CMS-10352 Notification of Involuntary Disenrollment

[CMS Notice for Plan Use -- Notification of Involuntary Disenrollment by the
Centers for Medicare & Medicaid Services for Failure to Pay the Part D Income
Related Monthly Adjustment Amount]

Important – You have been disenrolled from your Medicare Prescription
Drug Plan

Dear < Member>:

As of , you have been disenrolled from because you didn’t pay the extra amount in addition to your monthly Medicare
prescription drug plan premium (called the Income-Related Monthly Adjustment Amount or
IRMAA). Before being disenrolled, you should have received notices from Medicare showing
the amount you owe and providing information on how to pay this amount. This decision was
made by Medicare, not by . If your plan premium was paid for any
month after , you’ll get a refund from us within 30 days of this
letter.
How to get your coverage back
You have the right to ask to get your coverage back, if you can do the following:
1. Show “good cause” (a good reason) for not paying the extra amount,
(For example, you were mentally or physically unable to pay the amounts you owe)
2. Pay the extra amounts you owe, and
3. Pay any plan premiums you owe to , if you owe any.
4. Call at for more information about how you can get your coverage back no later than
. TTY
users should call .
Who can I call to get more information?
Call 1-800-MEDICARE (1-800-633-4227) if you have questions about the decision to
disenroll you because you didn’t pay the extra amount. TTY users should call 1-877486-2048.
Call < Part D plan sponsor name > at if you have questions about your
plan’s premium. TTY users should call . We are open .
Please remember, if you miss the timeframe to request reinstatement, you will not get your
coverage back. If you do not get your coverage back and go without other coverage that is at
least as good as Medicare drug coverage (also referred to as “creditable coverage”), you may

have to pay a late enrollment penalty in addition to the monthly extra and plan premium amounts
if you enroll in Medicare prescription drug coverage in the future.

PRA Disclosure Statement
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collection is 0938-XXXX. The time required to complete this information collection is estimated to average 1
minute per response, including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.