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Our Contract with Medicare
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.
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?"
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.
You also have another, more limited enrollment
period from January 1 through February 14, 2011. During this
period (called the “Medicare Advantage Annual Disenrollment
Period”), you could switch from our Plan to Original Medicare.
If you choose to switch to Original Medicare during this period,
you can also enroll in a separate Medicare prescription drug
plan at the same time.
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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