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Information for Essence Members
Potential for Contract Termination
What happens to you if Essence leaves the Medicare program or Essence leaves the area where I 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 in Essence 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 Essence 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 Essence 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 Essence 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 your Evidence of Coverage.
Essence 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 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.
Under certain conditions Essence can end your membership and make you leave the plan.
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, 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 Essence 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 membership in Essence:
- 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 Member Services to find out if the place you are moving to or traveling to is in Essence's 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 B.
- 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 Essence.
- 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 Essence. We cannot make you leave Essence 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 Essence.
If we ask you to leave Essence, we will tell you our reasons in writing and explain how you can file a complaint against us if you want to.