Annual Notice of Change (ANOC) and Evidence of Coverage (EOC)

<Plan name> MEMBER HANDBOOK

_Chapter 10: Ending your membership in our plan

Introduction

This chapter explains how you can end your membership with our plan and your health coverage options after you leave our plan. If you leave our plan, you’ll still be in the Medicare and <Medicaid program name> programs as long as you’re eligible. Key terms and their definitions appear in alphabetical order in the last chapter of this Member Handbook.

[Plans should edit this chapter as directed by the state to reflect Medicaid benefits such as if the plan can continue to provide Medicaid coverage when the member disenrolls from the Medicare plan or if the member is required to belong to a health plan to receive Medicaid benefits, etc.]

[Plans should refer to other parts of the Member Handbook using the appropriate chapter number and section. For example, "refer to Chapter 9, Section A." An instruction [insert reference, as applicable] appears with many cross references throughout the Member Handbook. Plans can always include additional references to other sections, chapters, and/or member materials when helpful to the reader.]

[Plans must update the Table of Contents to this document to accurately reflect where the information is found on each page after plan adds plan-customized information to this template.]

Table of Contents

A. When you can end your membership in our plan 2

B. How to end your membership in our plan 3

C. How to get Medicare and <Medicaid program name> services separately 3

C1. Your Medicare services 4

C2. Your <Medicaid program name> services 7

D. Your medical items, services and drugs until your membership in our plan ends 7

E. Other situations when your membership in our plan ends 8

F. Rules against asking you to leave our plan for any health-related reason 9

G. Your right to make a complaint if we end your membership in our plan 9

H. How to get more information about ending your plan membership 10

1. When you can end your membership in our plan

[States can modify this section for any differences in state disenrollment timeframes.]

Most people with Medicare can end their membership during certain times of the year. Since you have <Medicaid program name>, you have some choices to end your membership with our plan any month of the year.

In addition, you may end your membership in our plan during the following periods each year:

• The Open Enrollment Period, which lasts from October 15 to December 7. If you choose a new plan during this period, your membership in our plan ends on December 31 and your membership in the new plan starts on January 1.

• The Medicare Advantage (MA) Open Enrollment Period, which lasts from January 1 to March 31 and also for new Medicare beneficiaries who are enrolled in a plan, from the month of entitlement to Part A and Part B until the last day of the 3^rd month of entitlement. If you choose a new plan during this period, your membership in the new plan starts the first day of the next month.

There may be other situations when you’re eligible to make a change to your enrollment. For example, when:

• you move out of our service area,

• your eligibility for <Medicaid program name> or Extra Help changed, or

• if you recently moved into, currently are getting care in, or just moved out of a nursing facility or a long-term care hospital.

Your Medicare [delete Medicare if the end date is the same for Medicare and Medicaid] membership ends on the last day of the month that we get your request to change your plan. For example, if we get your request on January 18, your coverage with our plan ends on January 31. Your new coverage begins the first day of the next month (February 1, in this example). [If there’s a different end date for Medicaid coverage enter a description here.]

If you leave our plan, you can get information about your:

• Medicare options in the table in Section C1 [insert reference, as applicable].

• Medicaid services in Section C2 [insert reference, as applicable].

You can get more information about how you can end your membership by calling: [Insert any additional contact information as required by the state.]

• Member Services at the number at the bottom of this page. The number for TTY users is listed too.

• Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

• The State Health Insurance Assistance Program (SHIP), <State-specific SHIP name> at <phone number>. [TTY phone number is optional.]

[Optional language for inclusion by plans. NOTE: If you’re in a drug management program (DMP), you may not be able to change plans. Refer to Chapter 5 of this Member Handbook for information about drug management programs.]

2. How to end your membership in our plan

If you decide to end your membership you can enroll in another Medicare plan or switch to Original Medicare. However, if you want to switch from our plan to Original Medicare but you haven’t selected a separate Medicare 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 at the number at the bottom of this page if you need more information on how to do this.

• Call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users (people who have difficulty with hearing or speaking) should call 1-877-486-2048. When you call 1-800-MEDICARE, you can also enroll in another Medicare health or drug plan. More information on getting your Medicare services when you leave our plan is in the chart on page <page number>.

• [Insert if applicable: Call [insert name of state specific Medicaid program and contact information including TTY number]. Section C below includes steps that you can take to enroll in a different plan, which will also end your membership in our plan.]

3. How to get Medicare and <Medicaid program name> services separately

[Update this section as needed to include appropriate Medicaid information.] You have choices about getting your Medicare and Medicaid services if you choose to leave our plan.

C1. Your Medicare services

You have three options for getting your Medicare services listed below any month of the year. You have an additional option listed below during certain times of the year including the Open Enrollment Period and the Medicare Advantage Open Enrollment Period or other situations described in Section A. By choosing one of these options, you automatically end your membership in our plan.

1. You can change to: Another plan that provides your Medicare and most or all of your Medicaid benefits and services in one plan, also known as an integrated dual-eligible special needs plan (D-SNP) [insert the following if PACE offered in the state: or a Program of All-inclusive Care for the Elderly (PACE) plan, if you qualify.]	Here’s what to do: Call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. [Insert if applicable: For Program of All-Inclusive Care for the Elderly (PACE) inquiries, call <PACE phone number>.] If you need help or more information: Call the <SHIP program name> at <phone number>. [TTY phone number is optional.] [Insert as applicable: In <state>, the SHIP is called <SHIP program name>.] OR Enroll in a new integrated D-SNP. You’ll automatically be disenrolled from our Medicare plan when your new plan’s coverage begins. [Insert any additional information regarding the impact of Medicaid enrollment as directed by the state.]
2. You can change to: Original Medicare with a separate Medicare drug plan	Here’s what to do: Call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If you need help or more information: Call the <SHIP program name> at <phone number>. [TTY phone number is optional.] [Insert as applicable: In <state>, the SHIP is called <SHIP program name>.] OR Enroll in a new Medicare drug plan. You’ll automatically be disenrolled from our plan when your Original Medicare coverage begins. [Insert any additional information regarding the impact of Medicaid enrollment as directed by the state.]
3. You can change to: Original Medicare without a separate Medicare drug plan NOTE: If you switch to Original Medicare and don’t enroll in a separate Medicare drug plan, Medicare may enroll you in a drug plan, unless you tell Medicare you don’t want to join. You should only drop drug coverage if you have drug coverage from another source, such as an employer or union. If you have questions about whether you need drug coverage, call [Insert contact information regarding state SHIP program including name of program, phone number days and hours of operation, TTY number and website address.].	Here's what to do: Call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If you need help or more information: Call the <SHIP program name> at <phone number>. [TTY phone number is optional.] [Insert as applicable: In <state>, the SHIP is called <SHIP program name>.] You’ll automatically be disenrolled from our plan when your Original Medicare coverage begins. [Insert any additional information regarding the impact of Medicaid enrollment as directed by the state.]

4. You can change to: Any Medicare health plan during certain times of the year including the Open Enrollment Period and the Medicare Advantage Open Enrollment Period or other situations described in Section A.

Here's what to do: Call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. [Insert if applicable: For Program of All-Inclusive Care for the Elderly (PACE) inquiries, call <PACE phone number>.] If you need help or more information: Call the <SHIP program name> at <phone number>. [TTY phone number is optional.] [Insert as applicable: In <state>, the SHIP is called <SHIP program name>.] OR Enroll in a new Medicare plan. You’ll automatically be disenrolled from our Medicare plan when your new plan’s coverage begins. [Insert any additional information regarding the impact of Medicaid enrollment as directed by the state.]

C2. Your <Medicaid program name> services

[Insert instructions specific to state Medicaid program as directed by the state.]

4. Your medical items, services and drugs until your membership in our plan ends

If you leave our plan, it may take time before your membership ends and your new Medicare and Medicaid coverage begins. During this time, you keep getting your drugs and health care through our plan until your new plan begins.

• Use our network providers to receive medical care.

• Use our network pharmacies [insert if applicable: including through our mail-order pharmacy services] to get your prescriptions filled.

• If you’re hospitalized on the day that your membership in <plan name> ends, our plan will cover your hospital stay until you’re discharged. This will happen even if your new health coverage begins before you’re discharged.

5. Other situations when your membership in our plan ends

These are cases when we must end your membership in our plan:

• If there’s a break in your Medicare Part A and Medicare Part B coverage.

• If you no longer qualify for Medicaid. Our plan is for people who qualify for both Medicare and Medicaid.

• [Plans must insert rules for members who no longer meet special eligibility requirements.]

• If you move out of our service area.

• If you’re away from our service area for more than six months. [Plans with visitor/traveler benefits should revise this bullet to indicate when the plan must disenroll members.]

• If you move or take a long trip, call Member Services to find out if where you’re moving or traveling to is in our plan’s service area.

• [Plans with visitor/traveler benefits, insert: Refer to Chapter 4 of this Member Handbook for information on getting care through our visitor or traveler benefits when you’re away from our plan’s service area.]

• If you go to jail or prison for a criminal offense.

• If you lie about or withhold information about other insurance you have for drugs.

• If you’re not a United States citizen or aren’t lawfully present in the United States.

• You must be a United States citizen or lawfully present in the United States to be a member of our plan.

• The Centers for Medicare & Medicaid Services (CMS) notify us if you’re not eligible to remain a member on this basis.

• We must disenroll you if you don’t meet this requirement.

[Plans should include deemed continuous eligibility information here, if applicable. Plans should adjust language the following language as needed. If you’re within our plan’s [Insert number 1-6. Plans can choose any length of time from one to 6 months for deeming continued eligibility, as long as they apply the criteria consistently across all members and fully inform members of the policy]-month period of deemed continued eligibility, we’ll continue to provide all Medicare Advantage plan-covered Medicare benefits. However, during this period, [Plans should specify policy regarding coverage of Medicaid benefits during the period of deemed continued eligibility, as defined in the State Medicaid Agency Contract.] We won’t continue to cover Medicaid benefits that are included under the applicable Medicaid State Plan, nor will we pay the Medicare premiums or cost-sharing for which the state would otherwise be liable had you not lost your Medicaid eligibility. The amount you pay for Medicare-covered services may increase during this period.]

We can make you leave our plan for the following reasons only if we get permission from Medicare and Medicaid first:

• If you intentionally give us incorrect information when you’re enrolling in our plan and that information affects your eligibility for our plan.

• If you continuously behave in a way that’s disruptive and makes it difficult for us to provide medical care for you and other members of our plan.

• If you let someone else use your Member ID Card to get medical care. (Medicare may ask the Inspector General to investigate your case if we end your membership for this reason.)

6. Rules against asking you to leave our plan for any health-related reason

We can’t ask you to leave our plan for any reason related to your health. If you think we’re asking you to leave our plan for a health-related reason, call Medicare at 1‑800‑MEDICARE (1‑800‑633‑4227). TTY users should call 1‑877‑486‑2048.

7. Your 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 also refer to Chapter 9 of this Member Handbook for information about how to make a complaint.

8. How to get more information about ending your plan membership

If you have questions or would like more information on ending your membership, you can call Member Services at the number at the bottom of this page.

If you have questions, please call <plan name> at <toll-free phone and TTY numbers>, <days and hours of operation>. The call is free. For more information, visit <URL>. 1