Disenrollment from a Medicare Advantage (Part C) or Medicare prescription drug (Part D) plan may occur automatically if you:
- Move your permanent residence out of the plan’s service area (including incarceration).
- Lose your entitlement to Medicare benefits under Part A and/or are no longer enrolled in Part B.
- Become deceased.
- Enroll in a different prescription drug plan. You will automatically be disenrolled from your previous plan (if it has prescription drug coverage).
You may also be disenrolled for “disruptive behavior.” Disruptive behavior is defined as behavior that substantially impairs Healthy Mississippi's ability to arrange or provide care for you or other plan members. Other Medicare prescription drug plan sponsors may decline your enrollment if you have been disenrolled for disruptive behavior.
In all cases of disenrollment, your plan is required to provide proper notice to you and give you the opportunity to appeal the decision prior to disenrollment.
Medicare Disenrollment Information
You can request disenrollment from your Medicare Advantage (Part C) plan or Medicare prescription drug (Part D) plan and switch to Original Medicare (Parts A and B) online or by mail/fax:
Medicare Advantage Plan Disenrollment
Disenrollment form (online/PDF) Medicare Advantage Plan Disenrollment. You can submit the request online or print the PDF. If printing the PDF, please complete in black/blue ink only and mail or fax it back to Healthy Mississippi using the directions on the form.
Medicare Advantage Prescription Drug Plan Disenrollment
Disenrollment form (online/PDF) Medicare Advantage Prescription Drug Plan Disenrollment. You can submit the request online or print the PDF. If printing the PDF, please complete in black/blue ink only and mail or fax it back to Healthy Mississippi using the directions on the form.
Contract Termination
Availability of coverage or service areas beyond the end of the current contract year is not guaranteed. Termination or non-renewal of the contract by Centers for Medicare & Medicaid Services (CMS) or Healthy Mississippi as authorized by law may end your enrollment in the plan. If this occurs, you will be able to choose another plan without incurring a late enrollment penalty, as long as you do it within the time period required.