Ending Yur Membership in the Plan Yu must be eligible fr a valid disenrllment perid. Yur cverage will end the first day f the mnth after we receive yur request t disenrll. When can yu end yur membership in ur plan? Yu may end yur membership in ur plan nly during certain times f the year, knwn as enrllment perids. All members have the pprtunity t leave the plan during the Annual Enrllment Perid. In certain situatins, yu may als be eligible t leave the plan at ther times f the year. Usually, yu can end yur membership during the Annual Enrllment Perid. Yu can end yur membership during the Annual Enrllment Perid. This is the time when yu shuld review yur health and drug cverage and make a decisin abut yur cverage fr the upcming year. When is the Annual Enrllment Perid? This happens frm Octber 15 t December 7. What type f plan can yu switch t during the Annual Enrllment Perid? During this time, yu can review yur health cverage and yur prescriptin drug cverage. Yu can chse t keep yur current cverage r make changes t yur cverage fr the upcming year. If yu decide t change t a new plan, yu can chse any f the fllwing types f plans: Anther Medicare prescriptin drug plan. Original Medicare withut a separate Medicare prescriptin drug plan. If yu receive Extra Help frm Medicare t pay fr yur prescriptin drugs: If yu d nt enrll in a separate Medicare prescriptin drug plan, Medicare may enrll yu in a drug plan, unless yu have pted ut f autmatic enrllment. r A Medicare health plan. A Medicare health plan is a plan ffered by a private cmpany that cntracts with Medicare t prvide all f the Medicare Part A (Hspital) and Part B (Medical) benefits. Sme Medicare health plans als include Part D prescriptin drug cverage. If yu enrll in mst Medicare health plans, yu will be disenrlled frm ur plan when yur new plan s cverage begins. Hwever, if yu chse a Private Fee-fr-Service plan withut Part D drug cverage, a Medicare Medical Savings Accunt plan, r a Medicare Cst Plan, yu can enrll in that plan and keep ur plan fr yur drug cverage. If yu d nt want t keep ur plan, yu can chse t enrll in anther Medicare prescriptin drug plan r drp Medicare prescriptin drug cverage. Yur Rights & Respnsibilities Upn Disenrllment_PDP Y0012_MAWEB2019 1
Nte: If yu disenrll frm Medicare prescriptin drug cverage and g withut creditable prescriptin drug cverage, yu may need t pay a late enrllment penalty if yu jin a Medicare drug plan later. ( Creditable cverage means the cverage is expected t pay, n average, at least as much as Medicare s standard prescriptin drug cverage.) When will yur membership end? Yur membership will end when yur new plan s cverage begins n January 1. In certain situatins, yu may be eligible t end yur membership during a Special Enrllment Perid. Wh is eligible fr a Special Enrllment Perid? If any f the fllwing situatins apply t yu, yu are eligible t end yur membership during a Special Enrllment Perid. These are just examples. Fr the full list, yu can cntact the plan, call Medicare, r visit the Medicare website (http://www.medicare.gv): If yu have mved ut f yur plan s service area. If yu have Medicaid. If yu are eligible fr Extra Help with paying fr yur Medicare prescriptins. If we vilate ur cntract with yu. If yu are getting care in an institutin, such as a nursing hme r lng-term care (LTC) hspital. When are Special Enrllment Perids? Special Enrllment Perids vary depending n yur situatin. What can yu d? T find ut if yu are eligible fr a Special Enrllment Perid, please call Medicare at 1-800- MEDICARE (1-800-633-4227), 24 hurs a day, seven days a week. TTY users call 1-877-486-2048. If yu are eligible t end yur membership because f a special situatin, yu can chse t change bth yur Medicare health cverage and prescriptin drug cverage. This means yu can chse any f the fllwing types f plans: Anther Medicare prescriptin drug plan. Original Medicare withut a separate Medicare prescriptin drug plan. If yu receive Extra Help frm Medicare t pay fr yur prescriptin drugs: If yu switch t Original Medicare and d nt enrll in a separate Medicare prescriptin drug plan, Medicare may enrll yu in a drug plan, unless yu have pted ut f autmatic enrllment. r A Medicare health plan. A Medicare health plan is a plan ffered by a private cmpany that cntracts with Medicare t prvide all f the Medicare Part A (Hspital) and Part B (Medical) benefits. Sme Medicare health plans als include Part D prescriptin drug cverage. If yu enrll in mst Medicare health plans, yu will autmatically be disenrlled frm Yur Rights & Respnsibilities Upn Disenrllment_PDP Y0012_MAWEB2019 2
ur plan when yur new plan s cverage begins. Hwever, if yu chse a Private Feefr-Service plan withut Part D drug cverage, a Medicare Medical Savings Accunt plan, r a Medicare Cst Plan, yu can enrll in that plan and keep ur plan fr yur drug cverage. If yu d nt want t keep ur plan, yu can chse t enrll in anther Medicare prescriptin drug plan r drp Medicare prescriptin drug cverage. Nte: If yu disenrll frm Medicare prescriptin drug cverage and g withut creditable prescriptin drug cverage, yu may need t pay a late enrllment penalty if yu jin a Medicare drug plan later. ( Creditable cverage means the cverage is expected t pay, n average, at least as much as Medicare s standard prescriptin drug cverage.) When will yur membership end? Yur membership will end n the first day f the mnth after we receive yur request t change yur plan. Where Can Yu Get Mre Infrmatin Abut When Yu Can End Yur Membership? If yu have any questins r wuld like mre infrmatin n when yu can end yur membership: Yu can call Custmer Service at 1-888-645-6025. We are available 8 a.m. t 8 p.m., Eastern Time, Mnday thrugh Friday. Our autmated telephne system handles calls received after 8 p.m. and n Saturdays, Sundays, and hlidays. Frm Octber 1, 2018 t March 31, 2019, we are available 8 a.m. t 8 p.m., Eastern Time, seven days a week. TTY users shuld call 711. Calls t this number are free. Yu can find the infrmatin in the Medicare & Yu 2018 Handbk. Everyne with Medicare receives a cpy f Medicare & Yu each fall. Thse new t Medicare receive it within a mnth after first signing up. Yu can als dwnlad a cpy frm the Medicare website (http://www.medicare.gv). Or, yu can rder a printed cpy by calling Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hurs a day, seven days a week. TTY users shuld call 1-877-486-2048. Yu can cntact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hurs a day, 7 days a week. TTY users shuld call 1-877-486-2048. Hw D Yu End Yur Membership In Our Plan? Usually, t end yur membership in ur plan, yu simply enrll in anther Medicare plan during ne f the enrllment perids. Hwever, there are tw situatins in which yu will need t end yur membership in a different way: If yu want t switch frm ur plan t Original Medicare withut a Medicare prescriptin drug plan, yu must ask t be disenrlled frm ur plan. If yu jin a Private Fee-fr-Service plan withut prescriptin drug cverage, a Medicare Medical Savings Accunt Plan, r a Medicare Cst Plan, enrllment in the new plan will nt end yur membership in ur plan. In this case, yu can enrll in that plan and keep ur plan fr yur drug cverage. If yu d nt want t keep ur plan, yu can chse t enrll in anther Medicare prescriptin drug plan r ask t be disenrlled frm ur plan. Yur Rights & Respnsibilities Upn Disenrllment_PDP Y0012_MAWEB2019 3
If yu are in ne f these tw situatins and want t leave ur plan, there are tw ways yu can ask t be disenrlled: Yu can make a request in writing t us. Cntact Custmer Service if yu need mre infrmatin n hw t d this. --r--yu can cntact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hurs a day, seven days a week. TTY users shuld call 1-877-486-2048. Nte: If yu disenrll frm Medicare prescriptin drug cverage and g withut creditable prescriptin drug cverage, yu may need t pay a late enrllment penalty if yu jin a Medicare drug plan later. ( Creditable cverage means the cverage is expected t pay, n average, at least as much as Medicare s standard prescriptin drug cverage.) Until Yur Membership Ends, Yu Are Still a Member f Our Plan If yu leave ur plan, it may take time befre yur membership ends and yur new Medicare cverage ges int effect. During this time, yu must cntinue t get yur prescriptin drugs thrugh ur plan. Yu shuld cntinue t use ur netwrk pharmacies t get yur prescriptins filled until yur membership in ur plan ends. Usually, yur prescriptin drugs are nly cvered if they are filled at a netwrk pharmacy, including thrugh ur mail-rder pharmacy services. We Must End Yur Membership in Certain Situatins Our plan must end yur membership in the plan if any f the fllwing happens: If yu d nt stay cntinuusly enrlled in Medicare Part A r Part B (r bth). If yu mve ut f ur service area. If yu are away frm ur service area fr mre than 12 mnths. (If yu mve r take a lng trip, yu need t call Custmer Service t find ut if the place yu are mving r traveling t is in ur plan s area.) If yu becme incarcerated (g t prisn). If yu are nt a United States citizen r lawfully present in the United States. If yu lie abut r withhld infrmatin abut ther insurance yu have that prvides prescriptin drug cverage. If yu intentinally give us incrrect infrmatin when yu are enrlling in ur plan and that infrmatin affects yur eligibility fr ur plan. (We cannt make yu leave ur plan fr this reasn unless we get permissin frm Medicare first.) If yu cntinuusly behave in a way that is disruptive and makes it difficult fr us t prvide care fr yu and ther members f ur plan. (We cannt make yu leave ur plan fr this reasn unless we get permissin frm Medicare first.) If yu let smene else use yur membership card t get prescriptin drugs. (We cannt make yu leave ur plan fr this reasn unless we get permissin frm Medicare first. If we end yur membership because f this reasn, Medicare may have yur case investigated by the Yur Rights & Respnsibilities Upn Disenrllment_PDP Y0012_MAWEB2019 4
Inspectr General.) If yu d nt pay the plan premiums fr tw mnths. (We must ntify yu in writing that yu have tw mnths t pay the plan premium befre we end yur membership.) If yu are required t pay the extra Part D amunt because f yur incme and yu d nt pay it, Medicare will disenrll yu frm ur plan and yu will lse prescriptin drug cverage. Where can yu get mre infrmatin? If yu have questins r wuld like mre infrmatin n when we can end yur membership: Yu can call Custmer Service fr mre infrmatin. We are nt allwed t ask yu t leave ur plan fr any reasn related t yur health. What shuld yu d if this happens? If yu feel that yu are being asked t leave ur plan because f a health-related reasn, yu shuld call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users shuld call 1-877-486-2048. Yu may call 24 hurs a day, seven days a week. Yu have the right t make a cmplaint if we end yur membership in ur plan. If we end yur membership in ur plan, we must tell yu ur reasns in writing fr ending yur membership. We must als explain hw yu can make a cmplaint abut ur decisin t end yur membership. Call Custmer Service if yu have any questins r wuld like mre infrmatin n when we can end yur membership. Yur Rights & Respnsibilities Upn Disenrllment_PDP Y0012_MAWEB2019 5