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Following receipt of a CMS notification (via DTRR) of a disenrollment due to unlawful presence, CMS strongly suggests that the plan provide a notice (MA Exhibit 38; Part D Exhibit 37) to the individual within 10 calendar days of receipt of the DTRR regarding the loss of coverage. Involuntarily disenrolled individuals enrolled in an MA plan will be defaulted to Original Medicare.

The effective date for disenrollment based on not lawfully present status is the first of the month following notice by CMS that the individual is ineligible or the start date of ineligibility, whichever is later.

60.2.7 – Terminations/Non-renewals/Service Area Reduction 42 CFR §§ 422.62(b)(1), 422.74(b)(3), 422.74(d)(7), 422.506(a)(2), 422.508, 423.38(c)(6), 423.44(d)(6), 423.507(a)(2), and 423.508(c)

Plans are required to disenroll an individual if the plan’s contract is terminated, discontinued, or if the service area is reduced and the individual’s address is no longer within the plan’s approved service area or continuation area. Plans must give each affected enrollee the effective date of the plan termination, non-renewal, or service area reduction, and include a description of alternatives for obtaining benefits under the Medicare program. Required time frames for these notices are outlined in §§ 422.506–422.513 and §§ 423.507–423.509.

Individuals who are disenrolled under these provisions have an SEP, as described in § 30.6.10, to elect a different MA or Part D plan or Original Medicare.

Exception: When an MAO discontinues offering an MA plan in a portion of its service area, the MAO can also elect to offer an option to continue enrollment in an MA local plan in the same organization to enrollees affected by the MA plan service area reduction, provided that no other MA plans are available in the affected area at that time (refer to § 20.3.1 for additional information on continuation areas). The organization may require an enrollee who chooses to continue enrollment to agree to receive the full range of basic benefits (excluding emergency and urgently needed care) exclusively through facilities designated by the organization within the plan service area.

60.2.8 – Material Misrepresentation Regarding Third-Party Reimbursement – Part D only 42 CFR §§ 423.44(b)(2)(v) and 423.44(c)(7)

If CMS determines an individual materially misrepresents information about third-party reimbursement coverage to the sponsor of a Part D plan, CMS requires that the individual be disenrolled from the plan. Involuntary disenrollment for this reason requires CMS approval. The Part D sponsor must submit any information it has regarding the claim of material misrepresentation to its CMS account manager for review. Disenrollment for material misrepresentation is effective the first day of the calendar month after the month in which the plan gives the individual written notice of the disenrollment.