples of favorable and unfavorable "good cause" determinations:

"Example A:  Mr. Smith is disenrolled for failure to pay plan premiums on April 1. Mr. Smith contacts the plan and makes his request for reinstatement on April 15 and receives a favorable good cause determination on April 23. The plan notifies Mr. Smith of the amount he owes by June 30 in order to be reinstated into the plan. Mr. Smith pays the amount due on June 15. Mr. Smith is reinstated into the plan.  (Note: If Mr. Smith did not pay his owed amount by June 30, he would not be reinstated.)

Example B: Mr. Smith is disenrolled by the plan for failure to pay plan premiums on July 1. Mr. Smith mails in his past due amounts to the plan on July 30. He contacts the plan and makes his request on August 10, and does not receive a favorable good cause determination. Mr. Smith may not be reinstated.

Example C: Mr. Smith is disenrolled by the plan for failure to pay plan premiums on November 1. Mr. Smith mails in his owed amounts to the plan on December 15, but does not contact the plan to request reinstatement. Thus, Mr. Smith does not have a favorable good cause determination, and he may not be reinstated.
...

The above examples apply for [Medicare Part D plan or Medicare Advantage plan] disenrollments for either failure to pay plan premiums or failure to pay Part D-IRMAA." [emphasis and formatting added] 


Additional examples of "good cause" considerations

Example of favorable good cause determination:  "Mr. Lieber was disenrolled on April 30, 2015 following a plan’s two month grace period.  He states that he was in a car accident in mid-February, was hospitalized for one month and then sent to an assisted living facility for rehabilitation for one month. He indicated that he wasn’t able to pay his bills during that time and didn’t have any family to assist him. Because Mr. Lieber’s situation was unexpected and he was hospitalized and institutionalized for a significant portion of the plan’s grace period, the plan issues a favorable good cause determination. The plan’s favorable determination is appropriate because: 1) The creditable statement was provided about a serious illness and that the member was hospitalized and institutionalized for significant portion of the plan’s grace period ; 2) The event (illness and hospitalization) was unexpected and out of the person’s control; and 3) It is reasonable to conclude that Mr. Lieber could not have paid or made arrangements to pay the owed premiums within the plan’s grace period as a result of the illness."


Example of unfavorable good cause determination:  Mr. Jones was disenrolled on May 31, 2015 following the plan’s two month grace period.  He states that he was unable to pay his plan premiums because he has End-Stage Renal Disease (ESRD) and goes to a facility for dialysis three times a week.  Mr. Jones states that he sometimes has difficulty keeping track of his monthly premium billing statements because of his frequent trips to the dialysis facility.  The plan issues an unfavorable good cause determination because Mr. Jones has a known health issue and his need for routine dialysis is not unexpected in any way.  While he has a chronic illness, he was receiving regular care to treat his condition, and it is reasonable to expect him, or someone acting on his behalf, to resolve the delinquency at some point during the plan’s grace period.  The plan’s unfavorable determination is appropriate because: 1) The credible statement provided was not one in which a chronic illness had newly developed serious complications which inhibited the ability to pay premiums timely; 2) The situation (chronic condition with no complications) did not render the individual without control over timely payment of his premiums; and 3) It is reasonable to expect that Mr. Jones could have paid or made arrangements to pay the owed amounts within the plan’s grace period.  Mr. Jones may not be reinstated for good cause.


Sources include

Medicare Prescription Drug Benefit Manual, Chapter 3 - Eligibility, Enrollment and Disenrollment, Section 60.2.4 - Reinstatements Based on a Determination of Good Cause for Failure to Pay Plan Premiums or Part D-IRMAA Timely (and Appendix 4 for examples), Updated: August 19, 2011, (Revised: November 16, 2011, August 7, 2012, August 30, 2013, August 30, 2014, July 6, 2015, September 1, 2015, September 14, 2015 & December 30, 2015, May 27, 2016, August 25, 2016, June 15, 2017 & July 31, 2018)))

Medicare Managed Care Manual, Chapter 2 - Medicare Advantage Enrollment and Disenrollment, Updated: August 19, 2011 (Revised: November 16, 2011, August 7, 2012, August 30, 2013,August 14, 2014, July 6, 2015, September 1, 2015, September 14, 2015, December 30, 2015, May 27, 2016, August 25, 2016,June 15, 2017 & July 31, 2018)

The Centers for Medicare and Medicaid Services, Good Cause Process and Operational Changes, Frequently Asked Questions,  March 9, 2016


Related Questions

What should I do if my Medicare Part D plan says that I haven't paid my monthly premiums and will be disenrolled from my drug plan.

Can I be disenrolled from my Medicare prescription drug plan if I refuse to pay my Part D IRMAA?





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