CALIFORNIA - Pacificare Health Systems

PART B
184
Section 8 – Disenrollment From the Secure
Horizons Group Retiree Medicare Advantage Plan
November can be effective December 1 or
January 1. If you do not choose an Effective
Date for your Disenrollment request made
in November, your Disenrollment will be
effective on December 1. Please contact either
the University of California or Customer
Service for more information regarding your
Disenrollment effective date.
Until your membership ends, you will
continue to be a Member of the Secure
Horizons Group Retiree Medicare Advantage
Plan and must continue to receive all routine
Covered Services from Contracting Medical
Providers until the date your Disenrollment
is effective. PacifiCare will send you a letter
that informs you when your Disenrollment
is effective. Once your Disenrollment is
effective, you can begin using your red, white,
and blue Medicare card to obtain services
under Medicare unless you have joined
another Medicare Advantage Coordinated
Care plan. (Note: You can call Social Security
at 1-800-772-1213 if you need a new Medicare
card.)
Moves or an Extended Absence From the
Service Area
If you are permanently moving out of the
Service Area or plan an extended absence
of more than six (6) months, it is important
to notify PacifiCare of the move or extended
absence before you leave the Service Area.
If you move permanently out of PacifiCare’s
Service Area, or if you are away from
PacifiCare’s Service Area for more than
six consecutive months, you will need to
Disenroll from the Secure Horizons Group
Retiree Medicare Advantage Plan.
Failure to notify PacifiCare of a permanent
move or an extended absence may result
in your involuntary Disenrollment from the
Secure Horizons Group Retiree Medicare
Advantage Plan, since PacifiCare is required
to Disenroll you if you have moved out of the
Service Area for more than six (6) months. If
you remain enrolled after a move or extended
absence (and have not been involuntarily
Disenrolled as just described), you should
be aware that services will not be covered
unless they are received from Contracting
Medical Providers (except for Emergency
Services, Urgently Needed Services and Prior
Authorized Referrals).
Secure Horizons Medicare Advantage Plans
are currently offered in the following states:
Arizona, California, Colorado, Nevada,
Oklahoma, Oregon, Texas and Washington.
If you are moving outside of your Service
Area, you may be eligible to enroll in a
Secure Horizons Medicare Advantage Plan in
your new location. Health Plan Premiums,
Copayments and Covered Services will vary
from one area to another. Please contact
Customer Service for information and
assistance in completing any necessary
paperwork. For information on other plans
available in your area, you can call 1-800-
MEDICARE (1-800-633-4227), or the hearing
impaired TTY/TDD access line 1-877-486-
2048, or visit the CMS Web site at www.
medicare.gov.
What happens if Secure Horizons
Medicare Advantage Plan leaves the
Medicare Program or leaves the area
where you live?
If PacifiCare leaves the Medicare program or
discontinues the Secure Horizons Medicare
Advantage Plan in your Service Area,
PacifiCare will notify you in writing. If either
of these situations occur, you will be allowed
to change the way you receive Medicare
coverage. Your choices will always include
Original Medicare, and they may also include
joining another Medicare Advantage Plan, if
such plans are available in your area and are
accepting new Members.
PacifiCare of California has a contract with
the CMS. This contract renews each year.
At the end of each year, the contract is
reviewed, and either PacifiCare or CMS can
decide to terminate the contract. It is also
possible for PacifiCare’s contract to terminate
at some other time. If the contract is going
to terminate, PacifiCare will generally notify
you at least 90 days in advance. Your advance
notice may be as little as 30 days or even