Disclosure form and evidence of coverage - Kaiser Permanente ...

If you request disenrollment at a time other than the
University of California's open enrollment, your
disenrollment effective date will be the first day of the
month following our receipt of your disenrollment
request.
You may request disenrollment by calling toll free
1-800-MEDICARE/1-800-633-4227 (TTY users call
1-877-486-2048), 24 hours a day, seven days a week, or
sending written notice to the following address:
Northern California Region Members:
Kaiser Foundation Health Plan, Inc.
California Service Center
P.O. Box 232400
San Diego, CA 92193-2400
Southern California Region Members:
Kaiser Foundation Health Plan, Inc.
California Service Center
P.O. Box 232407
San Diego, CA 92193-2407
Other Medicare Health Plans. If you want to enroll in
another Medicare Health Plan or a Medicare prescription
drug plan, you should first confirm with the other plan
and the University of California that you are able to
enroll in their plan. Your new plan will tell you the date
when your membership in that plan begins and your
Senior Advantage membership will end on that same day
(your disenrollment date).
The Centers for Medicare & Medicaid Services will let
us know if you enroll in another Medicare Health Plan,
so you will not need to send us a disenrollment request.
Original Medicare. If you request disenrollment from
Senior Advantage and you do not enroll in another
Medicare Health Plan, you will automatically be enrolled
in Original Medicare when your Senior Advantage
membership terminates (your disenrollment date). On
your disenrollment date, you can start using 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 after you
disenroll. If you choose Original Medicare and you want
to continue to get Medicare Part D prescription drug
coverage, you will need to enroll in a prescription drug
plan.
If you receive Extra Help from Medicare to pay for your
prescription drugs, and you switch to Original Medicare
and do not enroll in a separate Medicare Part D
prescription drug plan, Medicare may enroll you in a
drug plan, unless you have opted out of automatic
enrollment.
Note: If you disenroll from Medicare prescription drug
coverage and go without creditable prescription drug
coverage, you may need to pay a late enrollment penalty
if you join a Medicare drug plan later. ("Creditable"
coverage means the coverage is expected to pay, on
average, as least as much as Medicare's standard
prescription drug coverage.) See "Premiums" in the
"Premiums, Eligibility, and Enrollment" section for more
information about the late enrollment penalty.
Termination of Contract with the
Centers for Medicare & Medicaid
Services
If our contract with the Centers for Medicare & Medicaid
Services to offer Senior Advantage terminates, your
Senior Advantage membership will terminate on the
same date. We will send you advance written notice and
advise you of your health care options. Also, you may be
eligible to transfer your membership to another Kaiser
Permanente plan offered by the University of California.
Termination for Cause
We may terminate your membership by sending you
advance written notice if you commit one of the
following acts:
• If you continuously 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 our other
members. We cannot make you leave our Senior
Advantage Plan for this reason unless we get
permission from Medicare first
• If you let someone else use your Plan membership
card to get medical care. We cannot make you leave
our Senior Advantage Plan for this reason unless we
get permission from Medicare first. If you are
disenrolled for this reason, the Centers for Medicare
& Medicaid Services may refer your case to the
Inspector General for additional investigation
• You commit theft from Health Plan, from a Plan
Provider, or at a Plan Facility
• You intentionally misrepresent membership status or
commit fraud in connection with your obtaining
membership. We cannot make you leave our Senior
Advantage Plan for this reason unless we get
permission from Medicare first
• If you become incarcerated (go to prison)
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