Making a Change

“Disenrollment” from Samaritan Advantage Health Plans HMO means ending your membership in the Conventional Plan, Premier Plan, Premier Plan Plus or Special Needs Plan. Disenrollment can be voluntary (your own choice) or involuntary (not your own choice):

• You might leave Samaritan Advantage Health Plans HMO because you have decided that you want to leave. You can do this for any reason. However, as we explain in this section, there are limits to when you may leave and how often you can make changes, what your other choices are for receiving Medicare services, and how you can make changes.
  
• There are also a few situations where you would be required to leave. For example, you would have to leave Samaritan Advantage Health Plans HMO if you move permanently out of our geographic service area, if you do not stay continuously enrolled in Medicare Part A and Part B, if you lie about or withhold information about other insurance you have that provides prescription drug coverage, or if our plan leaves the Medicare program. We are not allowed to ask you to leave the plan because of your health.

Whether leaving the plan is your choice or not, this section explains your Medicare coverage choices after you leave and the rules that apply.

If you leave Samaritan Advantage Health Plan HMO, it may take some time for your membership to end and your new way of getting Medicare to take effect (we discuss when the change takes effect later in this section). While you are waiting for your membership to end, you are still a member and must continue to get your care as usual through Samaritan Advantage.

If you get services from doctors or other medical providers who are not plan providers before your membership in Samaritan Advantage Health Plan HMO ends, neither Samaritan Advantage nor the Medicare program will pay for these services, with just a few exceptions. The exceptions are urgently needed care, care for a medical emergency, out-of-area renal (kidney) dialysis services, and care that has been approved by us. There is another possible exception: if you happen to be hospitalized on the day your membership ends. If this happens to you, call Customer Service at 541-768-4550 or 800-832-4580 (TTY 800-735-2900) to find out if your hospital care will be covered by Samaritan Advantage. If you have any questions about leaving Samaritan Advantage, please call Customer Service.

If you want to leave Samaritan Advantage:

• The first step is to be sure that the type of change that you want to make and when you want to make it fit with the new rules explained below about changing how you get Medicare. If the change does not fit with these rules, you won’t be allowed to make the change.
• Then, what you must do to leave Samaritan Advantage depends on whether you want to switch to Original Medicare or to one of your other choices.

In general, there are only certain times during the year when you can change the way you get Medicare.

From Oct. 15 through Dec. 7, during the Annual Coordinated Election Period (AEP), anyone with Medicare may switch from one way of getting Medicare to another for the following year. Your change will take effect on Jan. 1. During the AEP, you are not limited in the type of change you may make to your coverage. See “What are my choices, and how do I make changes, if I leave Samaritan Advantage Health Plans HMO between Oct. 15 and Dec. 7” below for details.

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.

If you leave Samaritan Advantage between Oct. 15 and Dec. 7 (during the AEP), you have a number of choices for how you receive your Medicare after you leave. If they are available in your area, and if they are accepting new members, you can switch to any of the following types of plans:

• Other Medicare Advantage Plans (including HMOs such as Samaritan Advantage, PPOs, and Private Fee-For-Service plans) are available in some parts of the country. In HMOs and PPOs, you generally get all your Medicare-covered Part A and Part B health care through the plan. Medicare Advantage Plans may include prescription drug coverage as part of the Medicare Prescription Drug (Part D) benefit. Medicare pays a set amount of money for your care every month to these private health plans whether or not you use services. The Conventional Plan, the Premier Plan, the Premier Plan Plus and the Samaritan Advantage Special Needs Plan are Medicare Advantage Plans offered by Samaritan Advantage Health Plan HMO.
• Original Medicare is available throughout the country. Original Medicare 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. Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance). Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance).
• Medicare Prescription Drug Plans (PDPs) are stand-alone drug plans that only cover prescription drugs, not other benefits or services. If you choose Original Medicare and want to receive Medicare prescription drug coverage, you must join a Medicare Prescription Drug Plan.
• Other Medicare Health Plans (including Medicare Cost Plans, Programs of All-Inclusive Care for the Elderly (PACE), and Demonstrations) may be available. In some of these plans, you generally get all your Medicare-covered health care from that plan. This coverage may include prescription drug coverage.
  Note: For more information about your choices, please refer to the “Medicare & You” handbook you received in the fall. You may also call 800-MEDICARE (800-633-4227) or visit medicare.gov to learn more about your choices.

If you want to change from Samaritan Advantage to a different Medicare Advantage Plan or Other Medicare Health Plan, here is what to do:

1. Contact the new plan you want to join to be sure it is accepting new members. Also, ask the plan if it offers the Medicare Part D prescription drug benefit.
2. Your new plan will tell you the date when your membership in that plan begins, and your membership in Samaritan Advantage will end on that same day (this will be your “disenrollment date”). Remember, you are still a member until your disenrollment date, and must continue to get your medical care as usual through Samaritan Advantage Health Plans HMO until the date your membership ends.

Original Medicare does not cover very many prescription drugs outside of a hospital. So, if you want to change from Samaritan Advantage to Original Medicare, you should think about whether you want to also join a Medicare Prescription Drug Plan.

To get information about Prescription Drug Plans that you can join, you can call 800-MEDICARE (800-633-4227), which is the national Medicare help line. TTY Users should call 877-486-2048. You can call 24 hours a day, 7 days a week.

• If you want Original Medicare and Medicare prescription drug coverage, simply enroll in a stand-alone Medicare Prescription Drug Plan (PDP). That will automatically disenroll you from Samaritan Advantage.
• If you want Original Medicare and do not want Medicare prescription drug coverage, simply tell us or Medicare that you want to leave Samaritan Advantage Health Plan HMO. You do not have to enroll in Original Medicare, because you will automatically be in Original Medicare when you leave Samaritan Advantage.

To tell us that you want to leave Samaritan Advantage:

• You can call Customer Service at 541-768-4550 or 800-832-4580 (TTY 800-735-2900) and request to speak to the Enrollment Department to request disenrollment from Samaritan Advantage Health Plan HMO. 

To tell Medicare you want to leave Samaritan Advantage, you can call 800-MEDICARE (800-633-4227), which is the national Medicare help line. TTY Users should call 877-486-2048. You can call 24 hours a day, 7 days a week.

Whether you tell us or Medicare that you want to leave Samaritan Advantage Health Plan HMO, you will receive a letter telling you when your membership will end. This is your disenrollment date – the day you officially leave Samaritan Advantage. Your disenrollment date will be Jan. 1. Remember, until Jan. 1, you are still a member of Samaritan Advantage Health Plan HMO and must continue to get your medical care as usual through our Plan.

Effective Jan. 1, your membership in Samaritan Advantage Health Plans HMO ends and you should use 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 Samaritan Advantage. (Call Social Security at 800-772-1213 if you need a new red, white, and blue Medicare card.)

Between January 1 and February 14 of every year, individuals who are enrolled in Medicare Advantage Plans can cancel their Medicare Advantage enrollment and switch to Original Medicare. If you choose to switch to Original Medicare and your Medicare Advantage Plan included Part D, you may also choose a separate Medicare Prescription Drug Plan at the same time. After February 14, you generally cannot change plans or discontinue your membership for the remainder of the year.

If you want to change from Samaritan Advantage Health Plan HMO to Original Medicare, you should think about whether you want to buy a Medigap policy to supplement your Original Medicare coverage. For Medigap advice, you should contact SHIBA (the phone number for SHIBA is in your Evidence of Coverage). You can ask SHIBA about how and when to buy a Medigap policy if you need one. SHIBA can tell you if you have a guaranteed right to buy a Medigap policy.

If you are at least 65 and have been 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 open enrollment period, a Medigap insurer cannot refuse to sell you any policy you choose, or impose limits based on your health. You might also have a “guaranteed issue right”. This means that in certain circumstances, and for a limited period of time, a Medigap insurer must sell you a Medigap policy, even if you have health problems. In general, you do not have a guaranteed issue right if you simply decide to disenroll from Samaritan Advantage. However, for example, you have a guaranteed issue right to buy a Medigap policy if you are in a trial period. You may be in a trial period if, in the past 12 months, you:

1. Dropped a Medigap policy to join Samaritan Advantage or another Medicare health plan for the first time; or
2. Joined Samaritan Advantage or another Medicare health plan when you first became 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. You may also have a guaranteed issue right if you move out of our service area. SHIBA can tell you about other situations where you may have guaranteed issue rights. If you do want to buy a Medigap policy, you have to follow the instructions below for changing from Samaritan Advantage to Original Medicare. (Buying a Medigap policy does not switch you from Samaritan Advantage to Original Medicare. In fact, while you are still enrolled in Samaritan Advantage, 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 with Samaritan Advantage and put you in Original Medicare.)

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 Samaritan Advantage Health Plans HMO 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 Evidence of Coverage will continue until your membership ends. This means that you must continue to get your medical care in the usual way through Samaritan Advantage until your membership ends.

Your choices for how to get your Medicare will always include Original Medicare and joining a Prescription Drug Plan to complement your Original Medicare coverage. Your choices may also include joining another Samaritan Advantage Health Plans, 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 Samaritan 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” and it is explained earlier in this section under the heading “Do you need to buy a Medigap (Medicare supplement insurance) policy?”

Samaritan Advantage Health Plans HMO has a contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that runs Medicare. This contract renews each year. At the end of each year, the contract is reviewed, and either Samaritan Advantage Health Plans HMO 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, too. In these situations we will try 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, 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.

Unless you are a member of a Medicare Advantage Special Needs Plan (SNP) for chronic conditions, you cannot be asked to leave your health plan for any health-related reasons. If you ever feel that you are being encouraged or asked to leave because of your health, you should call 800-MEDICARE (800-633-4227), which is the national Medicare help line. TTY users should call 877-486-2048. You can call 24 hours a day, 7 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 membership in Samaritan Advantage Health Plans HMO:

• 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 Customer Service at at 541-768-4550 or 800-832-4580 (TTY 800-735-2900) to find out if the place you are moving to or traveling to is in Samaritan Advantage Health Plan’s service area. If you move permanently out of our geographic service area, or if you are away from our service area for more than six months in a row, you generally cannot remain a member of Samaritan Advantage. In these situations, if you do not leave on your own, we must end your membership (“disenroll” you). An earlier part of this section tells about the choices you have if you leave Samaritan Advantage and explains how to leave. Your Evidence of Coverage gives more information about getting care when you are away from the service area.
• If you do not stay continuously enrolled in both Medicare Part A and Medicare Part B.
• If you are a Samaritan Advantage Special Needs Plan HMO member and your Medicaid eligibility or benefits change. You will be disenrolled from the Samaritan Advantage Special Needs Plan HMO on the first day of the month after a 60-day grace period, which begins on the day your Medicaid eligibility changes. Samaritan Advantage Health Plan HMO will notify you in writing about your options.
• 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 Samaritan Advantage Health Plans HMO.
• If you behave in a 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 our Plan. We cannot make you leave Samaritan Advantage for this reason unless we get permission first from the Centers for Medicare & Medicaid Services (CMS), the government agency that runs Medicare.
• If you let someone else use your plan membership card to get medical care. If you are disenrolled for this reason, CMS may refer your case to the Inspector General for additional investigation.
• If you do not pay the plan premiums. We will tell you in writing that you have a grace period during which you can pay the plan premiums before you are required to leave Samaritan Advantage Health Plans HMO.

You have the right to make a complaint if we ask you to leave Samaritan Advantage Health Plans HMO.

If we ask you to leave Samaritan Advantage, we will tell you our reasons in writing and explain how you can file a complaint against us if you want to.

If you have any questions or would like more information on when you can end your membership with our plan, when we may ask you to leave our plan, or your rights if you are asked to leave our plan, you can call Customer Service at 541-768-4550 or toll-free at 800-832-4580, daily from 8 a.m. to 8 p.m.