Ending your membership in our Plan may be voluntary (your own choice) or involuntary (not your own choice):
- You might leave our Plan because you have decided that you want to leave.
- There are also limited situations where we are required to end your membership. For example, if you move permanently out of our geographic service area.
There are only certain times during the year when you may voluntarily end your membership in our Plan. The key time to make changes is the Medicare Fall open enrollment period (also known as the "Annual Election Period"), which occurs from October 15 through December 7 for enrollments effective January 1. This is the time to review your health care and drug coverage for the following year and make changes to your Medicare health or prescription drug coverage. Any changes you make during this time will be effective January 1. Certain individuals, such as those with Medicaid, those who get extra help or who move, can make changes at other times. For more information on when you can make changes see the enrollment period table later in this section.
If you want to end your membership in our Plan during this time, here's what you'll need to do:
- If you are planning on enrolling in a new Medicare Advantage plan: Simply join the new plan. You will be disenrolled from our plan when your new plan’s coverage begins on January 1.
- If you are planning on switching to the Original Medicare Plan and joining a Medicare Prescription drug plan: Simply join the new Medicare Prescription drug plan. You will be disenrolled from our plan when your new plan's coverage begins on January 1.
- If you are planning on switching to the Original Medicare Plan without a Medicare Prescription drug plan: Contact customer service for information on how to request disenrollment. You may also call 1-800-MEDICARE (1-800-633-4227) to request disenrollment from our plan. TTY users should call 711. Your enrollment in Original Medicare will be effective January 1.
Please note: until your membership ends, you must keep getting your Medicare services and prescription drug coverage through our Plan
If you leave our Plan, it may take some time for your membership to end and your new way of getting Medicare to take effect (more information regarding effective dates is covered earlier in this section). While you are waiting for your membership to end, you are still a member and must continue to get your care and prescription drugs as usual through our Plan. If you happen to be hospitalized on the day your membership ends, generally you will be covered by our Plan until you are discharged. Call customer service for more information and to help us coordinate with your new plan. Until your prescription drug coverage with our Plan ends, use our network pharmacies to fill your prescriptions. While you are waiting for your membership to end, you are still a member and must continue to get your prescription drugs as usual through our Plan’s network pharmacies. In most cases, your prescriptions are covered only if they are filled at a network pharmacy (including our mail-order-pharmacy service), are listed on our formulary, and other coverage rules are followed.
We cannot ask you to leave your health plan for any health-related reasons. 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 may call 24 hours a day, 7 days a week.
If any of the following situations occur, we will end your membership in our Plan.
- If you do not stay continuously enrolled in Medicare A and B.
- If you move out of the service area or are away from the service area for more than 6 months, you cannot remain a member of our Plan. And we must end your membership ("disenroll" you)". If you plan to move or take a long trip, please call customer service to find out if the place you are moving to or traveling to is in our Plan’s service area.
- If you knowingly falsify or withhold information about other parties that provide reimbursement for your prescription drug coverage.
- If you intentionally give us incorrect information on your enrollment request that would affect your eligibility to enroll in our Plan.
- 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 our Plan for this reason unless we get permission first from 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 90-day grace period during which you may pay the Plan premiums before your membership ends.
- If you become incarcerated. You would be considered as residing outside of our service area for the purposes of Medicare Advantage plan eligibility, even if the correctional facility is located within our service area.
- For DSNP members only: If you lose special needs status and do not reestablish SNP eligibility prior to the expiration of the period of deemed continued eligibility.
You have the right to make a complaint if we end your membership in our Plan. If we end your membership in our Plan we will tell you our reasons in writing and explain how to file a complaint against us if desired.
To check on your status or level, call:
1-800-MEDICARE (1-800-633-4227), 24 hours per day, seven days per week. TTY/TDD users should call 1-877-486-2048.
- Medical appeals, determination and grievance processes
- Part D coverage determinations, exceptions, appeals and grievances
- Link to CMS' appointment of representative Form (PDF)
If you would prefer that someone else act on your behalf, please fill out this form, sign it and return it to us.
- In writing, to Providence Medicare Advantage Plans, Attn: Appeals and Grievance Department P.O. Box 4158 Portland, OR 97208-4158.
- By fax, at 1-800-396-4778.
- By telephone – if it is a fast appeal – at 503-574-8000 or 1-800-603-2340 (TTY: 711).
- In person, at Providence Medicare Advantage Plans, Appeals and Grievance Department, 3601 SW Murray Blvd., Suite 10 Beaverton, OR 97005.
You can contact customer service if you need additional information, including:
- How we control the use of services and costs;
- The number of appeals and grievances filed by our members;
- A summary description of how we pay our doctors; or
- A description of our financial condition, including a summary of our most recent audit statement.