2018 Optional Benefit Individual Enrollment Form

Transcription

1 Allwell Medicare s 2018 Optional Benefit Individual Enrollment Fm Allwell Medicare offers optional benefits f an additional monthly plan premium. This fm may be used only by our current members who are adding the Optional Benefits to their existing Allwell Medicare who are already enrolled in an Optional Benefit and are switching to a different package option. Please review the plan package options listed on this fm befe enrolling. The premium f optional supplemental benefits is paid in addition to the monthly plan premium and the Medicare Part B premium. PLEASE PRINT Name as it appears on Medicare card Last First MI Permanent residence address City State ZIP County of permanent residence address Mailing address (if different from above) Phone number City State ZIP address Medicare # (from red, white and blue Medicare card) Birth date M M D D Y Y Y Y Allwell Medicare Sex M F After you have completed this fm, please mail it to: Allwell, PO Box 2020, Farmington, MO Y0020_18_3746FORM_FINAL_3906 Approved

2 Please complete this section if you are enrolling in an Optional Benefits I am currently enrolled in an Allwell Medicare, paying a monthly plan premium of $ and wish to enroll in the Optional Benefits # f an additional monthly premium of $. Please complete this section if you are a current member and are switching Optional Benefits s I am currently enrolled in an Allwell Medicare, AND Optional Benefits # and wish to switch to Optional Benefits # f an additional monthly premium of $. Please do not use this fm to change Allwell Medicare s. If choosing a that includes dental, please make a dental provider selection from the Allwell Dental Provider Directy. Provider name Provider ID # New members can enroll until the end of the first month of initial enrollment. Benefits will become effective the first of the following month. I understand that to be eligible f the Optional Supplemental Benefits, I must remain a member of an Allwell Medicare. If I disenroll from my plan, I will be automatically disenrolled from the Optional Supplemental Benefits. If I discontinue payment of the Optional Supplemental Benefits, my membership in the Optional Supplemental Benefits will be terminated, and my Medicare (medical) plan enrollment status will not be affected. My coverage will default to my standard Allwell Medicare (medical) plan only. You may disenroll at any time from this option by providing written notice to Allwell, but once disenrolled, reenrollment during the same calendar year will be limited. The available election periods f the optional benefits are from October 15, 2017, through December 31, 2017, f a January 1, 2018, effective date; January 1, 2018, through January 31, 2018, f a February 1, 2018, effective date; from May 15, 2018, through June 30, 2018, f a July 1, 2018, effective date. When electing the HMO option, you understand that, beginning with the effective date of coverage f this Optional Benefits, in der f services to be covered, you must obtain those services through Allwell -contracted providers, with the exception of emergency urgently needed services as described in the Summary of Benefits Evidence of Coverage (EOC). If an Allwell provider denies a request f service payment of a claim, you may appeal the denial decision by using the Medicare appeals process as described in your Evidence of Coverage (EOC). Allwell will notify you when your effective date of coverage begins.

3 Release of infmation I allow the Centers f Medicare & Medicaid Services (CMS) to give infmation to the, and I allow the, s docts and clinics, anyone else with medical other relevant infmation about me, to give CMS CMS s agents the infmation needed to run the Medicare program. I also give the authization to release necessary other relevant infmation about me to service providers. I understand that my signature on this application means that I have read and understand the contents of this application and agree to abide by the plan rules concerning the optional benefits plans. (Please read your Evidence of Coverage document to know what rules you must follow in der to receive coverage with Allwell.) Print name Signature Date M M D D Y Y Y Y If you are the authized representative, you must provide the following infmation Last name First name MI Address City State ZIP code Relationship to applicant Phone number Thank you f choosing Allwell. If you have questions, please call (TTY users should call 711). From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends, and on federal holidays. OFFICE USE ONLY: Group # Crection of member infmation Effective date of coverage M M D D Y Y Y Y

4 Please review the options befe enrolling in an Optional Benefits. Allwell Medicare Complement (HMO), Allwell CHF/Diabetes Medicare (HMO SNP), Allwell Medicare Select (HMO), Allwell Cardio Medicare (HMO SNP), Allwell Medicare Premier (HMO), Allwell Medicare (HMO), Allwell Medicare Essentials I (HMO), Allwell Medicare Essentials II (HMO) Optional Benefit s Counties Complement Cochise #1 #2 Maricopa #1 #2 Pima Pinal Santa Cruz #1 #2 #1 #2 CHF/ Diabetes Select #5 Cardio Premier Medicare #1 #2 #1 #2 #1 #2 Essentials I Essentials II Please refer to the Summary of Benefits Evidence of Coverage (EOC) f detailed infmation, service areas, benefit premiums, and costs associated with each plan. Some plans are not available in all service areas. #1 Monthly plan premium: $49 Benefits: chiropractic/acupuncture, HMO dental and eyewear #2 Monthly plan premium: $25 Benefits: chiropractic/acupuncture, HMO dental and eyewear #3 Monthly plan premium: $45 Benefits: chiropractic/acupuncture and HMO dental Monthly plan premium: $21 Benefits: HMO dental #5 Monthly plan premium: $4 Benefits: chiropractic/acupuncture

5 Allwell complies with applicable federal civil rights laws and does not discriminate on the basis of race, col, national igin, age, disability, sex. Allwell does not exclude people treat them differently because of race, col, national igin, age, disability, sex. Allwell: Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written infmation in other fmats (large print, accessible electronic fmats, other fmats). Provides free language services to people whose primary language is not English, such as qualified interpreters and infmation written in other languages. If you need these services, contact Allwell s Member Services at: (HMO and HMO SNP) (TTY: 711). From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends, and on federal holidays. If you believe that Allwell has failed to provide these services discriminated in another way on the basis of race, col, national igin, age, disability, sex, you can file a grievance by calling the number above and telling them you need help filing a grievance; Allwell s Member Services is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office f Civil Rights, electronically through the Office f Civil Rights Complaint Ptal, available at by mail phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, (TDD: ). Complaint fms are available at Allwell is an HMO and HMO SNP plan with a Medicare contract. Allwell is a Codinated Care plan with a Medicare contract and a contract with the Arizona Medicaid program. Enrollment in Allwell depends on contract renewal. This infmation is not a complete description of benefits. Contact the plan f me infmation. Limitations, copayments and restrictions may apply. Benefits, premiums and/ copayments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. FRM014275EO00 (8/17)

6 SPANISH NAVAJO CHINESE VIETNAMESE ARABIC TAGALOG KOREAN FRENCH GERMAN RUSSIAN JAPANESE PERSIAN SYRIAC SERBOCROATIAN THAI ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (HMO and HMO SNP) (TTY: 711). SHOO KWE $: Din4 bizaad bee y1ni[ti go, saad bee 1ka e eyeed bee 1ka an7da awo, t 11 j77k eh, nih1 h0l=. kohj8 biniiy1 holne doolee[ (HMO and HMO SNP) (TTY: 711). 注意 : 如果您說中文, 您可以免費獲得語言援助服務 請致電 (HMO and HMO SNP) (TTY: 711) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (HMO and HMO SNP) (TTY: 711). تنبيھ: إذا كنت تتحدث العربية فإن خدمات المساعدة اللغوية المجانية متاحة لك. ي رجى االتصال بالرقم. SNP) (HMO and HMO (مكبالو مصال فتاھ مقر:.(711 PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (HMO and HMO SNP) (TTY: 711). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (HMO and HMO SNP) (TTY: 711) 번으로전화해주십시오. ATTENTION : Si vous parlez français, des services d aide linguistique vous sont proposés gratuitement. Appelez le (HMO and HMO SNP) (TTY: 711). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (HMO and HMO SNP) (TTY: 711). Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (HMO and HMO SNP) (TTY: 711). 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (HMO and HMO SNP) (TTY: 711) まで お電話にてご連絡ください توجھ: اگر بھ زبان فارسی گفتگو می کنيد تسھيالت زبانی بصورت رايگان برای شما فراھم می باشد. با ܓ 711) (TTY: (HMO and HMO SNP) تماس بگيريد. ܗܪ ܐ ܢ ܬܘ ܢ ܪ ܬ ܐ ܕܗ ܬ ܐ ܕ ܐ ܘ ܢ ܘ ܢ ܐ ܐ ܢ (HMO and HMO SNP) (TTY: 711) OBAVJEŠTENJE: Ako govite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite (HMO and HMO SNP) (TTY: 711). เร ยน: ถ าค ณพ ดภาษาไทยค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร โทร (HMO and HMO SNP) (TTY: 711).