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Our Contract with Medicare
How can I find out about the number of
grievances, appeals, and exceptions processed by Mercy Health
Plans?
To obtain information about the aggregate
number of grievances, appeals and exceptions please contact our
Customer Contact Center at the number listed in your Evidence of
Coverage (EOC) or on your ID card.
What happens to you if Mercy Health Plans
leaves the Medicare program or leaves the area where you live?
If we leave the Medicare program or change our
service area so that it no longer includes the area where you
live, we will tell you in writing. If this happens, your
membership will end, and you will have to change to another way
of getting your Medicare benefits. All of the benefits and rules
described in your EOC will continue until your membership ends.
This means that you must continue to get your medical care in
the usual way until your membership ends.
Your choices on how to get your Medicare will
always include Original Medicare and joining a Prescription Drug
Plan (PDP) to complement your Original Medicare coverage. Your
choices may also include joining another Medicare Advantage plan
or a Private Fee-for-Service plan, if these plans are accepting
new members. Once we have told you in writing that we are
leaving the Medicare program or the area where you live, you may
change how you get your Medicare benefits. If you decide to
change from Mercy to Original Medicare, you will have the right
to buy a Medigap policy regardless of your health. This is
called a "guaranteed issue right" and it is explained later
under the heading, "Do you need to buy a Medigap (Medicare
supplement insurance) policy?"
Mercy Health Plans has a contract with the
Centers for Medicare & Medicaid Services (CMS), the government
agency that runs Medicare. At the end of each year, the contract
is reviewed, and either Mercy Health Plans or CMS can decide to
end it. You will receive 90 days advance notice in this
situation. Our contract may end at other times too. If CMS ends
our contract in the middle of the year, your advance notice may
be as little as 30 days or even fewer days.
Whenever a Medicare health plan leaves the
Medicare program or stops serving your area, you will be
provided a Special Enrollment Period (SEP) to make choices about
how you get Medicare, including choosing a Medicare Prescription
Drug Plan and guaranteed issue rights to a Medigap policy.
What is "Disenrollment"?
"Disenrollment" means ending your membership.
You can end your membership for any reason. This is
called Voluntary disenrollment. However, there are limits on
when you may leave, how often you can make changes, and what
type of plan you can join after you leave.
When it is required that you end your membership, this
is called Involuntary disenrollment. Examples: a permanent
move out of our geographic service area or if Mercy leaves
the Medicare program. We cannot ask you to leave the plan
because of your health.
Disenrollment Process
Whether disenrolling from the plan is your
choice or not, this section explains your Medicare coverage
choices after you leave and the rules that apply.
It takes some time for your membership to end
and your new way of getting Medicare to take effect. During this
waiting period, you are still a member and must continue to
obtain your care as usual through Mercy. If you receive services
from doctors or other medical providers who are not plan
providers before your membership in the Mercy HMO ends, neither
Mercy Health Plans nor the Medicare program will pay for these
services. Exceptions are urgently needed care, care for a
medical emergency, out-of-area renal (kidney) dialysis services,
and care that has been pre-approved by Mercy. There is another
possible exception, if you happen to be hospitalized on the day
your membership ends. If this happens to you, call the Customer
Contact Center at the number on your ID card to find out if
Mercy will cover your hospital care. If you have any questions
about leaving, please call our Customer Contact Center
What are your choices for continuing Medicare
if you Disenroll?
If you leave Mercy, you may join a Medicare Advantage
plan or other Medicare Health Plan if they are available in
your area and accepting new members. You may also choose the
Original Medicare plan. If you choose Original Medicare, you
must choose a Prescription Drug Plan (PDP) if you wish to
continue to have Medicare prescription drug coverage.
Original Medicare is available throughout the country.
It is a "fee-for-service" health plan that lets you go to
any doctor, hospital, or other health care provider who
accepts Medicare. You must pay a deductible. Then Medicare
pays its share of the Medicare-approved amount, and you pay
your share. Original Medicare has two parts: Part A
(Hospital Insurance) and Part B (Medical Insurance). If you
choose Original Medicare and you want to continue to get
Medicare prescription drug coverage, you will need to enroll
in a Prescription Drug Plan (PDP) available in your area.
PDPs only cover prescription drugs (not other benefits or
services). If you switch to Original Medicare, you may be
required to join a PDP.
Other Medicare Advantage Plans (including Mercy
MedicareADVANTAGE) are available in some parts of the
country. In HMOs you go to the doctors, hospitals, and other
providers that are part of the plan. In PPOs, you can
usually see any doctor but you may pay more to see doctors,
hospitals, and other providers that are not part of the
plan. These plans must cover all Medicare Part A and Part B
health care. Some plans cover extras, such as prescription
drugs in the Medicare Part D (Prescription Drug) benefit.
Medicare Private Fee-for-Service Plans are available in
some parts of the country. In Private Fee-for-Service plans,
you may go to any Medicare-approved doctor or hospital that
accepts the plan’s payment. The Private Fee-for-Service plan
decides how much it will pay and what you pay. You may pay
more for Medicare-covered benefits. You may get extra
benefits that Original Medicare does not cover, such as
prescriptions drugs as part of the Medicare Part D
(Prescription Drug) benefit. Private Fee-for-Service plans
are not the same as Medigap (Medicare supplement insurance)
policies.
When and how often can you change your Medicare
choices and what choices can you make?
There are limits to when and how often you can
change the way you get Medicare and what choices you can make
when you make the change.
Here are the new rules for those with
Medicare:
From November 15 through December 31, you will have one
chance to change the Medicare product you receive as of
January 1st. You may add or drop Part D Prescription Drug
coverage at this time.
From January 1 through March 31, you will have another
chance to make one change between Medicare products.
However, if you had drug coverage under your old plan, you
must choose drug coverage under your new plan. Similarly, if
your old plan had no drug coverage, you must choose a new
plan without drug coverage.
Generally, you can’t make any other changes during the
year unless you meet special exceptions, such as if you move
or if you have Medicaid coverage. Contact us for
information. Later in the year, from November 15 through
December 31, anyone with Medicare can switch their way of
getting Medicare to another way for the following year.
When we receive your request to disenroll,
your disenrollment date will be the 1st of the next
month. For example, if we receive your request to leave during
the month of February, your disenrollment date will be March 1.
However, if we receive your request November 15th
through November 30th, you will be allowed to choose
either December 1 or January 1 as your disenrollment date. If
you do not choose a disenrollment date, your disenrollment will
be effective on December 1.
What should you do if you decide to Disenroll?
If you want to leave:
Be sure of the change you want to make.
Know when you want to make the change.
Remember the new rules explained above about changing
how you get Medicare. If the change does not fit with these
new rules, you won’t be allowed to make the change.
Then, what you must do to leave the plan
depends on whether you want to switch to Original Medicare or to
one of your other choices.
How to change from our Plan
Do you need to join a Prescription Drug Plan (PDP)?
Original Medicare does not cover very many prescription
drugs outside of a hospital. So, if you want to disenroll
from Mercy to Original Medicare, you should think about
whether you want to also join a Medicare Prescription Drug
Plan. It is important to know that if you are eligible to
join a prescription drug plan and you do not, you may have
to pay a higher premium when you do join. To get information
about Prescription Drug Plans that you can join, you can
call 1-800-MEDICARE (1-800-633-4227), which is the national
Medicare help line. TTY users should call 1-877-486-2048.
You can call 24 hours a day, 7 days a week.
Do you need to buy a Medigap (Medicare supplement
insurance) policy?
If you want to disenroll from Mercy to
Original Medicare, you should think about whether you need to
buy a Medigap policy to supplement your Original Medicare
coverage. For Medigap advice, you should contact the State
Health Insurance Program (SHIP) in your state (the phone number
is in Section 1 of your EOC). You can ask the SHIP about how and
when to buy a Medigap policy if you need one. The SHIP can tell
you if you have a guaranteed issue right to buy a Medigap
policy.
If you are at least 65 and eligible for Part B for less
than six months, you may still be in your Medigap open
enrollment period. If you leave our plan while you are still
in your Medigap open enrollment period, and if you have no
guaranteed issue right, the Medigap insurer can refuse to
sell you a policy, or impose limits based on your health. If
you have a "guaranteed issue right," this means that the
Medigap insurer must sell you a policy, even if you have
health problems. This is a special, temporary right, which
means that if you decide to change to Original Medicare in
certain situations you have a limited time to buy a Medigap
policy on a guaranteed issue basis. For example, you have a
guaranteed issue right to buy a Medigap policy if you are in
a Medicare managed care plan "trial period" and you change
to Original Medicare. Generally, a Medicare managed care
plan trial period begins on the date of "first time"
enrollment in a Medicare health plan (other than Original
Medicare) and ends 12 months later. You may be in a Medicare
managed care plan trial period if in the past 12 months you:
(1) dropped a Medigap policy to join a Medicare health plan
for the first time; or (2) joined a Medicare health plan
upon first becoming entitled to Medicare at age 65. Under
certain circumstances, if you lose your health plan coverage
while you are still in a trial period, the trial period can
last for an extra 12 months. The SHIP can tell you about
other situations where you may have guaranteed issue rights.
You may also have a guaranteed issue right if you move out
of our service area, or if we stop providing Medicare
benefits.
If you do buy a Medigap policy, you still have to follow the
instructions below for changing from our plan to Original
Medicare. (Buying a Medigap policy does not disenroll you
from our plan to Original Medicare. In fact, while you are
still enrolled in our plan it is against the law for a
Medigap insurance company to sell you a policy. A Medigap
sales person or insurance agent cannot cancel your
membership and put you in Original Medicare.)
How to change from Mercy to Original Medicare
If you decide to disenroll from Mercy to
Original Medicare, you must tell us (or Medicare) that you want
to leave our plan. You will automatically be in Original
Medicare when you leave our plan. Here is how it works:
First, to disenroll from Mercy, use any of the following
ways:
You can write or fax a letter to us or fill out a
disenrollment form and send it to our Customer Contact
Center at 14528 S. Outer 40, Ste. 300 Chesterfield, MO
63017, or to our fax number at 314-214-8002. Be sure to
sign and date your letter. To get a disenrollment form,
call us at the Customer Contact Center telephone number
listed in Section 1 of your EOC.
You can call 1-800-MEDICARE (1-800-633-4227), which
is the national Medicare helpline. TTY Users should call
1-877-486-2048.
Next, we will send you a letter that tells you when your
membership will end. This is your "disenrollment date" – the
day you officially leave our plan. In most cases, your
disenrollment date will be the first day of the next month.
For example, if we receive your request to leave during the
month of February, your disenrollment date will be March 1.
There is an exception: If we receive your request November
15th through November 30th, you will
be allowed to choose either December 1 or January 1 as your
disenrollment date. If you do not choose a disenrollment
date, your disenrollment will be effective on December 1.
Remember, while you are waiting for your membership to
end, you are still a member of our plan and must continue to
get your medical care as usual.
On your disenrollment date, your membership in our plan
ends, and you can start using your red, white, and blue
Medicare card to get services under Original Medicare. You
will not get anything in writing that tells you that you
have Original Medicare, because you will automatically be in
Original Medicare when you leave. (Call Social Security at
1-800-772-1213 if you need a new red, white, and blue
Medicare card.)
How to change from Mercy to another Medicare
Advantage plan or to a Private Fee-for-Service Plan
If you want to change to a different Medicare
Advantage plan including a Private Fee-for-Service Plan, here is
what to do:
Contact the plan you want to join to be sure it is
accepting new members.
If the plan is accepting new members, apply for
membership in the plan. Once you are enrolled in your new
plan, your membership in Mercy will automatically end. This
means that you do not need to tell us that you are leaving.
However, we do encourage you to tell us why you left.
When your new plan tells you, in writing, the date of
your new membership, that’s when your membership in Mercy
ends (this is your disenrollment date). Remember, you are
still a member with our plan until your disenrollment date,
and must continue to get your medical care as usual until
the date your membership ends.
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