Members

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Disenrollment Rights

Disenrollment from SWH means ending your membership in SWH.

Ending your membership in our plan may be voluntary (your own choice) or involuntary (not your own choice):

  • You might leave SWH because you have decided that you want to leave. You can do this for any reason.
  • There are also a few situations where you would be required to leave. For example, you would have to leave SWH if you move permanently out of our geographic service area or if SWH leaves the Medicare program. Also, you may leave SWH if you become ineligible for MassHealth Standard (Medicaid).
  • 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 coverage choices after you leave and the rules that apply.

Voluntarily ending your membership

As a member of SWH, you may leave the program on the last day of the month, any month of the year.

Until your membership ends, you must keep getting your Medicare/MassHealth services through SWH or you will have to pay for them yourself. Also, prior to disenrollment from SWH, it is important that you secure a Medicare Part D prescription drug plan. You may contact 1-800-MEDICARE to select a plan or you may call SWH Member Services for assistance at 1-888-794-7268.

If you leave SWH, it may take some time for your membership to end and your new way of getting Medicare to take effect (we discuss when the change takes effect later in this section). While you are waiting for your membership to end, you are still a member and must continue to get your care as usual through SWH.

If you must get services from plan providers and doctors or other medical providers who are not plan providers before your membership with SWH ends, neither we nor the Medicare program will pay for these services, with just a few exceptions. The exceptions are urgently needed care, care for a medical emergency, 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 Member Services to find out if your hospital care will be covered by SWH. If you have any questions about leaving SWH, please call us at Member Services.

We cannot ask you to leave your health plan for any health-related reasons. If you ever feel that you are being encouraged or asked to leave SWH because of your health, you should call 1-800-MEDICARE (1-800-633-4227), which is the national Medicare help line. TTY users should call 1-877-486-2048. You may call 24-hours-a-day, 7-days-a-week.

Involuntarily ending your membership

If any of the following situations occur, we will end your membership in SWH.

  • If you move out of the service area, or are away from the service area for more than 6 months in a row. If you plan to move or take a long trip, please call Member Services to find out if the place you are moving to or traveling to is in our plan’s service area. If you move permanently out of our geographic service area, or if you are away from our service area for more than six months in a row, you cannot remain a member of SWH. In these situations, if you do not leave on your own, we must end your membership ("disenroll" you).
  • If you lose your MassHealth/Medicaid Standard status. If you receive a notice that you have lost your MassHealth Standard, please call Member Services at 1-888-794-7268. TTY users should call 1-888-749-6455. SWH will work with you to identify the reason for your loss of MassHealth Standard. SWH will assist you in making the necessary contacts. If you are unable to regain your MassHealth status, SWH will assist you in identifying a new Medicare plan and other services.
  • If you give us information on your enrollment request that you know is false or deliberately misleading, and it affects whether or not you can enroll in SWH.
  • If you behave in a way that is disruptive, to the extent that your continued enrollment seriously impairs our ability to arrange or provide medical care for you or for others who are members of our plan. We cannot make you leave SWH for this reason unless we get permission first from Medicare.
  • If you let someone else use your plan membership card to get medical care. If you are disenrolled for this reason, CMS may refer your case to the Inspector General for additional investigation.

Member Services: Our hours of operation are weekdays, Monday through Friday, from 8AM to 8PM, and also on Saturdays and Sundays from November 15th to March 1st. Someone is available, however, 24-hours a day, if assistance is needed. Interpreter services are available upon request.

  • 1-888-794-7268 (toll-free)
  • 1-888-749-6455 (TTY)

Last modified: 04/01/2010