Gateway Health Plan Medicare Assured^SM
Disenrollment Rights and Instructions

Voluntary Disenrollment

You may choose to disenroll from Gateway Health Plan Medicare Assured^SM at any time in one of the following ways:

• Contact us to request a Disenrollment Form
• Send us a fax or letter with signature
• Call 1-800-MEDICARE (1-800-633-4227). TTY Users should call 1-877-486-2048. You can call 24 hours a day, 7 days a week.

Click here for Gateway Health Plan Medicare Assured^SM contact information.

Involuntary Disenrollment

If any of the following situations occur, Gateway Health Plan Medicare Assured^SM may end your membership in our Plan.

• If you no longer are continuously enrolled with Medicaid.
• 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 do not stay continuously enrolled in Medicare A and B.
• 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 our Plan.
• If you behave in a way that is disruptive, to the extent that you 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 our Plan for this reason unless we get permission first from Medicare.
• If you let someone else use your Plan membership card to get medical care.

Please refer to the Gateway Health Plan Medicare Assured^SM Evidence of Coverage for complete information on disenrollment rights.