CALIFORNIA - Pacificare Health Systems

Section 8 – Disenrollment From the Secure
Horizons Group Retiree Medicare Advantage Plan
fewer days if CMS terminates PacifiCare’s
contract in the middle of the year.
Until PacifiCare notifies you in writing that
you must Disenroll from the Secure Horizons
Group Retiree Medicare Advantage Plan and
indicates the date when your membership
ends, you will continue as a Member of the
Secure Horizons Group Retiree Medicare
Advantage Plan and you must continue to
receive all Covered Services from Contracting
Medical Providers until the date your
Disenrollment is effective. All Covered
Services and rules described in this document
will continue until your membership ends.
Once PacifiCare has notified you in writing
that PacifiCare is leaving the Medicare
program or the area where you live, you
may switch to another way of getting your
Medicare benefits at anytime. If you decide
to switch from Secure Horizons Medicare
Advantage Plan to Original Medicare, you
will have the right to buy a Medigap policy
regardless of your health. This is called
“guaranteed issue rights.” You may contact
the California Health Insurance Counseling
and Advocacy Program at 1-800-434-0222
about how and when to buy a Medigap policy
if you need one. 7
Coverage That Ends During an Inpatient
Hospital Stay
If your coverage under the Secure Horizons
Group Retiree Medicare Advantage Plan ends
while you are an inpatient in a Hospital (or
Hospital unit), PacifiCare may be responsible
for the inpatient services until the date of
your discharge. PacifiCare’s Customer Service
Representatives can advise you if PacifiCare is
responsible for your inpatient services.
PacifiCare is not responsible for services,
other than inpatient Hospital services,
furnished on or after the Effective Date of
your Disenrollment.
Involuntary Disenrollment
PacifiCare must Disenroll you from the Secure
Horizons Group Retiree Medicare Advantage
Plan under the conditions listed below. You
will not be Disenrolled due to your health
status:
1. If you move out of the Service Area or live
outside the Service Area for more than six
months at a time and do not voluntarily
Disenroll.
2. If you do not stay continuously enrolled in
both Medicare Part A and Medicare Part B.
You may be Disenrolled from Secure Horizons
Group Retiree Medicare Advantage Plan under
the following conditions:
1. If you provide information on your
Group Retiree Election Form that is
false or deliberately misleading, and it
affects whether or not you can enroll in
Secure Horizons Group Retiree Medicare
Advantage Plan.
2. If you behave in a way that is unruly,
uncooperative, disruptive or abusive, and
this behavior seriously affects our ability
to arrange Covered Services for you or for
others who are Members of the Secure
Horizons Medicare Advantage Plan. Before
PacifiCare can disenroll you for this
reason, PacifiCare must obtain permission
from the Centers for Medicare and
Medicaid Services (CMS), the government
agency that runs Medicare.
3. If you allow someone else to use your
Secure Horizons Group Retiree Medicare
Advantage Plan membership card to obtain
Covered Services. Before PacifiCare will
disenroll you for this reason, PacifiCare
must refer your case to the Inspector
General, which may result in criminal
prosecution.
4. If the University of California does not
pay the Health Plan Premiums, you will
be enrolled as an individual in the Secure
Horizons Medicare Advantage Plan.
Should the University of California decide
later to re-enroll you in the University of
California’s Secure Horizons Group Retiree
Medicare Advantage Plan, the University
of California must pay any outstanding
Health Plan Premiums due from your
Questions? Call the Customer Service Department at 1-800-228-2144,
(TDHI) 1-800-685-9355, Monday through Friday, 7:00 a.m. to 9:00 p.m.
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PART B