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60.3.3 – Fraud and Abuse 42 CFR §§ 422.74(d)(3) and 423.44(b)(2)(v)

A plan may request to cancel the enrollment of an individual who knowingly provides, on the enrollment request form or by another enrollment request mechanism, fraudulent information that affects the determination of the individual’s eligibility to enroll in the plan. The plan may also request to disenroll an individual who intentionally permits others to use their enrollment card to obtain services or supplies from the plan or any authorized plan provider.

Plans must provide the individual with a written notice of the disenrollment. This disenrollment is effective the first day of the calendar month after the plan provides the individual with the written notice. When such a cancellation or disenrollment occurs, the plan must immediately notify the CMS RO so the Office of the Inspector General may initiate an investigation of the alleged fraud and abuse.

NOTE: Any disenrollment processed for MA enrollees under these provisions will always result in a change of enrollment to Original Medicare.

60.4 – Disenrollment Procedures for Medicare MSA Plans 42 CFR §§ 422.62(d)(2), 422.74(b)(2)(vi), 422.74(d)(10), 422.74(e)(1)

Enrollees of Medicare MSA plans may only disenroll in writing through the MAO offering the Medicare MSA plan. Disenrollment through 1-800-MEDICARE is not accepted. MAOs offering Medicare MSA plans must otherwise follow the disenrollment policies and procedures outlined in this chapter.

Election periods and effective dates for disenrollment from Medicare MSA plans are outlined in § 30.9.

If an enrollee of a Medicare MSA plan no longer meets the MA MSA’s eligibility criteria due to a mid-year change in eligibility, they must be disenrolled. The disenrollment is effective the first day of the calendar month following the MAO’s notice to the individual that they are ineligible.

The plan must provide the individual with a written notice of the disenrollment with an explanation of why the MAO is planning to disenroll the individual. This notice must be provided to the individual before submission of the disenrollment to CMS. The notice must include an explanation of the individual’s right to submit a grievance under the MAO’s grievance procedures.

Any disenrollment processed for an MA enrollee due to loss of eligibility will always result in a change of enrollment to Original Medicare.