Prescription Drug Plans Eligibility, Enrollment, and Disenrollment

Eligibility, Enrollment, and Disenrollment

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Wisconsin Physicians Service Insurance Corporation (WPS Health Insurance) is authorized by law to refuse to renew its contract with the Centers for Medicare and Medicaid Services (CMS). CMS also may refuse to renew the contract. Termination or non-renewal of this contract may result in termination of the beneficiary's enrollment in the WPS MedicareRx Plan. In addition, the WPS MedicareRx Plan may reduce its service area and no longer offer services in the area where you reside.

Eligibility and Enrollment Requirements

A Part D-eligible beneficiary is defined as being:

• Entitled to Medicare benefits under Part A and/or enrolled in Part B.
• Having current eligibility in CMS systems.
• Is a U.S. citizen or lawfully present in the United States; and
• A permanent resident in the geographic service area of the Part D plan.

Additional Enrollment Information

• You may be enrolled in only one Part D plan at a time.
• If you enroll in a Private Fee-for-Service (PFFS) Plan that does not include Medicare prescription drug coverage, an MA Medical Savings Account (MSA) Plan, or an 1876 Cost Plan, you may enroll in a PDP and will not be automatically disenrolled from the PFFS, MSA, or 1876 Cost Plan.
• If you enroll in a Medicare plan that includes Medicare prescription drugs or any MA-coordinated care (HMO or PPO) plan, you will be automatically disenrolled from the HMO, PPO, or MA PFFS Plan if you enroll in a PDP.

Annual Enrollment Period (AEP)

The Annual Enrollment Period runs from Oct. 15 through Dec. 7. In general, enrollment is only allowed during the Annual Enrollment Period unless you recently became eligible for Medicare or qualify for a Special Enrollment Period.

Special Enrollment Period (SEP)

A Special Enrollment Period is when a person, under certain circumstances, may enroll in, or disenroll from, a Medicare prescription drug plan other than during the Annual Enrollment Period. Examples of such circumstances may include: receiving benefits from both Medicare and Medicaid; changing living situations (such as moving out of state or into a long-term care facility); losing creditable coverage from an employer or other plan sponsor; or losing coverage because a plan no longer offers Medicare prescription drug coverage.

Late Enrollment Penalty (LEP)

This is imposed when a beneficiary fails to maintain creditable prescription drug coverage for a period of 63 days or more following the last day of an individual's initial enrollment in a Part D plan. This means that if you do not have outpatient prescription drug coverage that pays as well as, or better than, Medicare Part D, you may receive a penalty..

Voluntary Disenrollment

Customers may disenroll from a prescription drug plan during one of the election periods by doing the following:

• Providing a signed written notice to their plan, or through their agent/broker if applicable.
• Giving a signed written notice to any Social Security Administration or the Railroad Retirement Board.
• Calling 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day, seven days a week.

Required Involuntary Disenrollment

A prescription drug plan organization must disenroll an individual from a prescription drug plan in the following cases:

• A change in residence, making the individual ineligible to be an enrollee of the prescription drug plan.
• The individual loses entitlement to Medicare.
• The individual dies.
• The prescription drug plan contract is terminated or the Prescription Drug Plan organization discontinues offering a prescription drug plan in any portion of the area where it had previously been available.
• The individual materially misrepresents information to the prescription drug plan organization regarding reimbursement for third-party coverage.

Involuntary Disenrollment for Disruptive Behavior

"Disruptive behavior" is behavior that substantially impairs the prescription drug plan organization's ability to arrange or provide care to the disruptive individual or other plan customers.

Premiums

You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party.

If you do not pay your premiums, you will be disenrolled from the WPS MedicareRx Plan.

Typically, your premium payment method must stay the same for a whole year. If you would like to change your premium payment method, please contact your plan. Please note, if you do choose to change your method, it may take up to three months for this change to take effect, and you will continue to be billed via the original method until your change takes effect.

You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting extra help, call:

• 1-800-MEDICARE (1-800-633-4227). TTY or TDD users should call 1-877-486-2048, 24 hours a day/seven days a week;
• The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY or TDD users should call 1-800-352-0778; or
• Your State Medical Assistance (Medicaid) Office.

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. Those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don't even know it. For more information about this Extra Help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, seven days per week. TTY users should call 1-877-486-2048.

If you decide to switch to premium withhold or move from premium withhold to direct bill, it could take up to three months for it to take effect and you will be responsible for the timely payment of all premiums during that time.

Medigap

If you have a Medigap (Medicare supplement insurance) policy that includes prescription drug coverage, you must contact your Medigap issuer to let them know that you have joined a Medicare prescription drug plan. Your Medigap issuer will remove the prescription drug coverage portion of your policy and adjust your premium. Call your Medigap issuer for details.

What happens if you have been disenrolled

If we end your membership in our plan, we must tell you our reasons in writing for ending your membership. We must also explain how you can make a complaint about our decision to end your membership.

If you are having trouble paying your premium on time, please contact Customer Support to see if we can direct you to programs that will help with your plan premium.

If we end your membership with the plan because you did not pay your premiums, and you don't currently have prescription drug coverage, then you may not be able to receive Part D coverage until the following year if you enroll in a new plan during the annual enrollment period. During the annual enrollment period, you may either join a stand-alone prescription drug plan or a health plan that also provides drug coverage. (If you go without "creditable" drug coverage for more than 63 days, you may have to pay a late enrollment penalty for as long as you have Part D coverage.)

If we end your membership because you did not pay your premiums, you will still have health coverage under Original Medicare. At the time we end your membership, you may still owe us for premiums you have not paid. We have the right to pursue collection of the premiums you owe. In the future, if you want to enroll again in our plan (or another plan that we offer), you will need to pay the amount you owe before you can enroll.

If you think we have wrongfully ended your membership, you have a right to ask us to reconsider this decision by making a complaint. You can make a complaint using the information found on the 'Complaints' tab on Medicare Complaint Form page.

If you had an emergency circumstance that was out of your control and it caused you to not be able to pay your premiums within our grace period, you can ask WPS to reconsider this decision and reinstate your enrollment in the plan. This is called a Reinstatement for Good Cause. You can do this by calling our Customer Support department at 1-800-944-2656 (TTY 711), 8 a.m.- 4:30 p.m. CT, Monday through Friday.

Please note, reinstatement of enrollment for “Good Cause” is provided only in rare circumstances in which you or your authorized representative (i.e. the individual responsible for the beneficiary’s financial affairs) was unable to make timely payment due to circumstances over which you had no control and you could not reasonably have been expected to foresee.

Examples of circumstances that may constitute “Good Cause” include:

• Federal government error (i.e., CMS, SSA or RRB) caused the payment to be incorrect or late, and the beneficiary was unaware of the error or unable to take action prior to the disenrollment effective date;
• A serious illness, institutionalization and/or hospitalization of the beneficiary or his/her authorized representative (i.e., the individual responsible for the beneficiary’s financial affairs) that lasted for a significant portion of the grace period for plan or Part D - IRMAA premium payment;
• Death of a spouse, immediate family member (i.e., person living in the same household) or person providing caregiver services to the beneficiary; or
• Loss of the beneficiary’s home or severe impact by fire, or other exceptional circumstance outside the beneficiary’s control (e.g., affected individual resides in a federal disaster area), such that the individual was prevented from making arrangement for premium payment during the grace period for plan or Part D-IRMAA payment.

Examples of circumstances that would not constitute “Good Cause” include:

• Allegation that bills or warning notices were not received due to unreported change of address, out of town for vacation, visiting out of town family, etc;
• Authorized representative did not pay timely on customer’s behalf;
• Lack of understanding of the ramifications of not paying plan premiums or Part D-IRMAA