CMS model disenrollment form · CMS
Request to disenroll from a Medicare Advantage or Part D plan and return to Original Medicare. Available during applicable enrollment periods.
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Medicare.gov
https://www.medicare.gov/plan-compare/Enroll in Original Medicare or switch plans during an eligible enrollment period.
Send written disenrollment request to your current MA plan
Mail to the address on the back of your plan membership card.
Contact your plan directly or visit your local SSA office
Filing Deadline
Annual Enrollment Period: Oct 15 - Dec 7. Medicare Advantage Open Enrollment: Jan 1 - Mar 31. Special Enrollment Periods may also apply.
Effective the first of the month after the plan processes the disenrollment. During AEP, coverage changes take effect January 1.
You will be returned to Original Medicare (Parts A and B). You should separately enroll in a standalone Part D plan if you want prescription drug coverage.
CMS-40B · CMS
Application for enrollment in Medicare Part B (medical insurance). Used during Initial Enrollment, General Enrollment, or Special Enrollment Periods.
CMS-L564 · CMS
Employer verification of group health plan coverage dates. Required alongside CMS-40B when using a Special Enrollment Period after employer coverage ends.
CMS-10797 · CMS
Application for Medicare Part A and Part B during a Special Enrollment Period for exceptional conditions such as natural disasters or employer misinformation.
CMS-10798 · CMS
Application for Part B immunosuppressive drug coverage for individuals who lose Part B but need ongoing immunosuppressive drug coverage after a kidney transplant.
Plan-specific (CMS model template) · CMS
Model enrollment form for Medicare Advantage or Part D prescription drug plans. Plans customize the CMS template but must include all required elements.
CMS-20027 · CMS
First-level appeal for Original Medicare (Part A/B) claim denials. Must be filed within 120 days of the initial determination.
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