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How Can I Disenroll?

When can I end my membership (disenroll)?

Generally you can disenroll from a plan only once during each of the following timeframes:

  • January 1 – March 31
  • April 1 – June 30
  • July 1 – September 30
  • October 1 – December 31: You may request to disenroll, but the disenrollment won’t go into effect until January 1 of the following year.

What type of plan can I switch to?

If you decide to change to a new Medicare plan, you can choose:

  • Another Medicare health plan. You can choose a plan that covers prescription drugs or one that does not cover prescription drugs.
  • Original Medicare with a separate Medicare prescription drug plan.
  • If you switch to Original Medicare and do not enroll in a separate Medicare prescription drug plan, Medicare may enroll you in a drug plan, unless you have opted out of automatic enrollment.

Note: If you disenroll from Medicare prescription drug coverage and go without "creditable" prescription drug coverage, you may need to pay a late enrollment penalty if you join a Medicare drug plan later. ("Creditable" coverage means the coverage is expected to pay, on average, at least as much as Medicare's standard prescription drug coverage.) See chapter 10, section 2, of Evidence of Coverage (PDF) for more information about the late enrollment penalty.

When should I fill out a disenrollment request form?

  • You should fill out the disenrollment request form (PDF) and attestation of disenrollment (PDF) if you want to change to Original Medicare only and don't want Medicare prescription drug coverage.
  • You should not fill out the disenrollment form if you are planning to enroll, or have enrolled, in another Medicare Advantage or other Medicare health plan. Enrolling in another Medicare plan will automatically disenroll you from Keystone First VIP Choice.
  • Until your disenrollment date, you must keep using Keystone First VIP Choice's doctors. To avoid unexpected costs, you should contact us to make sure you've been disenrolled before you seek medical services outside of Keystone First VIP Choice's network.

How do I submit the disenrollment request?

If you want Original Medicare, as described above, you may fill out the disenrollment request form (PDF) and attestation of disenrollment (PDF), sign, and send them back to us. You can also fax the form (with a readable signature and date) to 1-855-822-9400.
Call 1-800-MEDICARE (1-800-633-4227; TTY/TDD 1-877-486-2048) for information about Medicare plans in your area.

When will my membership end?

Your membership will usually end on the first day of the month after we receive your request to change health plans. Your enrollment in the new plan will also begin on this day.

What about Medigap and my rights?

If you are changing to Original Medicare, you might have a special temporary right to buy a Medigap policy — also known as Medicare supplemental insurance — even if you have health problems.

For example, if you are age 65 or older and you enrolled in Medicare Part B within the past 6 months or if you move out of the service area, you may have this special right.

Federal law requires the protections described above.
Your state may have laws that provide more Medigap protections.

If you have questions about Medigap or Medigap rights in your state, you can get more information by:

Can Keystone First VIP Choice choose to disenroll me?

Yes, there are also some situations where you do not choose to leave, but we are required to end your membership.

Keystone First VIP Choice must end your membership in the plan if any of the following happen:

  • You do not stay continuously enrolled in Medicare Part A and Part B.
  • You are no longer eligible for Medicaid. Our plan is for people who are eligible for both Medicare and Medical Assistance (Medicaid).
  • You lose your Medical Assistance (Medicaid) eligibility. If this happens, the plan will deem you eligible for 6 months following the month we were notified of the loss. We will notify you by letter, and a Care Coordinator will assist you to recertify your Medical Assistance (Medicaid) eligibility.
  • Your Medical Assistance (Medicaid) is not recertified. If this happens, you will be disenrolled the first of the month following the 6-month eligibility period.
  • You move out of our service area.
  • You are away from our service area for more than 6 months.
  • You go to prison.
  • You lie about or withhold information about other insurance you have that provides prescription drug coverage.
  • 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.)
  • 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. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.)
  • You let someone else use your membership card to get medical care. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.)
  • You are required to pay the extra Part D amount because of your income and you do not pay it. If this happens, Medicare will disenroll you from our plan.

If you have questions or would like more information on when we can end your membership, call Member Services at 1-800-450-1166 (TTY/TDD 711), 8 a.m. to 8 p.m., 7 days a week.

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