Enroll in an Essence Healthcare Plan

Essence Healthcare’s contract is renewed annually, and the availability of coverage beyond the end of this year is anticipated but not guaranteed. By law, plan sponsors may choose not to renew their government contract, and the government may also refuse to renew the contract. If this happened, beneficiaries would need to join another plan offered in their area. Each year, we are also allowed to reduce our service area and/or no longer offer services in the areas where a beneficiary resides. Such a change is not anticipated. If it happened, beneficiaries would need to join another plan offered in their area. Essence Healthcare includes HMO, HMO-POS, and PPO plans with Medicare contracts. Essence Healthcare also includes an HMO D-SNP plan with a contract with Medicare and the state Medicaid program. Enrollment in Essence Healthcare depends on contract renewal. Members must have Medicare Parts A and B, and reside in our service area, to participate in our plan. Enrollment is limited to certain times of the year. You must continue to pay your Medicare Part B premium. Members must use plan providers for routine care and receive their prescription drug benefits from a pharmacy that participates with Essence Healthcare. An additional cost may be assessed for using out-of-network providers. Please consult the Summary of Benefits and the Evidence of Coverage for other important enrollment and membership information. Medicare beneficiaries may also enroll in Essence Healthcare through the CMS Medicare Online Enrollment Center located at www.Medicare.gov.

Rights and Responsibilities when Leaving or Changing Plans

“Disenrollment” from Essence means ending your membership in our plan. Disenrollment can be voluntary or involuntary: You might leave Essence because you have decided that you want to leave. You can do this for any reason; however, there are limits to when you may leave, 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 our plan. For example, you would have to leave Essence if you permanently move out of our geographic service area or if Essence leaves the Medicare program. We will not ask you to leave our plan because of your health. Until your membership ends, you must keep getting your Medicare services through Essence, or you will have to pay for them yourself. 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. While you are waiting for your membership to end, you are still a member and must continue to get your care as usual through our health plan. Depending on the type of plan, if you get services from doctors or other medical providers who are not plan providers before your membership in our plan ends, neither Essence 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 dialysis services, and care that has been approved by us. Another possible exception is if you happen to be hospitalized on the day your membership ends. If this happens to you, call us to find out if your hospital care will be covered. If you have any questions about leaving Essence, please call us.

If you want to leave our health plan: The first step is to be sure that the type of change you want to make (and when you want to make it) fits within the rules 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 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. Each year, anyone can disenroll and join a different plan during the Medicare Annual Enrollment Period that starts October 15 and ends December 7. From January 1 through March 31, anyone can also disenroll from a Medicare Advantage plan, such as Essence Healthcare, and switch to another Medicare Advantage plan or Original Medicare. You can also add or drop Part D coverage during this time. You may be able to switch plans outside these periods under certain special circumstances called “Special Elections.” Your Essence plan’s Evidence of Coverage outlines these rules or you can contact us for information.