2015 Medi-Pak Advantage HMO Enrollment Form Instructions
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1 2015 Medi-Pak Advantage HMO Enrollment Form Instructions Please read first: You should use this enrollment form prior to October 15, 2014 only if you are: Requesting your enrollment be effective prior to January 1, 2015 First eligible for Medicare; or Eligible for a Special Election Period for example, you recently lost employer group health coverage. If you are completing this enrollment form to take advantage of the Annual Election Period (AEP) for an effective date of January 1, 2015, you cannot submit this form prior to October 15, If you would prefer, you can complete this same enrollment by: Going online to arkansasbluecross.com/medicare; or Calling (TTY ) 8 a.m. to 5 p.m., Monday through Friday Completely unfold the enrollment form and follow this simple checklist: SECTION 1 Provide the information requested. SECTION 2 Copy the information from your Medicare card to the enrollment form in the space provided, or attach a copy of the Medicare card itself. Please do not send your Medicare card. SECTION 3 Choose how you will pay your monthly premium. (Do not submit premium with the enrollment form.) If you choose Electronic Funds Transfer (EFT), please also provide the requested information. SECTION 4 Provide the information requested. Please include your primary care physician information. (If you need help finding a primary care physician, please give us a call.) SECTION 5 Sign and date the enrollment form. If you are the Medicare beneficiary s power of attorney, please provide the requested information below the signature section. Separate the copies of the enrollment form. Mail the top copy of the enrollment form in the postage paid envelope provided. Keep the bottom copy for your records. When we receive your completed enrollment form, we will contact the Centers for Medicare & Medicaid Services (CMS) for verification of your eligibility and effective date. If you have any questions regarding benefits, or how to enroll or complete this form, please call (TTY ) between the hours of 8 a.m. to 5 p.m., Monday through Friday. If you would like to contact Medi-Pak Advantage HMO customer service, please call tollfree (TTY 711), 8 a.m. to 8 p.m., 7 days a week. H9699_EI_2015_DR Accepted
2 2015 Health Advantage Medi-Pak Advantage HMO Enrollment Form Section 1 - To Enroll in Medi-Pak Advantage HMO, Please Provide the Following Information: Please check which plan you want to enroll in: R Medi-Pak Advantage HMO Please contact Medi-Pak Advantage HMO if you need information in another format. Last Name: First Name: Middle Initial: o Mr. o Mrs. o Ms. Birth Date: Sex: Home Phone Number: Alternate Phone Number: ( / / ) o M o F ( ) ( ) (M M / D D / Y Y Y Y) Permanent Residence Address (P.O. Box is not allowed): Street Address: City: County: State: ZIP Code: AR Mailing Address (Only if different from your Permanent Residence Address. May be your mailing address or another person that you would like to receive plan correspondence): Street Address: City: State: ZIP Code: Address: (Optional field) Section 2 Please Provide Your Medicare Insurance Information: Please take out your Medicare card to complete this section. Please fill in these blanks so they match your red, white and blue Medicare card. - OR - Attach a copy of your Medicare card or your letter from Social Security or the Railroad Retirement Board. (Please do not send your original Medicare card or letter.) You must have both Medicare Part A and Part B to join a Medicare Advantage plan such as Medi-Pak Advantage HMO. SAMPLE ONLY Name: Medicare Claim Number: - - Is Entitled To: HOSPITAL (Part A) MEDICAL (Part B) Sex: Effective Date:
3 Section 3 - Paying Your Plan Premium If CMS determines that you owe a late enrollment penalty (or if you currently have a late enrollment penalty), we need to know how would you prefer to pay it. You can pay your premium/ late enrollment penalty by mail or Electronic Funds Transfer (EFT) each month. You can also choose to pay your premium/late enrollment penalty by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month. If you are assessed a Part D-Income Related Monthly Adjustment Amount, you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security or RRB benefit check or be billed directly by Medicare. DO NOT pay Medi-Pak Advantage HMO the Part D-IRMAA. People with limited incomes may qualify for extra help to pay for their prescription drug costs. If you qualify, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify won t have a coverage gap or a late enrollment penalty. Many people are eligible for these savings and don t even know 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 If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn t cover. If you don t select a payment option, you will get a bill each month. Please select a premium payment option: o Get a monthly bill. o Electronic Funds Transfer (EFT) from your bank account each month. < Bank routing number < Bank account number Please enclose a VOIDED check or provide the following: Account holder name: Bank routing number: Bank account number: Account type: o Checking o Savings o Automatic deduction from your monthly Social Security or Railroad Retirement Board (RRB) benefit check. (The Social Security/RRB deduction may take two or more months to begin after Social Security or the RRB approves the deduction. In most cases, if Social Security or the RRB accepts your request for automatic deduction, the first deduction from your Social Security or RRB benefit check will include all premiums due from your enrollment effective date up to the point withholding begins. If Social Security or the RRB does not approve your request for automatic deduction, we will send you a paper bill for your monthly premiums.)
4 Section 4 - Please Read and Answer these Important Questions: 1. Do you have End Stage Renal Disease (ESRD)? o Yes o No If you have had a successful kidney transplant and/or you don t need regular dialysis anymore, please attach a note or records from your doctor showing you have had a successful kidney transplant or you don t need dialysis, otherwise we 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 Medi-Pak Advantage HMO? oyes o No If yes, please list your other coverage and your identification (ID) number(s) for this coverage: Name of other coverage: ID # for this coverage: Group # for this coverage: 3. Are you a resident in a long-term care facility, such as a nursing home? o Yes o No If yes, please provide the following information: Name of Institution: Address & Phone Number of Institution (number and street): 4. Are you enrolled in your State Medicaid program? o Yes o No If yes, please provide your Medicaid number: 5. Do you or your spouse work? o Yes o No Please list the name of your Primary Care Physician (PCP): First Name: Last Name: City: State: Zip: We will provide you with a paper copy of the Evidence of Coverage (EOC). If you would prefer to have EOC materials in large print, check here. o Please contact Medi-Pak Advantage HMO toll free at (TTY users 711) if you need additional information about this format. Our office hours are 8 a.m. to 8 p.m., 7 days a week. Please Stop and Read the Important Information Below If you currently have health coverage from an employer or union, joining Medi-Pak Advantage HMO could affect your employer or union health benefits. You could lose your employer or union health coverage completely and not get it back if you join Medi-Pak Advantage HMO. Read the communications your employer or union sends you. If you have questions, visit their Web site, or contact the office listed in their communications. If there isn t any information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.
5 Section 5 - Please Read and Sign Below By completing this enrollment application, I agree to the following: Health Advantage Medi-Pak Advantage HMO is a Medicare Advantage plan and has a contract with the Federal government. I will need to keep my Medicare Parts A and B. I can be in only one Medicare Advantage plan at a time, and I understand enrollment in this plan will 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. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave or make changes only at certain times of the year when an enrollment period is available (Example: Annual Enrollment Period every year), or under certain circumstances. Medi-Pak Advantage HMO serves a specific service area. If I move out of the area that Medi-Pak Advantage HMO serves, I need to notify the plan so I can disenroll and find a new plan in my new area. Once I am a member of Medi- Pak Advantage HMO, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage from Medi-Pak Advantage HMO when I get it to know which rules I must follow in order to get coverage with this Medicare Advantage plan. I understand that people with Medicare aren t usually covered under Medicare while out of the country except for limited coverage near the U.S. border. I understand that beginning on the date Medi-Pak Advantage HMO coverage begins, using services in-network can cost less than using services out-of-network, except for emergency or urgently needed services or out-of-area dialysis services. If medically necessary, Medi-Pak Advantage HMO provides refunds for all covered benefits, even if I get services out of network. Services authorized by Medi-Pak Advantage HMO and other services contained in my Medi-Pak Advantage HMO Evidence of Coverage document will be covered. Without authorization, NEITHER MEDICARE NOR Medi-Pak Advantage HMO 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 with Medi-Pak Advantage HMO, he/she may be paid based on my enrollment in Medi-Pak Advantage HMO. Release of Information: By joining this Medicare health plan, I acknowledge that the Medi-Pak Advantage HMO will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that Medi-Pak Advantage HMO will release my information including my prescription drug event data, to Medicare, who may release it for research and other purposes which follow all applicable federal statutes and regulations. The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan. I understand that my signature (or the signature of the person authorized to act on my behalf under the laws of the state where I live) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (as described above), this signature certifies that 1) this person is authorized under State law to complete this enrollment and 2) documentation of this authority is available upon request from Medicare. Your Signature: Today s Date: If you are the authorized representative, you must sign above and provide the following information: Name: Address: City: State: ZIP Code: Phone Number: ( ) - Relationship to Enrollee:
6 Typically, you may enroll in a Medicare Advantage Plan only during the Annual Enrollment Period each year. There are exceptions that may allow you to enroll in a Medicare Advantage plan outside of this period. Please read the following statements carefully and check the box if the statement applies to you. By checking any of the following boxes you are certifying that, to the best of your knowledge, you are eligible for an Enrollment Period. If we later determine that this information is incorrect, you may be disenrolled. 1. o I m leaving employer or union coverage (including COBRA) on ( / / ) (MM/DD/YYYY). 2. o I recently moved outside of the service area for my current plan or I recently moved and this plan is a new option for me. I moved/will move on ( / / ) (MM/DD/YYYY). I notified my health plan about my move on ( / / ) (MM/DD/YYYY). 3. o I recently returned to the United States after living permanently outside of the U. S. I returned to the U. S. on ( / / ) (MM/DD/YYYY). 4. o I have both Medicare and Medicaid or my state helps pay for my Medicare premiums. 5. o I get extra help paying for Medicare prescription drug coverage. 6. o I no longer qualify for extra help paying for my Medicare prescription drugs. I received notice of the loss on ( / / ) (MM/DD/YYYY). 7. o I m no longer eligible for Title XIX (Medicaid) benefits. I received notice of the loss on ( / / ) (MM/DD/YYYY). 8. o I recently was notified that I, involuntarily, will lose/have lost my coverage that is creditable prescription drug coverage (coverage as good as Medicare s). I was notified of the loss on ( / / ) (MM/DD/YYYY). I lost/will lose my coverage on ( / / ) (MM/DD/YYYY). 9. o I m moving into or live in a Long Term Care facility (for example, a nursing home or Long Term Care facility). I moved/will move into the facility on ( / / ) (MM/DD/YYYY). 10. o I recently moved out of a Long Term Care facility (for example, a nursing home or Long Term Care facility). I moved out of the facility on ( / / ) (MM/DD/YYYY). 11. o I m being disenrolled from a Medicare Special Needs Plan because I no longer have Special Needs status. I was notified of this change in status on ( / / ) (MM/DD/YYYY) and I m disenrolling/i disenrolled on ( / / ) (MM/DD/YYYY). 12. o I recently left a PACE program on ( / / ) (MM/DD/YYYY). 13. o I m new to Medicare with a retroactive Medicare effective date. I received notice of my entitlement on ( / / ) (MM/DD/YYYY). 14. o My Medicare Advantage Organization notified me that my plan terminates on ( / / ) (MM/DD/YYYY). 15. o I m new to Medicare. 16. o None of these statements apply to me.* *Please contact Medi-Pak Advantage HMO at (TTY users should call 711), 8 a.m. to 8 p.m., 7 days a week to see if you are eligible to enroll. For Agent and Office Use Only: Plan ID #: H9699 Requested Effective Date of Coverage: Sales Representative Signature: X Sales Representative s Name (please print) Plan Representative Name: Agent Information: Date Signed: P.O. Box 3835, Scranton, PA 18505, ATTN: Medi-Pak Choice Enrollment
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