Beneficiary Eligibility
Members who wish to enroll in Healthy Advantage (HMO), a Medicare Advantage SNP, must meet the following criteria:
- Be enrolled in both Medicare Part A and Part B;
- Be enrolled in Medicaid;
- Not be medically determined to have End-Stage Renal Disease (ESRD) prior to completing the enrollment form;
- Permanently reside in the Healthy Advantage (HMO) service area (Davis, Salt Lake, Weber and/or Utah Counties);
- Beneficiary or beneficiary's legal representative completes an enrollment election form completely and accurately;
- Beneficiary is fully informed and agrees to abide by the rules of Healthy Advantage (HMO); and
- Is entitled to elect Healthy Advantage (HMO) according to the election rules that apply to the beneficiary.
Healthy Advantage (HMO) will accept all Members that meet the above criteria and elect Healthy Advantage (HMO) during appropriate enrollment periods without reference to race, color, national origin, sex, religion, age, disability, political affiliations, sexual orientation or family status.
Beneficiary Enrollment/Disenrollment Information for Healthy Advantage (HMO)
All Members of Healthy Advantage (HMO) are dual eligible (i.e. they receive both Medicare and Medicaid); therefore, Centers for Medicare & Medicaid
Services (CMS) rules state that these Members may enroll or disenroll from Healthy Advantage (HMO) on a monthly basis.
Persons who are dually eligible have special enrollment options. Additional information regarding enrollment and disenrollment are available on
the following CMS Websites:
CMS - People with Medicare & Medicaid
CMS Manuals
Prospective Members may call the Healthy Advantage (HMO) Potential Member Customer Services Department - 1-866-472-9479 or TTY toll free at (800) 346-4128, Monday through Sunday 8 a.m. to 8 p.m.
The effective date of coverage for Healthy Advantage (HMO) Members will be the first (1st) day of the month following the acceptance of a completed application form by the Member or the Member's authorized representative.
An enrollment cannot be effective prior to the date the beneficiary or their legal representative signed the enrollment form or completed the enrollment election.
During the applicable enrollment periods, if Healthy Advantage (HMO) receives a completed enrollment form on the last day of the month, Healthy Advantage (HMO) ensures that the effective date is the first (1st) day of the following month.
Disenrollment
Staff Members of UUHP may never, verbally, in writing, or by any other action or inaction, request or encourage a Medicare Member to
disenroll except when the Member has:
- Moved outside the geographic service area;
- Committed fraud;
- Abused their membership card;
- Displayed disruptive behavior;
- Lost Medicare Part A or B;
- Died; or
- Other justifiable causes as outlined below.
The Healthy Advantage (HMO) Membership Accounting Department is responsible for the involuntary disenrollment of any such Member, as it pertains to all other types of non-compliant behavior.
When Members permanently move out of the service area, or leave the service area for over six (6) consecutive months, they must disenroll from Healthy Advantage (HMO). There are a number of ways that the Membership Accounting Department may be informed that the Member has relocated. The majority of time, out-of-area notification will be received from The CMS on the monthly Membership report.
On occasion, the Member will call to advise Healthy Advantage (HMO) that they have relocated. Other means of notification can be made through the Claims Department, if out-of-area claims are received with a residential address other that the one on file.
Healthy Advantage (HMO) does not offer a visitor/traveler program to Members.
Requested Disenrollment
Healthy Advantage (HMO) will request disenrollment of Members from the health plan only as allowed by CMS regulations.
Healthy Advantage (HMO) will request that a Member be disenrolled from the Health Plan under the following circumstances:
- The Member requests disenrollment;
- The Member provided fraudulent information on the election form; or
- The Member has engaged in disruptive behavior;
Disruptive behavior is defined as behavior that substantially impairs the plan's ability to arrange for or provide services to the individual or other plan Members. An individual cannot be considered disruptive if such behavior is related to the use of medical services or compliance (or noncompliance) with medical advice or treatment.
Healthy Advantage (HMO) will attempt to resolve the issues surrounding the disruptive behavior including providing reasonable accommodations, as determined by CMS, for individuals with mental or cognitive conditions, including mental illness and developmental disabilities. In addition, Healthy Advantage (HMO) will inform the individual of the right to use the organization's grievance procedures. The beneficiary has a right to submit any information or explanation to Healthy Advantage (HMO) before requesting disenrollment from CMS; and
Healthy Advantage (HMO) will document and provide CMS with the documentation of the enrollee's behavior and efforts to resolve any problems, and any extenuating circumstances. Healthy Advantage (HMO) will request from CMS the desire to decline future enrollment by the individual.
If CMS agrees with Healthy Advantage (HMO)'s assessment of the situation and agrees to the disenrollment, the individual's disenrollment will be processed within twenty (20) days. The disenrollment will be effective the first (1st) day of the calendar month after the month in which Healthy Advantage (HMO) gives the individual notice of the disenrollment.
Other reasons for the disenrollment may be one of the following
- The Member abuses the enrollment card by allowing others to use it to obtain fraudulent services;
- The Member leaves the service area and directly notifies Healthy Advantage (HMO) of the permanent change of residence;
- If the Member has not permanently moved but has been out of the service area for six (6) months or more, Healthy Advantage (HMO) will request that the Member be disenrolled;
- The Member loses entitlement to Medicare Part A or Part B benefits;
- The Member dies;
- The Member loses Medicaid eligibility;
- Members enrolled in the SNP for Institutionalized beneficiaries lose their eligibility for the plan if they no longer qualify for institutionalized services;
- Healthy Advantage (HMO) loses or terminates its contract with CMS;
- In the event of plan termination by CMS, Healthy Advantage (HMO) will send CMS approved notices and a description of alternatives for obtaining benefits under the Healthy Advantage (HMO) Program. The notice will be sent timely, before the termination of the plan; or
- Healthy Advantage (HMO) discontinues offering services in specific service areas where the Member resides.
For members to enroll, please go to Healthy Advantage (HMO) Member Enrollment.
Please click here* to download a printable copy of the enrollment form. Please follow the instructions on the form to apply. We encourage you to read the Summary of Benefits before completing an enrollment form.
If members need help enrolling, please call us at 1-866-472-9479
(TTY/TDD 1-800-346-4128) from 8:00 a.m. to 8:00 p.m. Monday - Sunday
Paper copies of information posted on our web site are available upon request.
University Health Plans, a health plan with a Medicare contract, offers Healthy Advantange a Medicare Advantage Prescription Drug Special Needs Plan (MAPD-SNP).
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