hsainsurance.com New Case Submission Checklist Tufts Health Plan Tufts Medicare Preferred HMO Prime For Working-Aged Employees Check if Complete To ensure that your applications are processed as quickly as possible, just follow this checklist Employer completes and signs the New Group Application For Working-Aged Employees. Employer checks off choice of plan and Rx option Employer encloses the first monthly premium (Payable to HSA). Employer provides copy of most recent Schedule C or WR-1. Enclose the first monthly premium (Payable to HSA) or pay online at www.hsainsurance.com. If paying online, Indicate Confirmation Number from online payment to Unibank Online payment is not a guarantee of coverage. Completed enrollment materials must be received by carrier deadline. Eligible enrollee completes Employer Group HMO Election Form. Eligible enrollee writes in their Medicare number and effective dates of Part A and B on Election Form and includes a copy of their Medicare card or letter from the Social Security Administration. Eligible enrollee selects a Primary Care Physician on Election Form. Eligible enrollee signs and dates the Election Form. HSA Main Office 135 Wood Road Braintree, MA 02184 Send all required documents (including this checklist) to: Sales Rep: Contact Info: HSA Regional Office 574 Boston Road Billerica, MA 01821 Special instructions: All coverage will be effective on the 1 st day of the month. Enrollment materials should be received by the 25 th of the preceding month. Keep a copy of your application as your temporary ID. Once your enrollment have been approved and processed, you will receive a member confirmation by mail with your group number. Your permanent ID cards will be issued to you directly from the carrier. Permanent ID cards generally take 7-10 business days from date your enrollment was approved and processed. www.hsainsurance.com 781-848-4950 877-777-4414
hsainsurance.com Medicare Preferred HMO Prime Thank you for your inquiry into the HSA sponsored group Medicare HMO Advantage Plans by Tufts Health Plan. This plan offers more benefits at lower cost than most other options available to Medicare eligible recipients in Massachusetts. Foremost among the added benefits is unlimited prescription drug coverage. This Medicare plan has two Rx benefit options: Preferred HMO Rx, copays of $10/$25/$50, $282 monthly premium Preferred HMO Rx Plus, copays of $10/$20/$35, $288 monthly premium Premiums are guaranteed through December 31, 2015. Eligible Companies An Eligible company is one that: Employs less than 20 total employees (includes full and part time) Is actively in business. Is located in the Medicare Preferred service area. Is a member in good standing of HSA Eligibility Guidelines Eligible Enrollee An eligible enrollee is one that: Is enrolled in Medicare Part A and Part B Lives in the Medicare Preferred service area Working Aged: Is a full-time employee. Part-time employees are not eligible. Retired: Is no longer working for this employer. Effective Dates All coverage will be effective on the 1 st day of the month Applications must be received by MBA by the 25 th of the month. Corporate Office: 135 Wood Rd, Braintree, MA 02184 (781) 848-4950 (877) 777-4414 (781) 848-7020 fax
new group application for medicare eligible working-aged employees please answer every question completely Effective date: (Will renew in January) please check the box for your chosen plan below: Tufts Medicare Preferred HMO Prime Group Rx ($10/$25/$50) Group Rx Plus ($10/$20/$35) Tufts Medicare Complement (TMC) With prescription drug coverage (TMC Rx Plus $8/$20/$35) With prescription drug coverage (TMC Rx $10/$25/$50) No prescription drug coverage group information Full legal name of group: (the Group ) Corporate headquarters address: City: State: Zip: Contact name: Title: Mailing address (if different): Billing address (if different): Billing contact name (if different): Title: Phone #: ( ) Fax #: ( ) Email address: Web site: SIC code: Organization type: Date business established: Tax I.D. number: Number of full time employees: Number of part time employees: Number of seasonal employees: How many were employed 12 months ago? Intermediaries_9/11
group information (continued) How many employees are eligible for health insurance? Is this group a: Corporation Partnership Sole Proprietorship Other If other, please specify: Is the group a subsidiary, an affiliate or branch of a parent company with more than 50 employees? Yes No If yes, what is the total number of employees in all locations? Subsidiaries or affiliates to be covered and locations: Are there office locations other than the one listed above? Yes No If yes, what are they? Do you offer group Commercial insurance for your employees? If yes, current carrier(s): information related to medicare secondary payer (MSP) Group attests that Group has fewer than 20 employees as defined in the Medicare Secondary Payer regulations at 42 CFR 411.170: An employer is considered to employ 20 or more employees if the employer has 20 or more employees for each working day in each of 20 or more calendar weeks in the current calendar year or the preceding calendar year. The total number of current employees who receive wages, tips, or other compensation (refer to line 1 of your most recent federal tax return form 941 or 944): Previous Year Current Year Q1 Q1 Q2 Q2 Q3 Q3 Q4 Q4 (includes FT, PT, seasonal, new hire); as of this date (mm/dd/yy). 2 Intermediaries_9/11
IMPORTANT Group represents and warrants that Group is actively engaged in business, and coverage will become effective only upon Tufts Health Plan s acceptance of this application and payment of the required premium or fee at rates Tufts Health Plan determines. If approved, the effective date of coverage will be the effective date mutually agreed upon between Tufts Health Plan and the employer, however coverage will renew on January 1 every calendar year. Group further acknowledges that Group has fewer than 20 employees as defined in the Medicare Secondary Payer statute 42 U.S.C. 1395y. Group will immediately notify Tufts Health Plan if Group s employee count according to the Medicare Secondary Payer statute were to change so that it is no longer eligible for Medicare to be the primary payer. In the event of this change, Group acknowledges that the Group s Medicare eligible employees would no longer be eligible for this product. The Group acknowledges that it offers the coverage described under this agreement to all of its full-time Medicare eligible employees who live in the commonwealth. The Group further acknowledges that it does not make a smaller premium contribution percentage amount to any employees than it makes to any other employees who receive an equal or greater total hourly or annual salary for each specific health plan offered. However, the Group may establish separate contribution percentages for employees covered by collective bargaining agreements. Group acknowledges that if Group commits fraud or misrepresents matters related to this application, Tufts Health Plan has the authority to retroactively terminate coverage back to the date of the fraud or misrepresentation. Group represents and warrants that, to the best of its knowledge, the information contained in this application is complete and true. Signed at (City & state) Name of Applicant/Employer Date Signed By (Signature/Title) 3 Intermediaries_9/11
2015 Employer Group HMO Election Form DATE STAMP Please Select One: 9 Rx 9 Rx Plus Coverage Through Employer Grp# Last Name: First Name: Middle Initial: Birth Date: ( / / ) ( M M / D D / Y Y Y Y ) Email Address: Sex: 9 M 9 F Effective Date of Coverage: Permanent Resident Street Address (P.O. Box is not allowed): Street Address: City: State: ZIP Code: County: Home Phone: ( ) Alternate Phone: ( ) Mailing Address (only if different from your Permanent Residence Address): Street Address: City: State: ZIP Code: Emergency contact: Phone Number: ( ) Relationship to You: Please Provide Your Medicare Insurance Information Please take out your Medicare card to complete this section. MEDICARE HEALTH INSURANCE 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. You must have Medicare Part A and Part B to join a Medicare Advantage plan. SAMPLE ONLY Name: Medicare Claim Number Sex - - Is Entitled To Effective Date HOSPITAL (Part A) MEDICAL (Part B)
Please Read And Answer The Following Questions: Name of Tufts Medicare Preferred HMO contracted Primary Care Physician (PCP) 9 Yes 9 No 1. Are you a current patient of this PCP? 9 Yes 9 No 2. Do you have End-Stage Renal Disease (ESRD) If you 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 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. 9 Yes 9 No 3. Are you a resident in a long-term care facility, such as a nursing home? If yes, please provide the following information: Name of Institution: Address & Phone Number of Institution (number and street): 9 Yes 9 No 4. Some individuals may have other drug coverage, including other private insurance, Worker s Compensation, VA benefits, or State pharmaceutical assistance programs. Will you have other prescription drug coverage in addition to Tufts Medicare Preferred HMO? 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 9 Yes 9 No 5. Do you or your spouse work? 9 Yes 9 No 6. Are you the retiree? If yes, retirement date (month/date/year): If no, name of retiree: 9 Yes 9 No 7. Are you covering a spouse or dependents under this employer or union plan? If yes, name of spouse: Name of dependents: Please check one of the boxes below if you would prefer us to send you information in a language other than English or in another format: 9 Spanish 9 Large Print Please contact Tufts Health Plan Medicare Preferred at 1-800-936-1902 (TTY: 1-888-899-8977) if you need information in another format or language. Representatives are available Monday - Friday, 8:00 a.m. - 8:00 p.m. (From Oct. 1 - Feb. 14, representatives are available 7 days a week, 8:00 a.m. - 8:00 p.m.) After hours and on holidays, please leave a message and a representative will return your call on the next business day.
Please Read and Sign Below By completing this enrollment application, I agree to the following: Tufts Health Plan Medicare Preferred 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 only be in one Medicare Advantage plan at a time and I understand that my enrollment in this plan will automatically end my enrollment in another Medicare health 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 this plan or make changes only at certain times of the year if an enrollment period is available, or under certain special circumstances. If enrolling in a Medicare Advantage without prescription drug coverage plan: I understand that if I don t have Medicare prescription drug coverage, or creditable prescription drug coverage (as good as Medicare s), I may have to pay an late enrollment penalty if I enroll in Medicare prescription drug coverage in the future. Tufts Medicare Preferred HMO serves a specific service area. If I move out of that area that Tufts Medicare Preferred 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 Tufts Medicare Preferred HMO, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from Tufts Health Plan Medicare Preferred when I get it to know which rules I must follow 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 Tufts Medicare Preferred HMO coverage begins, I must get all of my health care from Tufts Medicare Preferred HMO, except for emergency or urgently needed services or out-of-area dialysis services, and I must choose a primary care physician (PCP) and get a referral before seeing a specialist within my PCPs referral circle. If I obtain routine care from providers outside my PCP s referral circle neither Medicare nor Tufts Health Plan Medicare Preferred will be responsible for the cost. Services authorized by Tufts Health Plan Medicare Preferred and other services contained in my Tufts Medicare Preferred HMO Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR TUFTS HEALTH PLAN MEDICARE PREFERRED 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 Tufts Health Plan Medicare Preferred, he/she may be paid based on my enrollment in Tufts Medicare Preferred HMO. Release of Information: By joining this Medicare health plan, I acknowledge that the Medicare health plan will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that Tufts Health Plan Medicare Preferred 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 statues 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. Signature: Today s Date: If you are the authorized representative, you must sign above and provide the following information: Name: Address: Phone Number: Relationship to Enrollee: Office use Only Name of staff member, agent, broker (if assisted in enrollment): Plan ID #: Effective Date of Coverage: ICEP/IEP: AEP: SEP (type): Not Eligible: 11-EGHMOINTENR-15
hsainsurance.com Authorization Agreement for Electronic Payments HSA members have the option of enrolling in our Electronic Payment (EP) Program. With the EP Program, you authorize HSA to deduct your monthly payments directly from your checking account. Simply fill out this form and include a copy of a voided check. Once Electronic Payment has been established, your billing statement will reflect the message Please Do Not Pay This Bill towards the middle/top section of your statement. This program could take 2-4 weeks to begin due to timing and processing factors. Electronic payments can be deducted from your account on either the 15 th or 24 th of each month. For example, July premium payments will be processed on June 15 th or June 24 th. All outstanding balances owed, including fees, will be transferred at that time. Please note, this form cannot be used for initial premium and/or dues payment upon enrollment with HSA. Client Name: 6 Digit HSA Member #: I (we) hereby authorize HSA, hereinafter called COMPANY, to initiate debit entries for my (our) Checking account indicated below and the depository named below, hereinafter called DEPOSITORY, to debit the same to such account. Please indicate which date you prefer withdrawals to start by checking one below: 15 th of Current Month 24 th of Current Month 15 th of Next Month 24 th of Next Month Bank Name: Branch: City: State: Zip: Name on Account: Routing Number: Bank Account Number: This authorization is to remain in full force and effect until COMPANY has received written notification from me (us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it Authorized Signer Sign Name Print Name and Title Authorized Signer (if more than one required) Sign Name Print Name and Title Date: Client Telephone: NOTE: ALL WRITTEN DEBIT AUTHORIZATIONS MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE AUTHORIZATION. Attach voided check here Please fax or secure email the completed form to: (781) 848-7020 or enrollment@hsainsurance.com *This form is for new enrollment in the EP Program ONLY. For changes to existing bank information, please contact Customer Service at (781) 222-2123 Corporate Office: 135 Wood Rd, Braintree, MA 02184 (781) 848-4950 (877) 777-4414 (781) 848-7020 fax