Potential for Contract Termination
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 CoxHealth MedicarePlus 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 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 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 Essence Healthcare 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 CoxHealth MedicarePlus 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 is explained in the Evidence of Coverage.
Essence Healthcare 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 Essence Healthcare
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 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 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, 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 CoxHealth MedicarePlus membership:
- 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 are moving to or traveling to is in our service area.
If you move permanently out of our geographic service area, of if you are away from
our service area for more than six months in a row, you generally cannot remain
a member of Essence. In these situations, if you do not leave on your own, we must
end your membership ("disenroll" you).
- If you do not stay continuously enrolled in both Medicare Part A and Medicare Part
- 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 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 an CoxHealth MedicarePlus plan. We cannot make
you leave our plan for this reason unless we get permission first from the Centers
for Medicare & Medicaid Services, 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.
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.