Form CMS-10309 Grandfather Non-Election Letter

Sample Letter to Beneficiary from Supplier that Chooses NOT to Grandfather
Our records show that our company, [insert supplier name], is currently furnishing you with
rented [insert name of equipment].
On January 1, 2011, Medicare started a new competitive bidding program for certain durable
medical equipment, prosthetics, orthotics, and supplies (DMEPOS) in your area. The current
competitive bidding program supplier contracts in your area will end on December 31, 2016. On
January 1, 2017, Medicare will start new contracts with suppliers for your area. Under this
program, people with Original Medicare in your area will almost always need to buy or rent
certain medical equipment and supplies from suppliers that contract directly with Medicare to
furnish these items. We won’t be a Medicare contract supplier under this program, so we won’t
be providing [insert name of equipment] to people with Original Medicare starting January 1,
2017.
We will only continue to provide your [insert name of equipment] until [insert first
anniversary date after January 1, 2017]. After this date, you must get your equipment and
related accessories and supplies from a new Medicare contract supplier for [insert name of
equipment]. We will contact you ten (10) business days before picking up your equipment to
arrange for the equipment to be picked up and new equipment to be delivered by your new
Medicare contract supplier. We will coordinate the pick-up and the delivery of the equipment with
your new contract supplier to occur on the same day so there is no interruption in service. We
will contact you again two (2) business days before picking up your equipment to remind you of
the scheduled date and time.
Any new Medicare contract supplier for [insert name of equipment] for your area is required to
furnish your [insert name of equipment]. You need to contact a new Medicare contract supplier
for [insert name of equipment] as soon as possible to make arrangements for the new Medicare
contract supplier to begin furnishing you with [insert name of equipment] beginning on [insert
first anniversary date after January 1, 2017].
To find a new Medicare contract supplier, visit www.medicare.gov/supplier or call 1-800MEDICARE (1-800-633-4227) and have your ZIP code ready. TTY users should call 1-877-4862048.
If you have any questions, please contact us at [insert supplier phone number] or call 1-800MEDICARE (1-800-633-4227).

Exp. 2-29-2020