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Chapter 10 - Ending your membership in the plan


Chapter 10 - Ending your membership in the plan




Section 1.1 - This chapter focuses on ending your membership in our plan

Ending your membership in KelseyCare Advantage Rx+Choice may be voluntary (your own choice) or involuntary (not your own choice):

  • You might leave our plan because you have decided that you want to leave.

    • There are only certain times during the year, or certain situations, when you may voluntarily end your membership in the plan. Section 2 tells you when you can end your membership in the plan.

    • The process for voluntarily ending your membership varies depending on what type of new coverage you are choosing. Section 3 tells you how to end your membership in each situation.
  • There are also limited situations where you do not choose to leave, but we are required to end your membership. Section 5 tells you about situations when we must end your membership.

If you are leaving our plan, you must continue to get your medical care through our plan until your membership ends.

You may end your membership in our plan only during certain times of the year, known as enrollment periods. All members have the opportunity to leave the plan during the Annual Enrollment Period and during the Medicare Advantage Open Enrollment Period. In certain situations, you may also be eligible to leave the plan at other times of the year.


Section 2.1 - You can end your membership during the Annual Enrollment Period

You can end your membership during the Annual Enrollment Period (also known as the "Annual Open Enrollment Period"). This is the time when you should review your health and drug coverage and make a decision about your coverage for the upcoming year.

  • When is the Annual Enrollment Period? This happens from October 15 to December 7.

    Note: If you’re in a drug management program, you may not be able to change plans. Chapter 5, Section 10 tells you more about drug management programs.

  • What type of plan can you switch to during the Annual Enrollment Period? You can choose to keep your current coverage or make changes to your coverage for the upcoming year. If you decide to change to a new plan, you can choose any of the following types of plans:

    • Another Medicare health plan. (You can choose a plan that covers prescription drugs or one that does not cover prescription drugs.)

    • Original Medicare with a separate Medicare prescription drug plan.

    • – or – Original Medicare without a separate Medicare prescription drug plan.

      • If you receive "Extra Help" from Medicare to pay for your prescription drugs: If you switch to Original Medicare and do not enroll in a separate Medicare prescription drug plan, Medicare may enroll you in a drug plan, unless you have opted out of automatic enrollment.

    Note: If you disenroll from Medicare prescription drug coverage and go without creditable prescription drug coverage, you may have to pay a Part D late enrollment penalty if you join a Medicare drug plan later. ("Creditable" coverage means the coverage is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.) See Chapter 1, Section 5 for more information about the late enrollment penalty.

  • When will your membership end? Your membership will end when your new plan’s coverage begins on January 1.

Section 2.2 - You can end your membership during the Medicare Advantage Open Enrollment Period

You have the opportunity to make one change to your health coverage during the Medicare Advantage Open Enrollment Period.

  • When is the annual Medicare Advantage Open Enrollment Period? This happens every year from January 1 to March 31.
  • What type of plan can you switch to during the annual Medicare Advantage Open Enrollment Period? During this time, you can:

    • Switch to another Medicare Advantage Plan. (You can choose a plan that covers prescription drugs or one that does not cover prescription drugs.)

    • Disenroll from our plan and obtain coverage through Original Medicare. If you choose to switch to Original Medicare during this period, you have until March 31 to join a separate Medicare prescription drug plan to add drug coverage.
  • When will your membership end? Your membership will end on the first day of the month after you enroll in a different Medicare Advantage plan or we get your request to switch to Original Medicare. If you also choose to enroll in a Medicare prescription drug plan, your membership in the drug plan will begin the first day of the month after the drug plan gets your enrollment request.

Section 2.3 - In certain situations, you can end your membership during a Special Enrollment Period

certain situations, members of KelseyCare Advantage Rx+Choice may be eligible to end their membership at other times of the year. This is known as a Special Enrollment Period.

  • Who is eligible for a Special Enrollment Period? If any of the following situations apply to you, you may be eligible to end your membership during a Special Enrollment Period. These are just examples, for the full list you can contact the plan, call Medicare, or visit the Medicare website (https://www.medicare.gov):

    • Usually, when you have moved.

    • If you have Medicaid.

    • If you are eligible for "Extra Help" with paying for your Medicare prescriptions.

    • If we violate our contract with you.

    • If you are getting care in an institution, such as a nursing home or long-term care (LTC) hospital.
  • When are Special Enrollment Periods? The enrollment periods vary depending on your situation.
  • What can you do? To find out if you are eligible for a Special Enrollment Period, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users call 1-877-486-2048. If you are eligible to end your membership because of a special situation, you can choose to change both your Medicare health coverage and prescription drug coverage. This means you can choose any of the following types of plans:

    • Another Medicare health plan. (You can choose a plan that covers prescription drugs or one that does not cover prescription drugs.)

    • Original Medicare with a separate Medicare prescription drug plan.

    • – or – Original Medicare without a separate Medicare prescription drug plan.

      • If you receive "Extra Help" from Medicare to pay for your prescription drugs: If you switch to Original Medicare and do not enroll in a separate Medicare prescription drug plan, Medicare may enroll you in a drug plan, unless you have opted out of automatic enrollment.

    Note: If you disenroll from Medicare prescription drug coverage and go without creditable prescription drug coverage for a continuous period of 63 days or more, you may have to pay a Part D late enrollment penalty if you join a Medicare drug plan later. ("Creditable" coverage means the coverage is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.) See Chapter 1, Section 5 for more information about the late enrollment penalty.

  • When will your membership end? Your membership will usually end on the first day of the month after your request to change your plan is received.

Section 2.4 - Where can you get more information about when you can end your membership?

If you have any questions or would like more information on when you can end your membership:

  • You can call Member Services (phone numbers are printed on the back cover of this booklet).
  • You can find the information in the Medicare & You 2019 Handbook.

    • Everyone with Medicare receives a copy of Medicare & You each fall. Those new to Medicare receive it within a month after first signing up.

    • You can also download a copy from the Medicare website (https://www.medicare.gov). Or, you can order a printed copy by calling Medicare at the number below.
  • You can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

Section 3.1 - Usually, you end your membership by enrolling in another plan

Usually, to end your membership in our plan, you simply enroll in another Medicare plan during one of the enrollment periods (see Section 2 in this chapter for information about the enrollment periods). However, if you want to switch from our plan to Original Medicare without a Medicare prescription drug plan, you must ask to be disenrolled from our plan. There are two ways you can ask to be disenrolled:

  • You can make a request in writing to us. Contact Member Services if you need more information on how to do this (phone numbers are printed on the back cover of this booklet).
  • --or--You can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

Note: If you disenroll from Medicare prescription drug coverage and go without creditable prescription drug coverage for a continuous period of 63 days or more, you may have to pay a Part D late enrollment penalty if you join a Medicare drug plan later. ("Creditable" coverage means the coverage is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.) See Chapter 1, Section 5 for more information about the late enrollment penalty.

The table below explains how you should end your membership in our plan.

If you would like to switch from our plan to: This is what you should do:
  • Another Medicare health plan.
  • Enroll in the new Medicare health plan.

    You will automatically be disenrolled from KelseyCare Advantage Rx when your new plan’s coverage begins.
  • Original Medicare with a separate Medicare prescription drug plan.
  • Enroll in the new Medicare prescription drug plan.

    You will automatically be disenrolled from KelseyCare Advantage Rx when your new plan’s coverage begins.
  • Original Medicare without a separate Medicare prescription drug plan.

    • Note: If you disenroll from a Medicare prescription drug plan and go without creditable prescription drug coverage, you may have to pay a late enrollment penalty if you join a Medicare drug plan later. See Chapter 1, Section 5 for more information about the late enrollment penalty.
  • Send us a written request to disenroll. Contact Member Services if you need more information on how to do this (phone numbers are printed on the back cover of this booklet).
  • You can also contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week, and ask to be disenrolled. TTY users should call 1-877-486-2048.
  • You will be disenrolled from KelseyCare Advantage Rx when your coverage in Original Medicare begins.

Section 4.1 - Until your membership ends, you are still a member of our plan

If you leave KelseyCare Advantage Rx+Choice, it may take time before your membership ends and your new Medicare coverage goes into effect. (See Section 2 for information on when your new coverage begins.) During this time, you must continue to get your medical care and prescription drugs through our plan.

  • You should continue to use our network pharmacies to get your prescriptions filled until your membership in our plan ends. Usually, your prescription drugs are only covered if they are filled at a network pharmacy.
  • If you are hospitalized on the day that your membership ends, your hospital stay will usually be covered by our plan until you are discharged (even if you are discharged after your new health coverage begins).

Section 5.1 - When must we end your membership in the plan?

KelseyCare Advantage Rx+Choice must end your membership in the plan if any of the following happen:

  • If you no longer have Medicare Part A and Part B.
  • If you move out of our service area.
  • If you are away from our service area for more than six months.

    • If you move or take a long trip, you need to call Member Services to find out if the place you are moving or traveling to is in our plan’s area. (Phone numbers for Member Services are printed on the back cover of this booklet.)
  • If you become incarcerated (go to prison).
  • If you are not a United States citizen or lawfully present in the United States.
  • If you lie about or withhold information about other insurance you have that provides prescription drug coverage.
  • If you intentionally give us incorrect information when you are enrolling in our plan and that information affects your eligibility for our plan. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.)
  • If you continuously behave in a way that is disruptive and makes it difficult for us to provide medical care for you and other members of our plan. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.)
  • If you let someone else use your membership card to get medical care. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.)

    • If we end your membership because of this reason, Medicare may have your case investigated by the Inspector General.
  • If you do not pay the plan premiums for two (2) calendar months after you reach an account balance of $150.

    • We must notify you in writing that you have two (2) calendar months after you reach an account balance of $150 to pay the plan premium before we end your membership.
  • If you are required to pay the extra Part D amount because of your income and you do not pay it, Medicare will disenroll you from our plan and you will lose prescription drug coverage.

Where can you get more information?

If you have questions or would like more information on when we can end your membership:

  • You can call Member Services for more information (phone numbers are printed on the back cover of this booklet).

Section 5.2 - We cannot ask you to leave our plan for any reason related to your health

KelseyCare Advantage Rx+Choice is not allowed to ask you to leave our plan for any reason related to your health.

What should you do if this happens?

If you feel that you are being asked to leave our plan because of a health-related reason, you should call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may call 24 hours a day, 7 days a week.


Section 5.3 - You have the right to make a complaint if we end your membership in our plan

If we end your membership in our plan, we must tell you our reasons in writing for ending your membership. We must also explain how you can file a grievance or make a complaint about our decision to end your membership. You can look in Chapter 9, Section 10 for information about how to make a complaint.