Disenrollment from the Passport Advantage (HMO-SNP) may occur voluntarily or involuntarily.
  • Voluntary disenrollment from the plan happens when you, the member, make the decision to leave the plan.
  • Involuntary disenrollment from the plan happens when you, the member, are required to leave the plan for reasons other than your decision.
Voluntary Disenrollment from Passport Advantage (HMO-SNP)

You can end your membership in Passport Advantage (HMO-SNP) at any time.

  • When can you end your membership? Most people with Medicare can end their membership only during certain times of the year. However, because you get assistance from Medicaid, you can end your membership in Passport Advantage at any time.
  • What type of plan can you switch to? If you decide to change to a new plan, you can choose any of the following types of Medicare plans:
    • Another Medicare health plan. (You can choose a plan that covers prescription drugs or on that does not cover prescription drugs.)
    • Original Medicare with a separate Medicare prescription drug plan.

Special Election Periods

  • This time periods occur when certain requirements are met. These Special Election Periods can happen at any time.
    • For a full list of the Special Election Periods, you can speak with our Member Services department at 1-844-859-6152 (TTY/TDD 711) or CMS at 1-800-MEDICARE.
  • Plan member can do the following during a Special Election Period:
    • Choose another Medicare plan.
    • Change back to Original Medicare.
    • Remember that disenrollment from prescription drug plan coverage can result in possible late enrollment penalties. Ask your Passport Advantage representative about LEP (Late Enrollment Penalty).
  • Changes made during the Special Election Period will take effect on the first day of the month after your change request is received.
  • You can voluntarily disenroll through the following means:
    • Submit a request to us in writing.
    • Enroll in another plan. This will disenroll you from your current plan.
    • Contact CMS at 1-800-MEDICARE.
Involuntary Disenrollment from Passport Advantage (HMO-SNP)
  • You will be involuntarily disenrolled from the plan if you fall into any variety of categories.  Some examples may include:
    • Change of residence
    • Loss of enrollment in Part A and/or Part B
    • Loss of special needs status
    • If you do not stay continuously enrolled in Medicare Part A and Part B
    • If you permanently move out of our service area.
    • If you are away from our service area for more than 6 months.
    • If you become incarcerated.
    • If you lie about or withhold information about other insurance you have that provides prescription drug coverage.
    • If you intentionally give us incorrect information when you are enrolling in our plan and that information affects your eligibility for our plan.
    • We cannot make you leave our plan for this reason unless we get permission from Medicare first.
    • If you continuously behave in a way that is disruptive and makes it difficult for us to provide medical care for you and other members of our plan.
    • If you let someone else use your membership card to get medical care.
  • For more information for the types of events that can cause involuntary disenrollment, please contact Passport Advantage’s Member Services department at 1-844-859-6152 (TTY/TDD 711); available from February 15 – September 30, Mon – Fri, 8 a.m. to 8 p.m. (EST) and  from October 1 to February 14, 7 days a week, 8 a.m. to 8 p.m. (EST) or Medicare at 1-800-Medicare (1-800-633-4227), 24 hours a day, 7 days a week; TTY users call 1-877-486-2048.
  • Involuntary disenrollments take effect based on the event that caused the involuntary disenrollment
  • If you are involuntarily disenrolled, please contact our Member Services department for more information on your next steps.

 


Disenrollment Information

The form below can be used for disenrollment or you may submit a letter in writing with your signature. Mail the completed document to the location below. If you have questions, please contact member services at 1-844-859-6152 (TTY/TDD 711); available from February 15 – September 30, Mon – Fri, 8 a.m. to 8 p.m. (EST) and  from October 1 to February 14, 7 days a week, 8 a.m. to 8 p.m. (EST).

For the Member Disenrollment form, click here.

Send your completed form to:

Passport Advantage
5100 Commerce Crossings Drive
Louisville, KY 40229

Last Modified: December 21, 2017