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 in PHPBRAND will end, and you will have to change to another way of getting your Medicare benefits. All of the benefits and rules described in the EOC will continue until your membership ends. This means that you must continue to get your medical care and prescription drugs in the usual way through our plan until your membership ends.
Your choices for how to get your Medicare coverage will always include Original Medicare and joining a prescription drug plan to complement your Original Medicare coverage. Your choices may also include joining another PHPBRAND plan, another Medicare Advantage plan, or a private fee-for-service plan, if these plans are available in your area and 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 will have a chance to change to another way of getting your Medicare benefits. If you decide to change from PHPBRAND Advantage to Original Medicare, you will have the right to buy a Medigap policy regardless of your health. This is called a “guaranteed issue right.”
PHPBRAND has a contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that administers Medicare. This contract renews each year. At the end of each year, the contract is reviewed, and either PHPBRAND Advantage or CMS can decide to end it. You will get 90 days advance notice in this situation. It is also possible for our contract to end at some other time during the year. In these situations, we will attempt to tell you 90 days in advance, but your advance notice may be as little as 30 or fewer days if CMS must end our contract in the middle of the year.
Whenever a Medicare health plan leaves the Medicare program or stops serving your area, you will be provided a special enrollment period to make choices about how you get Medicare coverage, including choosing a Medicare prescription drug plan and guaranteed issue rights to a Medigap policy.
Generally, we cannot ask you to leave the plan because of your health. If you ever feel that you are being encouraged or asked to leave our plan because of your health, you should 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, seven days a week.
We can ask you to leave the plan under certain special conditions. If any of the following situations occur, we will end your PHPBRAND membership:
- If you are not a United States citizen or lawfully present in the United States
- If you move out of the service area or are away from the service area for more than six months in a row. If you plan to move or take a long trip, please call us to find out if the place you’re moving to or traveling to is in our service area. If you move permanently out of our geographic service area, or if you’re away from our service area for more than six months in a row, you generally can’t remain a member of PHPBRAND. In these situations, if you don’t leave on your own, we must end your membership (“disenroll” you)
- If you don’t stay continuously enrolled in both Medicare Part A and Medicare Part B
- 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
- If you give us information on your enrollment request that you know is false or deliberately misleading, and it affects whether or not you can enroll in our plan
- If you lie about or withhold information about other insurance you have that provides prescription drug coverage
- If you behave in any way that is disruptive, to the extent that your continued enrollment seriously impairs our ability to arrange or provide medical care for you or for others who are members of a PHPBRAND plan. We can’t make you leave our plan for this reason unless we get permission first from the CMS, the government agency that runs Medicare
- If you let someone else use your plan membership card to get medical care. If you’re disenrolled for this reason, CMS may refer your case to the Inspector General for additional investigation
- If you become incarcerated (go to prison)
You have the right to make a complaint if we ask you to leave our plan. If we ask you to leave, we will tell you our reason(s) in writing and explain how you can file a complaint against us if you so choose.