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What is disenrollment?
Remember, if you choose to leave the UPREHS Medicare Plans, they may not be offered to you again.
Disenrollment from the UPREHS HCPP means ending your membership in the UPREHS HCPP & Medicare Secondary Plan and the UPREHS Prime Medicare Plan pharmacy program. Disenrollment can be voluntary (your own choice) or involuntary (not your own choice).
- You might leave the UPREHS Medicare Plans because you have decided that you want to leave. You can do this for any reason. However, as we explain in this section, there are limits to when you may leave and how often you can make changes, and what your other choices are for receiving Medicare services, and how you can make changes.
- There are also a few situations where you would be required to leave. For example, you would have to leave the UPREHS Medicare Plans if we leave the Medicare program. We are not allowed to ask you to leave the plan because of your health.
Whether leaving the plan is your choice or not, this section explains your choices for continuing with Medicare after you leave and the rules that apply.
Eligibility for the UPREHS Medicare Plans
UPREHS Medicare Plan membership is restricted to certain UPREHS Medicare retirees and their spouse and is not offered to the public. UPREHS does not exclude or limit membership based on your health condition. UPREHS members with five consecutive years of current active or other retiree plan membership may be eligible for the UPREHS Medicare Plans when other stipulations are met. When you retire from active railroad employment, you must enroll in Medicare Parts A and B at the time of first eligibility and convert your UPREHS active or early retiree coverage to the UPREHS Medicare Plans. Continued eligibility for all other UPREHS plans terminates at the time of Medicare eligibility.
The UPREHS MSP pays supplemental benefits to Original Medicare. When a member refuses membership in the UPREHS Medicare Plans at the time of Medicare eligibility and enrollment, all other UPREHS plan eligibility ends, and no UPREHS plan, including the UPREHS Medicare Plans may be offered again.
The following stipulations apply to eligibility for membership in the UPREHS Medicare Plans: - Premiums for membership are paid monthly or quarterly (three months at-a-time) to UPREHS. Premiums must be paid on time. The UPREHS Board of Trustees determines the amount of premiums.
- Eligibility for the UPREHS Medicare Plans requires at least five years (60 months) of consecutive membership in UPREHS at the time of entitlement for Medicare Part A and enrollment in Part B.
- Failure to enroll in Medicare Part A and B at the time of first eligibility will terminate eligibility for all UPREHS plans unless you are still actively employed by the railroad.
- Medicare members are not permitted to duplicate benefits that are available from Medicare with benefits that are provided under any other UPREHS plan.
- A Medicare spouse (of a retiree who is a member of UPREHS Medicare Plans) is eligible for the UPREHS Medicare Plans when that spouse is entitled to Medicare Part A and enrolled in Part B. The UPREHS Medicare Plan benefits are the same for the Medicare spouse as those available to all Medicare plan members. Eligibility for UPREHS membership for a Medicare spouse terminates upon divorce.
- A Medicare spouse of an active working UPREHS member continues to have eligibility for health care coverage under the Railroad National Health and Welfare Dependent Plan. They are not eligible for the UPREHS Medicare Plans until the active working spouse becomes a Medicare retiree.
- A Medicare widow(er) is eligible for the UPREHS Medicare Plans when they become entitled to Medicare Part A and enrolled in Part B if the deceased spouse was a UPREHS member at the time of death. Eligibility for UPREHS membership for a Medicare widow(er) terminates upon remarriage.
Enrollment in the UPREHS Medicare Plans
UPREHS members must enroll in Medicare at the time of first eligibility and convert to the UPREHS Medicare Plans. Eligibility for all other UPREHS plans terminates at the time of Medicare eligibility. It is your — the member’s — responsibility to inform UPREHS when you become eligible for Medicare benefits. Informing UPREHS of your Medicare eligibility status is important so that you do not lose your rights to UPREHS Medicare Plan membership.
When you are eligible for Medicare, UPREHS mails a notice and application form to you so that you can convert your UPREHS plan coverage to the UPREHS Medicare Plans. The completed and signed application form is returned to UPREHS with proof of your Medicare enrollment. UPREHS then submits the information to Centers for Medicare and Medicaid Services (CMS) for approval. Once approved by CMS, UPREHS is authorized to make the Medicare HCPP Part B payment for your services, your secondary coverage starts under the UPREHS MSP, and you begin receiving your Medicare Part D pharmacy benefits through the UPREHS Prime Medicare Plan.
If you refuse membership in the UPREHS Medicare Plans or fail to inform UPREHS of Medicare eligibility at the time you first become eligible for Medicare, all other UPREHS plan eligibility ends, and no UPREHS plan, including the UPREHS Medicare Plans may be offered to you again. Members who disenroll from the UPREHS Medicare Plans may not be allowed to enroll again.
Effective date of enrollment in the UPREHS Medicare Plans
The effective date of your enrollment in the UPREHS Medicare Plans is the date indicated on the enrollment confirmation letter we send you after we receive your completed application. That date usually coincides with your Medicare effective date if you informed us in time. You will also receive information regarding premiums, your new UPREHS Health Insurance Card, your new UPREHS Prime Medicare Plan prescription drug ID card, a current UPREHS Prime Medicare Plan Benefit Guide and a UPREHS HCPP and Medicare Secondary Plan Benefit Guide.
You may continue to obtain services from the same UPREHS participating providers that you have used under other UPREHS plans. If you need a new list of UPREHS participating providers for your area, you may call UPREHS Customer Services at 1-800-547-0421 and order a customized directory. You may receive services from nonparticipating providers, but you will be responsible for payment of a portion of the charges. The UPREHS MSP reduces payment for covered benefits to nonparticipating providers to 40% of the allowed amount after Medicare payment.
Until your membership officially ends, you should continue receiving Medicare services from UPREHS participating providers or you will have to pay more for your services
If you leave UPREHS Medicare Plans, it may take time for your membership to end and your new way of getting Medicare to take effect. (When the changes take effect is discussed later in this section.)
While you are waiting for your membership to end, you are still a member and should continue to get your care as usual through UPREHS participating providers.
If you get services from doctors or other medical providers who are not participating providers before your membership in UPREHS ends, your Original Medicare Part A and B benefits continue, but you will have to pay the remainder of charges because your UPREHS MSP benefits are reduced to 40% after Medicare payment. The exceptions are urgently needed care, care for a medical emergency for the first 24 hours, and care that has been approved by us. There is another possible exception, if you happen to be hospitalized on the day your membership ends. If this happens to you, call UPREHS Customer Services at 1-800-547-0421 to find out if secondary benefits for your hospital care will be covered by UPREHS. If you have any questions about leaving UPREHS, please call our UPREHS Customer Services.
What you should do if you decide to leave the UPREHS Medicare Plans
Remember, if you leave the UPREHS Medicare Plans, they may not be offered to you again.
If you want to leave the UPREHS Medicare Plans:- The first step is to be sure that the type of change you want to make and the timing of this change fit with the new rules that we just explained about changing from one of your Medicare choices to another. If you are not following these rules, you won’t be allowed to make the change you request.
Then, as we explain below, what you must do to leave UPREHS depends on whether you want to continue with Original Medicare or switch to one of your other choices
When and how often can you change your Medicare choices
Remember, if you choose to leave the UPREHS Medicare Plans, they may not be offered to you again.
In general, there are only certain times during the year when you change the way you get Medicare.
Here are the rules: - From November 15 through December 31, during the Annual Coordinated Election Period (AEP), anyone with Medicare may switch from one way of getting Medicare to another for the following year. Your change will take effect on January 1. During the AEP, you are not limited in the type of change you may make to your coverage. You will not be able to re-enroll in the UPREHS Medicare Plans during any of these periods. See “Your choices and how to make changes if you leave the UPREHS Medicare Plans between November 15 and December 31” below for details.
- From January 1 until March 31, during the Medicare Advantage Open Enrollment Period (OEP), anyone eligible for Medicare Advantage has another chance to review the coverage they have and make one change. Your new enrollment will be effective the first day of the month that comes after the month we receive your request to leave. However, with this chance, you are limited in the type of plan you may join. You will not be able to re-enroll in the UPREHS Medicare Plans during any of these periods. You may not use this chance to add or drop Medicare prescription drug coverage. See Your choices and how to make changes if you leave the UPREHS Medicare Plans between January 1 and March 31 below for details.
Generally, you can’t make any other changes during the year unless you meet special exceptions, such as if you move or if you have Medicaid coverage. Contact us for information.
Your choices and how to make changes if you leave the UPREHS Medicare Plans between November 15th and December 31st
If you leave the UPREHS Medicare Plans between November 15 and December 31 (during the AEP), you have a number of choices for how you receive your Medicare after you leave. If they are available in your area, and if they are accepting new members, you can switch to any of the following types of plans:
- Other Medicare Advantage Plans (including PPOs, HMOs, and Private Fee-for-service plans) are available in some parts of the country. In HMOs and PPOs, you generally get all your Medicare-covered Part A and Part B healthcare through the plan. Medicare Advantage Plans may include prescription drug coverage as part of the Medicare Prescription Drug (Part D) benefit. Medicare pays a set amount of money for your care every month to these private health plans whether or not you use services.
- Original Medicare is available throughout the country. Original Medicare is a fee-for-service health plan that lets you go to any doctor, hospital, or other health care provider who accepts Medicare. You must pay a deductible. Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance). UPREHS Medicare Plan members have Original Medicare. Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance).
- Medicare Prescription Drug Plans ((PDPs) are stand-alone drug plans that only cover prescription drugs, not other benefits or services. If you choose Original Medicare and want to receive Medicare prescription drug coverage, you must join a Medicare Prescription Drug Plan.
- Other Medicare Health Plans (including Medicare Cost Plans, Programs of All-Inclusive Care for the Elderly (PACE), and Demonstrations) may be available. In some of these plans, you generally get all your Medicare-covered health care from that plan. This coverage may include prescription drug coverage.
NOTE: For more information about your choices, please refer to your 2008 Medicare & You book you received in the fall. You may also call 1-800-MEDICARE (1-800-633-4227), or visit www.medicare.gov to learn more about your choices.
If you want to switch from the UPREHS Medicare Plans to Original Medicare between November 15th and December 31st
Remember, if you leave the UPREHS Medicare Plans, they may not be offered to you again.
As a member of the UPREHS Medicare Plans, you already have Original Medicare and are receiving your Medicare benefits through them. If you want to leave the UPREHS Medicare Plans, so that you just have Original Medicare, you must tell us (or one of the offices listed below) that you want to leave UPREHS. You do not have to notify Original Medicare, because you will still automatically be in Original Medicare when you leave UPREHS. Here is how it works:
- First, use any of the following ways to tell us that you want to leave UPREHS:
- You can write or fax a letter to us and send it to Customer Services at UPREHS, PO Box 161020, Salt Lake City, UT 84116-1020, or to our fax number at 801-595-4399. Be sure to sign and date your letter.
- You can call 1-800-MEDICARE (1-800-633-4227), which is the national Medicare help line. TTY users should call 1-877-486-2048. You can call 24 hours a day, 7 days a week.
- We will then send you a letter that tells you when your membership will end. This is your disenrollment date — the day you officially leave UPREHS. Your disenrollment date will be the first day of the month that comes after the month we receive your request to leave, or, at your request, a later date of up to 3 months after we receive your request. For example, if we receive your request to leave during the month of February, your disenrollment date will be March 1. Remember, while you are waiting for your membership to end, you are still a member of UPREHS and continue to get your medical care as usual through our participating providers.
- On your disenrollment date, your membership in UPREHS ends, and you will no longer use your UPREHS Health Insurance ID card, your UPREHS Prime Medicare Plan prescription drug card but you will continue to use your red, white, and blue Medicare card to get services under Original Medicare. You will not get anything in writing that tells you that you have Original Medicare, because you are still automatically in Original Medicare when you leave UPREHS.
Your choices and how you make changes if you want to leave the UPREHS Medicare Plans between January 1st and March 31st
If you leave the UPREHS Medicare Plans between January 1st and March 31st, your Medicare coverage will revert to Original Medicare only. You will need to wait until November 15th through December 31st to join a Medicare Advantage Plan or join another Medicare Prescription Drug Plan.
Do you need to buy a Medigap (Medicare supplement insurance) policy to replace your UPREHS MSP?
Remember, if you leave the UPREHS Medicare Plans, they may not be offered to you again.
If you want to change from the UPREHS Medicare Plans to Original Medicare, you should think about needing to buy a Medigap policy to supplement your Original Medicare coverage to replace your UPREHS MSP. For Medigap advice, you should contact the SHIP in your state (see Section 1). You can ask SHIP about how and when to buy a Medigap policy if you need one. SHIP can tell you if you have a guaranteed issue right to buy a Medigap policy.
If you are at least 65 and have been eligible for Part B for less than six months, you may still be in your Medigap open enrollment period. If you leave our plan while you are still in your open enrollment period, a Medigap insurer cannot refuse to sell you any policy you choose or impose limits based on your health. You might also have a guaranteed issue right. This means that in certain circumstances, and for a limited period of time, a Medigap insurer must sell you a Medigap policy, even if you have health problems. In general, you do not have a guaranteed issue right if you simply decide to disenroll from the UPREHS Medicare Plans. However, for example, you have a guaranteed issue right to buy a Medigap policy if you are in a trial period. You may be in a trial period if, in the past 12 months you: (1) dropped a Medigap policy to join the UPREHS Medicare Plans or another Medicare health plan for the first time; or (2) joined the UPREHS Medicare Plans or another Medicare health plan when you first became entitled to Medicare at age 65. Under certain circumstances, if you lose your health plan coverage while you are still in a trial period, the trial period can last for an extra 12 months. You may also have a guaranteed issue right if you move out of our service area. Your SHIP can tell you about other situations where you may have guaranteed issue rights. If you do want to buy a Medigap policy, you have to follow the instructions below for changing from the UPREHS Medicare Plans to Original Medicare. Buying a Medigap policy does not switch you from the UPREHS Medicare Plans to Original Medicare. In fact, while you are still enrolled in the UPREHS Medicare Plans it is against the law for a Medigap insurance company to sell you a policy. A Medigap sales person or insurance agent cannot cancel your UPREHS membership and put you in Original Medicare.
How to switch from the UPREHS Medicare Plans to a Medicare Advantage Plan or Other Medicare Health Plan between November 15th and December 31st
Remember, if you leave the UPREHS Medicare Plans, they may not be offered to you again.
If you want to change from the UPREHS Medicare Plans to a Medicare Advantage Plan or to a Private Fee-for-Service Plan, here is what to do:
- Contact the plan you want to join to be sure it is accepting new members. Also ask the plan if it offers the Medicare Part D prescription drug benefit.
- Your new plan will tell you the date when your membership in that plan begins, and your membership in the UPREHS Medicare Plans will end on that same day (this will be your disenrollment date). Remember, you are still a member until your disenrollment date, and must continue to get your medical care as usual through UPREHS participating providers until the date your membership ends.
What happens to you if UPREHS leaves the Medicare program or leaves the area where you live?
If we leave the Medicare program or change our service area so that it no longer includes the area where you live, we will tell you in writing. If this happens, your membership in UPREHS will end, and you will have to change to another way of getting your Medicare benefits. All of the benefits and rules described in this booklet will continue until your membership ends. This means that you must continue to get your medical care in the usual way through UPREHS participating providers until your membership ends, or you will have to pay out-out-pocket for the MSP benefit reduction.
Your choices will always include continuing with Original Medicare and joining a Prescription Drug Plan to complement your Original Medicare coverage. Your choices may also include joining a Medicare Advantage Plan, or a Private Fee-for-Service Plan, if these plans are available in your area and are accepting new members. Once we have told you in writing that we are leaving the Medicare program or the area where you live, you may switch to another way of getting your Medicare benefits. If you decide to continue with Original Medicare, you will have the right to buy a Medigap policy regardless of your health. This is called a guaranteed issue right and it is explained earlier in this section.
UPREHS has a contract with the Centers for Medicare and Medicaid Services (CMS), the government agency that runs Medicare. This contract renews each year. At the end of each year, the contract is reviewed, and either UPREHS or CMS can decide to end it. You will get 60 days advance notice in this situation. It is also possible for our contract to end at some other time, too. In these situations, we will try to tell you 60 days in advance, but your advance notice may be as little as 30 or fewer days if CMS must end our contract in the middle of the year.
Whenever a Medicare health plan leaves the Medicare program or stops serving your area, you will be provided a special enrollment period to make choices about how you get Medicare, including whether to enroll in a Medicare Prescription Drug Plan and guaranteed issue rights to a Medigap policy.
Under certain conditions UPREHS can end your membership and make you leave the plan
We cannot ask you to leave the plan because of your health. No member of any Medicare health plan can be asked to leave the plan for any health-related reasons. If you ever feel that you are being encouraged or asked to leave UPREHS because of your health, you should call 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048), which is the national Medicare help line.
We can ask you to leave the plan under certain special conditions. If any of the following situations occur, we will need to end your membership in UPREHS: - If you do not stay continuously enrolled in both Medicare Part A and Medicare Part B.
- If you give us information on your enrollment form that you know is false or deliberately misleading, and it affects whether or not you can enroll in UPREHS.
- If you behave in a way that is unruly, uncooperative, disruptive, or abusive, and this behavior seriously affects our ability to arrange or provide medical care for you or for others who are members of UPREHS. We cannot make you leave UPREHS for this reason unless we get permission first from the Centers for Medicare & Medicaid Services, the government agency that runs Medicare.
- If you let someone else use your plan membership cards to get medical care or prescription drugs. Before we ask you to leave UPREHS for this reason, we must refer your case to the Inspector General, and that may result in criminal prosecution.
- If you do not pay the plan premiums, you have a 30-day grace period during which you can pay the plan premiums before you are required to leave UPREHS.
You have the right to make a complaint if we ask you to leave UPREHS
If we ask you to leave UPREHS, we will tell you our reasons in writing and explain how you can file a complaint against us if you want to.
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UPREHS. Plan for Life.™ 
