Can a Part D plan disenroll a member for disruptive behavior?
Yes, but only after CMS approves the disenrollment and the plan has gone through a required process of notices and documented efforts to resolve the behavior first. A member cannot be considered disruptive if the behavior relates to use of medical services or compliance/noncompliance with medical advice or treatment.
What the rule says
Definition and requirement for CMS approval:
“A PDP enrollee is disruptive if his or her behavior substantially impairs the plans ability to arrange or provide for services to the individual or other plan members.”
“An individual cannot be considered disruptive if the behavior is related to the use of medical services or compliance (or noncompliance) with medical advice or treatment.”
“A PDP may disenroll an individual whose behavior is disruptive as defined in § 423.44(d)(2)(i) only after the PDP sponsor meets the requirements described in this section and after CMS has reviewed and approved the request.”
Effort to resolve required first:
“The PDP sponsor must make a serious effort to resolve the problems presented by the individual, including providing reasonable accommodations, as determined by CMS, for individuals with mental or cognitive conditions, including mental illness, Alzheimer's disease, and developmental disabilities.”
Two required notices before CMS submission:
“The PDP sponsor must provide the individual two notices prior to submitting the request for disenrollment to CMS.”
“The sponsor must wait at least 30 days after sending the advance notice before sending the second notice, during which 30-day period the individual has the opportunity to cease their behavior.”
CMS review and timeline:
“CMS reviews the information and make a decision to approve or deny the request for disenrollment, including conditions on future enrollment, within 20 working days.”
Guidance confirms the standard (this guidance applies to enrollment requests received on or after January 1, 2027):
“The plan may disenroll an individual for disruptive behavior only after it has met the requirements of 42 CFR §§ 422.74(d)(2) and 423.44(d)(2) and has CMS' approval.”
Carrier and FMO rules are often stricter than CMS rules. This tool reports what CMS sources say and is not legal advice. Enrollment guidance shown is the CY 2027 version. Regulation text reflects the CY 2027 marketing rules, which apply to marketing beginning October 1, 2026.
This answer was generated by mapdbot from the sources listed below on October 2, 2026 and checked against them. Regulation text: eCFR as of 09/15/2026. It is for licensed insurance agents, is not legal advice, and does not cover carrier or FMO rules.