Disenrollment Rights

How Do You Disenroll?

There are only certain times during the year when you may voluntarily end your membership with us. The key time to make changes is the Medicare fall open enrollment period (also known as the "Annual Enrollment Period"), which occurs every year from October 15 - December 7. This is the time to review your health care and drug coverage for the following year and make changes to your Medicare health or prescription drug coverage. Any changes you make during this time will be effective January 1. Certain individuals, such as those with Medicaid, those who get extra help or who move, may make changes at other times. For more information on other times during the year you may be eligible to voluntarily end your membership, please call our Customer Service Department at 1-877-883-9577 (TTY: 711), 8 a.m. - 8 p.m., Monday - Friday. From Oct. 1 - March 31, representatives are available 7 days a week from 8 a.m. to 8 p.m.

If you wish to leave Excellus BlueCross BlueShield and you are not enrolling in another Medicare Prescription Drug Plan, you will need to submit a disenrollment request. You may send your request in writing to us at: PO Box 546, Buffalo, NY 14201-0546. Or, you may send your request to our fax number at 1-716-843-7860. Please be sure to sign and date your letter.

To obtain a copy of a disenrollment form, please call our Customer Service Department at 1-877-883-9577 (TTY: 711), 8 a.m. - 8 p.m., Monday - Friday. From Oct. 1 - March 31, representatives are also available 7 days a week from 8 a.m. to 8 p.m.

During the Fall open enrollment period, if you want to end your membership in our plan, this is what you need to do:

• If you are planning on joining another Medicare Prescription drug plan: Simply join the new Medicare Prescription drug plan. You will be disenrolled automatically from our plan when your new coverage begins on January 1.
• If you are planning on enrolling in a Medicare Advantage plan: Request enrollment in the new plan. In most cases, you will be disenrolled automatically when your new plan's coverage begins on January 1.
• Exception: If you are joining a Medicare Advantage "Private Fee-for-Service" plan and that plan does not offer drug coverage, or a Medicare Medical Savings Account (MSA) Plan, enrollment will not automatically disenroll you from our plan. Therefore, you will need to do the following:
  • To join a new Medicare prescription drug plan, simply join the new Medicare prescription drug plan, or
  • If you do not want Medicare prescription drug coverage, find out how to request disenrollment from our plan by contacting Member Services. You may also call 1-800-MEDICARE (1-800-633-4227) (TTY: 711) to request disenrollment from our plan. Your enrollment in Original Medicare will be effective January 1.
• If you would like to end your membership without joining any other Medicare health or prescription drug plan: Contact our Customer Service Department to find out how to request disenrollment. You may also call 1-800-MEDICARE (1-800-633-4227) (TTY: 711) to request disenrollment from our plan. Your enrollment in Original Medicare will be effective January 1.

Important: If you disenroll from a Medicare prescription drug plan and go without creditable prescription drug coverage (coverage that is at least as good as Medicare drug coverage), you may have to pay a penalty if you join later.

When may Excellus BlueCross BlueShield Disenroll You?

Excellus BlueCross BlueShield may disenroll you for the following reasons:

• You do not stay continuously enrolled in Medicare Part A and Part B
• If Excellus BlueCross BlueShield is no longer contracting with Medicare or leaves your service area
• If you move out of the Excellus BlueCross BlueShield service area or are away from the service area for more than 6 months
• You materially misrepresent third-party reimbursement
• You fail to pay your Plan premium
• You engage in disruptive behavior, provided fraudulent information when you enrolled or abuse your enrollment card
• If you let someone else use your Plan membership card to get medical care

If we end your membership in our Plan we will tell you our reasons in writing and explain how you may file a complaint against us if you want to.

We cannot ask you to leave the plan because of your health

No member of any Medicare Prescription Drug Plan may be asked to leave the Plan for any health-related reasons or the number of prescriptions a member takes. If you ever feel that you are being encouraged or asked to leave Excellus BlueCross BlueShield because of your health, you should call 1-800-MEDICARE (1-800-633-4227) (TTY: 711) - the national Medicare help line.

Potential for Contract Termination

If Excellus BlueCross BlueShield leaves the Medicare program or no longer offers prescription drug coverage in the service area where you live, we will notify you in writing. If this happens, your membership in Excellus BlueCross BlueShield will end, and you will have to enroll in another Medicare Prescription Drug Plan to continue your prescription drug coverage.

Your choices include joining another Medicare Prescription Drug Plan or a Medicare Advantage Plan with prescription drug coverage if these plans are available in your area and are accepting new members. Once we have notified you in writing that we are leaving the Medicare program or the area where you live, you may enroll in another plan.

Excellus BlueCross BlueShield has a contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that runs Medicare. This contract may be renewed each year. However, Excellus BlueCross BlueShield or CMS can decide to end the contract at any time. You will generally be notified 90 days in advance if this situation occurs. However, your advance notice may be as little as 30 days or even fewer days if CMS must end our contract in the middle of the year.

Excellus BlueCross BlueShield contract with the Centers for Medicare & Medicaid Services (CMS) is reviewed annually, and the availability of coverage beyond the end of the current contract year is not guaranteed.