1. <151 Farmington Avenue, MS###
Hartford, CT 06156>
[Employee Name
Title (if needed)
Department
Telephone
Fax Number]
<Addressee
Street Address
City, State, Zip+4>
<Date>
You’re no longer eligible for Medicare and
Medicaid and need to take action
To be a member of <hpms_name>, you must be eligible for both Medicare and
Medicaid. We’re sending you a second notice because we see that you’re no longer
eligible for these programs. You need to take action now.
What you needto do
You have until <snp_deemed_eligib_end_date> to requalify for our plan.
<hpms_name> will continue to cover your Medicare benefits until then.
You need to reestablish your Medicaid eligibility status and enroll in a different plan by
<snp_deemed_eligib_start_date>. After this date, we’ll have to disenroll you from our
plan. Original Medicare will then cover you as of <snp_deemed_eligib_end_date>.
What to do if your coverage ends
When your <hpms_name> coverage ends, your Medicare prescription drug coverage
will end too. Before <snp_deemed_eligib_start_date>, you need to do one of these:
 Get new health care coverage and prescription drug coverage
 Buy a Medigap policy while you still have a guaranteed right to buy one

2. For example, if you’re returning to Original Medicare, you must join a Medicare
Prescription Drug Plan to get prescription drug coverage. Please remember, if you
disenroll from <hpms_name>:
 You need to get other creditable prescription drug coverage (as good as
Medicare’s prescription drug coverage)
 If you don’t get creditable prescription drug coverage, you may have to pay a
late enrollment penalty if you enroll in Medicare prescription drug coverage in
the future.
When you can join another plan
Because you’re no longer eligible for our plan, Medicare gives you a special, one-time
chance to change to a different Medicare Advantage plan or Medicare Prescription
Drug Plan.
 Your chance to do this starts now and it ends when you enroll in a different plan
or on <snp_other_plan_exp_dt>, whichever comes first.
 If you don’t take any action, <hpms_name> will continue to cover your Medicare
benefits until <snp_deemed_eligib_end_date>.
Once you use the one-time chance to change plans, there are limits to when, and how
often, you can change the way you get Medicare. Here are important dates to
remember:
 October 15 through December 7
- Anyone with Medicare can switch from one way of getting Medicare to
another for the following year.
- This includes adding or dropping Medicare prescription drug coverage.
 January 1 through February 14
- You can disenroll from a Medicare Advantage plan and return to Original
Medicare.
- You can add drug coverage to Original Medicare by joining a Medicare
Prescription Drug Plan.
- If you join a Medicare Prescription Drug Plan, we’ll disenroll you from our
plan and you’ll return to Original Medicare.
Generally, you can only make changes during these two time frames. However, there
are special exceptions:
 You move out of the plan’s service area
 You qualify for the Extra Help program, which helps with prescription drug costs

3. - If you qualify for Extra Help, you may enroll in, or disenroll from, a plan at
any time.
- If you lose Extra Help during the year, you can make a change for two
months after you find out that you no longer qualify for it.
About ExtraHelp
People with limited incomes may qualify for Extra Help to pay for their prescription
drug costs. Many people qualify for these savings and don’t even know it. If you qualify,
Medicare could pay for 75 percent or more of your drug costs. These include monthly
prescription drug premiums, annual deductibles and coinsurance. Also, you won’t have
a coverage gap or a late enrollment penalty.
For more information about Extra Help:
 Contact your local Social Security office.
 Call Social Security at <1-800-772-1213 (TTY: <1-800-325-0778>)>.
 Apply at www.socialsecurity.gov/prescriptionhelp.
If you disagree withour decisionor have questions
Please call us at <member _services_phone_number>. TTY users should call
<member_services_TTY_number#57>. We’re open from
<cust_serv_hours_of_operation#56, time zone>.
<Aetna Medicare is an HMO/PPO plan with a Medicare contract. Enrollment in Aetna
Medicare depends on contract renewal.> Plans are offered by Aetna Health Inc., Aetna
Health of California Inc., and/or Aetna Life Insurance Company (Aetna). Not all health
services are covered. See Evidence of Coverage for a complete description of benefits,
exclusions, limitations and conditions of coverage. Plan features and availability may
vary by location.
Aetna complies with applicable Federal civil rights laws and does not discriminate on the
basis of race, color, national origin, age, disability, or sex. ATTENTION: If you speak a
language other than English, free language assistance services are available. Visit our
website at www.aetnamedicare.com or call the phone number on your member
identification card. ESPAÑOL (SPANISH): ATENCIÓN: Si usted habla español, se
encuentran disponibles servicios gratuitos de asistencia de idiomas. Visite nuestro sitio
web en www.aetnamedicare.com o llame al número de teléfono que se indica en su tarjeta
de identificacion de afiliado. 繁體中文 (CHINESE):
請注意：如果您說中文，您可以獲得免費的語言協助服務。請造訪我們的網站www.aetn
amedicare.com 或致電您的會員卡上的電話號碼。

4. ©2016 Aetna Inc.
XX.XX.XXX.X (XX/16)
Y0022_2011_2043_399_Ex32a CMS Approval Date: 03/02/2011