PRIMETIME HEALTH PLAN

Transcription

1 AULTCARE'S PRIMETIME HEALTH PLAN INSTRUCTIONS ON HOW TO ENROLL IN PRIMETIME HEALTH PLAN _... YOU MUST LIVE IN THE PRIMETIME HEALTH PLAN SERVICE AREA, WHICH IS:..._ CARROLL, COLUMBIANA, HARRISON, HOLMES, MAHONING, MEDINA, LL PORTAGE, STARK, SUMMIT, TRUMBULL, TUSCARAWAS AND WAYNE COUNTIES 1-..J..J j:: :::> 1- <( I- I- C HAVE YOUR MEDICARE CARD AVAILABLE You must have both Medicare Part A and Part B to enroll in PrimeTime Health Plan. SIGN AND DATE THE ENROLLMENT FORM This enrollment form is not complete until you or your authoried representative have signed and dated the form on page 5. RETURN ENTIRE ENROLLMENT FORM You ill receive a Confirmation Letter once e receive confirmation of your enrollment from Centers for Medicare and Medicaid Services (CMS). Copies of your enrollment form are available upon request. You cannot have End-Stage Renal Disease at the time of enrollment, unless you do not need regular dialysis or have had a successful kidney transplant. (certain exceptions may apply) WOULD YOU LIKE FURTHER INFORMATION ON WHICH PRIMETIME HEALTH PLAN IS BEST FOR YOU? Call us at the numbers listed belo or attend one of our informational meetings. Ask us for dates and times. IF YOU NEED ASSISTANCE AT ANY TIME, PLEASE CONTACT PRIMETIME HEALTH PLAN CUSTOMER SERVICE AT OR (TTY USERS SHOULD CALL OR l ). OUR CALL CENTER IS OPEN MONDAY THROUGH FRIDAY FROM 8: a.m. TO 8: p.m., E.S.T. (OCTOBER lst- FEBRUARY 14TH, WE ARE AVAILABLE 7 DAYS A WEEK, 8: a.m. TO 8: p.m., E.S.T.) OUR LOBBY IS OPEN MONDAY THROUGH FRIDAY 8: a.m. TO 4:3 p.m., E.S.T. H3664_CY218APP Approved

2 AULTCARE'S ~PRIMETIME HEALTH PLAN 218 ENROLLMENT FORM Prime Time Health Plan is a Medicare Advantage HMO-POS Plan (Health Maintenance Organiation (HMO) ith a Point-of-Service (POS) option) PLEASE CHECK THE PLAN YOU WANT TO ENROLL IN: Premium Includes Prescription Drug Coverage D Aultimate Plan (HMO-POS) $ per month D Classic Plan (HMO-POS) $42 per month D Plus Plan (HMO-POS) $89 per month No Prescription Drug Coverage D Basic-MA Only Plan (HMO-POS)-14 - $ per month YOU MUST CONTINUE TO PAY YOUR MEDICARE PART B PREMIUM G TO ENROLL IN PRIMETIME HEALTH PLAN, PLEASE PROVIDE THE FOLLOWING INFORMATION: First Name: Middle Initial: Last Name: JR/SR Birth Date (mm/dd/yyyy): I I Sex: Home Phone Number: Permanent Residence Street Address (P. Box is not alloed): City: State: Zip Code: County: Mailing Address (Only ifdifferent from your Permanent Residence Address): 8 PLEASE PROVIDE YOUR MEDICARE INSURANCE INFORMATION: You MUST have Medicare Part A AND Part B to Join a Medicare Advantage Plan. City: State: Zip Code: Please take out your red, hite and blue Medicare card to complete this section. Fill out this information as it appears on your Medicare card. -OR- Attach a copy of your Medicare card or your letter from Social Security or the Railroad Retirement Board. Name (as it appears on your Medicare card): Medicare Number: Is Entitled To Effective Date HOSPITAL (Part A) MEDICAL (Part B) You must have Medicare Part A and Part B to join a Medicare Advantage plan. Individual Enrollment Form for PrimeTime Health Plan Medicare 218 Advantage Plans 1

3 YOUR PRIMARY CARE PHYSICIAN (PrimeTime Health Plan netork physician only): We request that all applicants include their primary care physician's name belo. For an up-to-date listing of PrimeTime Health Plan Netork Providers, visit.primetimehealthplan.com. Name of Primary Care Physician: ADDITIONAL CONTACT INFORMATION (Optional): Address: Mobile Phone Number: EMERGENCY CONTACT INFORMATION (Optional): Name: Phone: Relationship to you: PAYING YOUR PLAN PREMIUM: ZERO PREMIUM PLANS (With Prescription Dru2 Covera2e}: Ife determine that you oe a late enrollment penalty or if you currently have a late enrollment penalty, e need to kno ho you ould prefer to pay it. You can pay by mail or Electronic Funds Transfer (EFT) each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month. PLANS WITH PREMIUMS: You can pay your monthly plan premium (including any late enrollment penalty that you currently may have or may oe) by mail or Electronic Funds Transfer (EFT) each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month. PLANS WITH PRESCRIPTION DRUG COVERAGE: If you are assessed a Part D-Income Related Monthly Adjustment Amount, you ill be notified by the Social Security Administration. You ill be responsible for paying this extra amount in addition to your plan premium. You ill either have the amount ithheld from your Social Security benefit check or be billed directly by Medicare or the RRB. DO NOT PAY PRIMETIME HEALTH PLAN THE PART D-IRMAA. LIMITED INCOMES: People ith limited incomes may qualify for extra help to pay for their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those ho qualify ill not be subject to the coverage gap or late enrollment penalty. Many people are eligible for these savings and don't even kno it. For more information about this extra help, contact your local Social Security Office, or call Social Security at TTY users should call You can also apply for extra help online at.socialsecurity.gov/prescriptionhelp. Ifyou qualify for extra help ith your Medicare Prescription Drug Coverage Costs, Medicare ill pay all or part of your plan premium. IfMedicare pays only a portion of the premium, e ill bill you for the amount that Medicare doesn't cover. IF YOU DON'T SELECTA PAYMENT OPTION, YOU WILL GETA BILL EACH MONTH PLEASE SELECT APREMIUM PAYMENT OPTION: D Receive a monthly bill D Electronic Funds Transfer (EFT) from your bank account each month PLEASE ENCLOSE A VOIDED CHECK AND PROVIDE THE FOLLOWING: Account Holder Name: Bank Routing Number: Bank Account Number: D Automatic Deduction from your monthly Social Security Check D Automatic Deduction from your monthly Railroad Retirement Board (RRB) Benefit Check (The Social Security/RRB deduction may take to or more months to begin after Social Security or RRB approves the deduction. In most cases, if Social Security or RRB accepts your request for automatic deduction, the first deduction from your Social Security or RRB benefit check ill include all premiums due from your enrollment effective date up to the point ithholding begins. If Social Security or RRB does not approve your request for automatic deduction, e ill send you a paper bill for your monthly premiums.) 2

4 PLEASE READ AND ANSWER THESE IMPORTANT QUESTIONS: 1. Do you have End-Stage Renal Disease (ESRD)?... D Yes D No Ifyou have had a successful kidney transplant and/or you don't need regular dialysis any more, please attach a note or records from your doctor shoing you have had a successful kidney transplant or you don 't need dialysis. Otherise, e may need to contact you to obtain additional information. 2. Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal Employee Health Benefits Coverage, VA benefits or State Pharmaceutical Assistance Programs. Will you have other prescription drug coverage in addition to PrimeTime Health Plan?... D Yes If"yes", please list your other coverage and your identification (ID) number(s) for this coverage: D No Name of Coverage: ID#: Group#: 3. Are you enrolled in your State Medicaid Program?... D Yes D No If"yes", please provide your Medicaid Number: 4. Are you a resident in a long-term care facility, such as a nursing home?..... D Yes D No 5. Once enrolled in PrimeTime Health Plan, ill you or your spouse ork?... D Yes D No If"yes", is health care coverage provided?... D Yes D No If"yes", once enrolled, ill you continue to carry this coverage?... D Yes D No If"yes", does the employer have 2 or more employees?... D Yes D No 8 CONFIRM YOUR ENROLLMENT PERIOD: Please read the folloing statements carefully and check the box if the statement applies to you. By checking any of the folloing boxes, you are certifying that, to the best of your knoledge, you are eligible for an Enrollment Period. Ife later determine that this information is incorrect, you may be disenrolled. Typically, you may enroll in a Medicare Advantage Plan only during the Annual Enrollment Period from October 15 through December 7 ofeach year. There are exceptions that may allo you to enroll in a Medicare Advantage Plan outside ofthis period. D I am enrolling during the Annual Enrollment Period, October 15-December 7. D I am ne to Medicare. D I am leaving employer or union coverage. (insert date you ill lose coverage or lost coverage): / /. D I recently moved outside of the service area for my current plan or I recently moved and this plan is a ne option for me. I moved on (insert date): / /. D I recently returned to the United States after living permanently outside of the U.S. I returned to the U.S. on (insert date): / /. D I have both Medicare and Medicaid or my state helps pay for my Medicare Premiums. D I get extra help paying for Medicare Prescription Drug Coverage. D I no longer qualify for extra help paying for my Medicare Prescription Drugs. I stopped receiving extra help on (insert date): / /. 3

5 D I am moving into, live in, or recently moved out of a Long-Term Care Facility (For Example; a Nursing Horne or Long-Term Care Facility). I moved/ill move into/out of facility on (insert date): / /. D I recently left a PACE Program ithin the last to months. (insert date): / /. D I recently involuntarily lost my creditable prescription drug coverage (coverage as good as Medicare's) I lost my drug coverage on (insert date): / /. D I belong to a Pharmacy Assistance Program provided by my state. D My plan is ending its contract ith Medicare, or Medicare is ending its contract ith my plan. D I as enrolled in a Special Needs Plan (SNP), but I have lost the special needs qualification required to be in that plan. I as disenrolled from the SNP on (insert date): / I. D I as recently released from incarceration. I as released on (insert date): / /. D I recently obtained laful presence status in the United States. I got this status on (insert date): / /. If none of these statements apply to you or you're not sure, please contact PrimeTime Health Plan at OR (TTY users should call OR ). Our Call Center is open Monday through Friday from 8: a.m. to 8: p.m., E.S.T. (October 1st - February 14th, e are available 7 days a eek, 8: a.m. to 8: p.m., E.S.T.) Our Lobby is open Monday through Friday 8: a.m. to 4:3 p.m., E.S.T. Ifyou currently have health coverage from an employer or union, joining PrimeTime Health Plan could affect your employer or union health benefits. You could lose your employer or union health coverage if you join PrimeTime Health Plan. Read the communications your employer or union sends you. Ifyou have questions, visit their ebsite, or contact the office listed in their communications. Ifthere isn't any information on hom to contact, your benefits administrator or the office that ansers questions about your coverage can help. PLEASE READ AND SIGN ON PAGE 5 By completin~ this enrollment application, I a~ree to the folloin~: PrirneTirne Health Plan is a Medicare Advantage Plan and has a contract ith the Federal Government. I ill need to keep my Medicare Parts A and B. I can be in only one Medicare Advantage Plan at a time, and I understand that my enrollment in this plan ill automatically end my enrollment in another Medicare Health Plan or Prescription Drug Plan. It is my responsibility to inform you of any prescription drug coverage that I have or may get in the future. [Basic-MA Only Plan: I understand that ifl don't have Medicare prescription drug coverage or creditable prescription drug coverage (as good as Medicare's). I may have to pay a late enrollment penalty ifl enroll in Medicare prescription drug coverage in the future.] Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes only at certain times of the year hen an enrollment period is available (Example: October 15 -December 7 of every year), or under certain special circumstances. PrirneTirne Health Plan serves a specific service area. IfI move out of the area that Prime Time Health Plan serves, I need to notify the plan so I can disenroll and find a ne plan in my ne service area. Once I am a member of PrirneTirne Health Plan, I have the right to appeal plan decisions about payment or services if I disagree. I ill read the Evidence of Coverage Document from PrirneTirne Health Plan hen I get it to kno hich rules I must follo to get coverage ith this Medicare Advantage Plan. I understand that people ith Medicare aren't usually covered under Medicare hile out of the country except for limited coverage near the U.S. Border. 4

6 I understand that beginning on the date PrimeTime Health Plan coverage begins, I must get all of my health care from PrimeTime Health Plan, except for emergency or urgently needed services or out-of-area dialysis services. Services authoried by Prime Time Health Plan and other services contained in my Prime Time Health Plan Evidence ofcoverage Document (also knon as a member contract or subscriber agreement) ill be covered. Without authoriation, NEITHER MEDICARE NOR PRIMETIME HEALTH PLAN WILL PAY FOR THE SERVICES. I understand that if I am getting assistance from a sales agent, broker or other individual employed by or contracted ith PrimeTime Health Plan, he/she may be paid based on my enrollment in PrimeTime Health Plan. Release of Information: By joining this Medicare Health Plan, I acknoledge that PrimeTime Health Plan ill release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknoledge that PrimeTime Health Plan ill release my information (Plans ith prescription drug coverage: including my prescription drug event data) to Medicare, ho may release it for research and other purposes hich follo all applicable Federal statutes and regulations. The information on this enrollment form is correct to the best of my knoledge. I understand that if I intentionally provide false information on this form, I ill be disenrolled from the plan. PrimeTime Health Plan, or a vendor on behalf of PrimeTime Health Plan, may contact you for demographic, satisfaction, and/or medical care management information in accordance ith its obligations under Federal La. (FCC TCPA Ruling 215). I understand that my signature ( or the signature of the person authoried to act on my behalf under the las of the State here I live) on this application means that I have read and understand the contents ofthis application. Ifsigned by an authoried individual ( as described above), this signature certifies that: 1) this person is authoried under State la to complete this enrollment and 2) documentation of this authority is available upon request from Medicare. Signature: Today's Date: Ifyou are the authoried representative, you must sign above and provide the folloing information: Name: Address: Phone Number: ( ) Relationship to Enrollee: PrimeTime Health Plan is an HMO-POS plan ith a Medicare Contract. Enrollment in PrimeTime Health Plan depends on contract reneal. Ifyou need information in another language or in another format (like Braille, audiotape, or large print), please contact PrimeTime Health Plan at or (TTYusers should call or ). Our Call Center is open Monday through Friday from 8: a.m. to 8: p.m., E.S.T. (October 1st- February 14th, e are available 7 days a eek, 8: a.m. to 8: p.m., E.S.T.) AGENT/BROKER USE ONLY: Name ofagent Assisting ith Enrollment: AultCare Writing Code: Proposed Effective Date (Subject to CMS approval): PRIMETIME ELIGIBILITY USE ONLY: Date: Election: ICEP (I)_ IEP (E) _ SEP _ /SEP Reason AEP OEPI Member ID No: Rep Initials: 5