Disenrollment

Ending your membership in Champion Health Plan may be voluntary (your own choice) or involuntary (not your own choice):

Please note these important points

• If Champion Health Plan ends your membership involuntarily, we will send you a notification telling you our reasons.
• If you disenroll from our plan voluntarily we will send you a confirmation letter acknowledging the receipt of your request and stating the effective date of your disenrollment
• You have the right to make a complaint if we end your membership in our Plan.

Voluntarily ending your membership

You can voluntarily disenroll from Champion Health Plan by submitting a written notification requesting to disenroll from our plan. Please include your name and member ID on the written letter and mail it to:

Champion Health Plan
Attn: Enrollment/Disenrollment
PO Box 15337
Long Beach, CA 90815-9995

You can also call 1-800-MEDICARE or switch to another Medicare organization. If you disenroll by calling 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week, or consult www.medicare.gov or switch to another Medicare organization, you do not need to submit written notification to Champion Health Plan. Your membership will end automatically once we receive the notification from Medicare. Once notification of the disenrollment request is received, typically your membership will end the first of the following month after the request is received.

If you leave our plan, it may take time before your membership ends and your new Medicare coverage goes into effect. During this time, you must continue to get your medical care and prescription drugs through our plan until your disenrollment goes into effect and your Champion Health Plan coverage ends.

Involuntarily ending your membership

Involuntary disenrollment means that Champion Health Plan can disenroll you from the plan if the following situations occur:

• If you no longer meet the eligibility requirements to remain a member of Champion Health Plan.
• If you engage in disruptive behavior, to the extent that your continued enrollment seriously impairs the ability to arrange or provide medical care for you or for others who are members of the Plan.
• If you provide fraudulent information on an enrollment request
• If you permit abuse of an enrollment card by letting someone else use your medical ID card. If you are disenrolled for this reason, the Centers for Medicare and Medicaid Services (CMS) may refer your case to the Inspector General for additional investigation.

If you are leaving our plan, you must continue to get your medical care through our plan until your membership ends.

For more information on ending your membership, please refer to your Evidence of Coverage (EOC) Document, Chapter 10 or click on this link to view an EOC online: Evidence of Coverage (EOC)