Scott & White Health Plan

Disenrollment Information

Voluntary Disenrollment

You may disenroll during:

The annual enrollment period.

• The annual enrollment period is November 15th through December 31st of each year.

A special enrollment period which includes situations where:

• You have made a change in residence outside the service area or have experienced another change in circumstances as determined by the Centers for Medicare & Medicaid Services (CMS) that causes you to no longer be enrolled in SeniorCare Rx (Cost) Plan.
• You are entitled to Medicare Part A and Part B and you receive any type of assistance from the Title XIX (Medicaid) program.
• CMS or the organization has terminated SeniorCare Rx (Cost) Plan contract in the area in which you reside, or the organization has notified you of the impending termination of SeniorCare Rx (Cost) Plan or the impending discontinuation of SeniorCare Rx (Cost) Plan in the area in which you reside.
• You demonstrate that SeniorCare Rx (Cost) Plan substantially violated a material provision of its contract with CMS in relation to you, or SeniorCare Rx (Cost) Plan (or its agent) materially misrepresented SeniorCare Rx (Cost) Plan when marketing SeniorCare Rx (Cost) Plan.
• You were not adequately informed of the creditable status of drug coverage provided by an entity required to give such notice, or a loss of creditable coverage.
• Your enrollment or non-enrollment in SeniorCare Rx (Cost) Plan is erroneous due to an action, inaction or error by a Federal Employee.
• You meet such other exceptional conditions as CMS may provide.

During a special enrollment period, you may discontinue enrollment in a Prescription Drug Plan (PDP) offered by a PDP sponsor or change to a different Part D plan. If you disenroll from or are disenrolled from SeniorCare Rx (Cost) Plan, you may subsequently enroll in a new Part D plan within the special enrollment period time period. Once you have enrolled in a new Part D plan, the special enrollment period ends for you even if the time frame for the special enrollment period is still in effect. You may disenroll by:

1. Mailing or faxing a signed written notice to a Scott & White Health Plan office.

2. Calling 1-800-MEDICARE.

Involuntary Disenrollment

SeniorCare Rx (Cost) Plan may disenroll you if:

• Premiums are not paid on a timely basis.
• You engage in disruptive behavior.
• You provide fraudulent information on an enrollment request, or if you permit abuse of an enrollment card in SeniorCare Rx (Cost) Plan.

In situations where SeniorCare Rx (Cost) Plan disenrolls you involuntarily for any of the reasons addressed above, SeniorCare Rx (Cost) Plan must send notice of the upcoming disenrollment that:

• Advises you SeniorCare Rx (Cost) Plan is planning to disenroll you and why such action is occurring
• Provides the effective date of termination

• Includes an explanation of your right to a hearing under SeniorCare Rx (Cost) Plan grievance procedures.

Required Involuntary Disenrollment

SeniorCare Rx (Cost) Plan must disenroll you in the following cases:

• A permanent change in residence making you ineligible to be an enrollee of SeniorCare Rx (Cost) Plan.
• You lose entitlement to Medicare.
• You die
• The SeniorCare Rx (Cost) Plan contract is terminated, or SeniorCare Rx (Cost) Plan discontinues offering a Prescription Drug Plan in the area where SeniorCare Rx (Cost) Plan had previously been available. Note: SeniorCare Rx (Cost) Plan is authorized by law to refuse to renew its contract with CMS. In addition, CMS also may refuse to renew the contract, and that termination or non-renewal may result in termination of your enrollment in SeniorCare Rx (Cost) Plan.
• You materially misrepresent information to SeniorCare Rx (Cost) Plan regarding reimbursement for third-party coverage.

Please refer to Evidence of Coverage  for Full Disclosure.

The above information is current as of October 2010.

"A Health Plan with a Medicare Contract"

H4564_SC_WEB_DISENROLL_2011  CMS Approved 11/17/2010