Group Health Medicare Advantage | Election Form

Group Health Cooperative
Medicare Advantage (HMO) election form
This application is for plans offered in the following counties:
King, Pierce, Kitsap, Snohomish, Thurston, Lewis,
Please print clearly using black or blue ink only.
and parts of Mason and Grays Harbor.
Required fields are indicated with an asterisk (*).
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SELECT A PLAN*
A. Choose one plan with prescription drug coverage:
Essential (HMO): $114 per month
Optimal (HMO): $249 per month
Vital (HMO): $28 per month
OR choose a plan without prescription drug coverage:
Basic (HMO): $79 per month. NOTE: See Section 7 for late enrollment penalty information.
B. Requested effective date (subject to Medicare guidelines):
What effective date are you requesting? (Month):_________________________ - 01-2016
C. Dental coverage:
If you want the optional dental plan for 2016, be sure to check the box below.
Dental plan: $54 per month (in addition to monthly premium)
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MEDICARE INFORMATION
Please fill in the information at right exactly
as it is on your Medicare card.
You must have Medicare Parts A and B
to join a Medicare Advantage plan.
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Last name*
______________________________________________
First name*
MI*
______________________________________________
Medicare claim number*
______________________________________________
Is entitled to
Effective date
Hospital (Part A)
_______________________________
Medical (Part B)
_______________________________
PERSONAL & CONTACT INFORMATION
Date of birth* __________________________________ Sex*
Male
Female
Mr.
Mrs.
Ms.
Group Health member # (if applicable) _____________________________________________________
Permanent residential street address* (do not use a P.O. Box or a mail delivery service)
_______________________________________________________________________________________
____________________________________________________Length of time at this address ___________
City _______________________________________ County______________ ST ___ ZIP ____________
Mailing address (if different from above)
_______________________________________________________________________________________
_______________________________________________________________________________________
City ________________________________________ ST _____________________ ZIP _______________
Y0033_H5050_15-MED-1531-03
Approved 08-12-2015 FINAL
Please make a copy of this form for your records.
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Contact information
Telephone
Telephone
(primary) _________________________________ (secondary) _________________________________
A. Best time to reach you
Morning
Afternoon
Evening
B. If we need additional information in order to complete the processing of this election form,
No If yes, e-mail address:
may we use e-mail to communicate with you? Yes
__________________________________________________________________________________________________
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PLEASE READ AND ANSWER THESE IMPORTANT QUESTIONS
A. Do you currently have End-Stage Renal Disease (ESRD)—permanent kidney failure
requiring kidney dialysis or a transplant to stay alive?*
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.
B. 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 your Medicare Advantage plan?
Yes
No
Yes
No
Yes
No
Yes
No
If yes, name of other plan _____________________________________________
ID # for other plan ___________________________________________________
Group # for other plan ___________________________________________________
Effective date of other plan ____________________________________________
C. Do you live in a long-term care facility, such as a nursing home?
If yes, name of facility ________________________________________________
Address of facility ____________________________________________________
Phone number of facility ______________________________________________
Date admitted ______________________________________________________
D. Are you enrolled in a state Medicaid program?
If yes, Medicaid number_______________________________________________
Selecting a primary care provider:
If you have a current primary care provider who contracts with Group Health
Cooperative (primary care providers do not include specialists) and you would
like to continue seeing that physician, please include their name here.
(If you are a current Group Health member and are not making a primary
care provider change, please leave blank):
_____________________________________________________________________________________
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PAYING YOUR INDIVIDUAL MEDICARE ADVANTAGE PLAN PREMIUM
You can pay your monthly plan premium (and any late enrollment penalty that you currently
have or may owe, if you are on a Medicare Advantage plan that includes prescription drug
coverage) by mail. You can also choose to pay your premium by automatic deduction from your
Social Security (SSA) or Railroad Retirement Board (RRB) benefit check each month if you receive
SSA or RRB income. If you don’t select a payment option, you will get a bill for your premium
each month.
If you are assessed a Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA),
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 benefit check or be billed directly by Medicare or RRB. DO NOT pay
Group Health Cooperative the Part D-IRMAA.
Please select a premium payment option:
Receive a monthly bill from Group Health.
If you want your monthly premium bill mailed to a different address than your other mail,
please provide that address here.
__________________________________________________________________________________
__________________________________________________________________________________
City _____________________________________ ST _______________________ ZIP_________
Automatic deduction from your monthly Social Security or Railroad Retirement Board
benefit check.
The SSA withholding option is limited to premiums that do not exceed $300. The Social Security/
RRB deduction may take two 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 will include all premiums due
from your enrollment effective date up to the point withholding begins. If Social Security or RRB
does not approve your request for automatic deduction, we will send you a paper bill for your
monthly premiums.
People with 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 coinsurance. Additionally, those who qualify will not be
subject to the 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 1-800-772-1213 between 7 a.m. and 7 p.m.,
Monday through Friday. TTY users should call 1-800-325-0778. You can also apply for extra help
online at www.socialsecurity.gov/prescriptionhelp.
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.
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ATTESTATION OF ELIGIBILITY FOR AN ENROLLMENT PERIOD
Typically, you may enroll in a Medicare Advantage plan only during the annual enrollment period
from October 15 through December 7 of 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.
Qualifying reason for Enrollment
I am new to Medicare.
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 on (insert date) ____________________________________________ .
I recently returned to the United States after living permanently outside of the U.S. I returned to the
U.S. on (insert date) ______________________________________________________________ .
I have both Medicare and Medicaid or my State helps pay for my Medicare premiums.
I get extra help paying for Medicare prescription drug coverage.
I no longer qualify for extra help paying for my Medicare prescription drugs. I stopped receiving extra
help on (insert date) ______________________________________________________________ .
I am moving into, live in, or recently moved out of a long-term care facility (for example, a nursing
home or long-term care facility). I moved/will move into/out of the facility on (insert date)
______________________________________________________________________________ .
(This Enrollment Period lasts as long as you live in the institution and for 2 full months after the month
you move out of the institution.)
I recently left a PACE program on (insert date)__________________________________________ .
(This Enrollment Period lasts for 2 full months after the effective date of your PACE disenrollment.)
I recently involuntarily lost my creditable prescription drug coverage (coverage as good as Medicare’s).
I lost my drug coverage or was notified of the loss on (insert date) ___________________________ .
(This Enrollment Period lasts for 2 full months after the month you lose your creditable coverage or for
2 full months after you are notified of the loss, whichever is later.)
I am leaving employer or union coverage on (insert date)__________________________________ .
(This Enrollment Period lasts for 2 full months after the month your coverage ends.)
I belong to a pharmacy assistance program provided by my State.
My plan is ending its contract with Medicare, or Medicare is ending its contract with my plan.
I was enrolled in a Special Needs Plan (SNP) but I have lost the special needs qualification required to
be in that plan. I was disenrolled from the SNP on (insert date) _____________________________ .
If none of these statements applies to you or you’re not sure, please contact Group Health at
1-800-446-8882 (TTY users should call 1-800-833-6388 or 711) to see if you are eligible to
enroll. We are open Monday–Friday from 8 a.m. to 8 p.m. From October 1 through February 14,
call 7 days a week from 8 a.m. to 8 p.m.
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BY COMPLETING THIS FORM, I AGREE TO THE FOLLOWING:
If you currently have health coverage from an
employer or union, joining Group Health
Cooperative could affect your employer or union
health benefits. You could lose your employer
or union health coverage if you join Group
Health Cooperative. Read the communications your
employer or union sends you. If you have questions,
visit their website, 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.
Those services authorized by Group Health and
other services contained in your plan Evidence of
Coverage document (also known as a member
contract or subscriber agreement) will be covered.
If you obtain routine care from out-of-network
providers without authorization, neither Medicare
nor Group Health will pay for the services.
Group Health Cooperative is an HMO plan with a
Medicare contract. Enrollment in Group Health HMO
depends on contract renewal. You will need to keep
your Medicare Parts A and B. You must continue to
pay your Medicare Part B premium. Enrollment in
this plan is generally for the entire year. Once you
enroll, you may leave this plan or make changes
only at certain times of the year when an enrollment
period is available (Example: October 15–December 7),
or under certain special circumstances.
NOTE: You can only be in one Medicare Advantage
plan at a time, and understand that your enrollment
in this plan will automatically end your enrollment in
another Medicare health plan or prescription drug
plan. It is your responsibility to inform Group Health
of any prescription drug coverage that you have or
may get in the future.
Group Health Medicare Advantage (HMO) plans
serve a specific service area. If you move out of the
area that the Group Health Medicare Advantage
(MA) plans serve, you need to notify the plan so you
can disenroll and find a new plan in your new area.
Once you are a Group Health MA plan member,
you have the right to appeal plan decisions about
payment or services if you disagree. Read your
plan’s Evidence of Coverage from Group Health
when you receive it to learn which rules you must
follow in order to get coverage with this MA plan.
People with Medicare are not usually covered under
Medicare while out of the country except for limited
coverage near the U.S. border.
Beginning on the date your Group Health Medicare
Advantage (HMO) coverage begins, you must use
plan providers except in emergency or urgent
care situations or for out-of-area renal dialysis.
If you are receiving assistance from a sales agent,
broker, or other individual employed by or contracted
with Group Health, he/she may be paid based
on your enrollment in a Group Health Medicare
Advantage (HMO) plan.
NOTE: The Basic plan does not include prescription
drug coverage. If I enroll in this 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 a
late enrollment penalty if I enroll in Medicare
prescription drug coverage in the future.
The effective date of coverage in any of these
Medicare Advantage plans will depend on when we
receive your signed and completed election form.
Generally, your effective date of coverage is the first
day of the month following the month we receive
your completed election form. For example, if we
receive your election form in January, generally your
effective date will be February 1. There are exceptions
to these rules. To obtain detailed information
concerning these exceptions, or to ask questions
regarding this information, please call our Medicare
Advantage sales staff. Group Health will send you a
letter that confirms when your coverage begins.
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RELEASE OF INFORMATION:
By joining this Medicare Advantage health plan, I acknowledge that Group Health Cooperative will release
my information to Medicare and other plans as is necessary for treatment, payment, and health care
operations. I also acknowledge that Group Health Cooperative will release my information including my
prescription drug event data (if I join a Medicare Advantage plan with prescription drug benefits) 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 by Group Health Cooperative or by Medicare.
Your signature*_____________________________________________ Date ______________________
If you are the authorized representative, you must sign above and provide the following information.*
Proof of your authority must be presented to Group Health or to Medicare upon request.
Name__________________________________________________________ Phone ______________________
Relationship to applicant __________________________________________________________________
Address__________________________________________________________________________________
___________________________________________________________________________________________
ONE LAST THING
Please return all pages of this election form.
Completed election form can be sent to:
Group Health Medicare Enrollment, ANB-2
P.O. Box 34255
Seattle, WA 98124-1255
Or, fax to 206-988-7543.
QUESTIONS
This information is available in an alternate format such as Braille, larger print, or audio. To obtain
information or to ask questions regarding this election form, please call Customer Service.
This information is available for free in other languages. Please call our Customer Service number at
1-888-901-4600. (TTY users should call 1-800-833-6388 or 711.) Hours are Monday–Friday from
8 a.m. to 8 p.m. From October 1 to February 14, call 7 days a week from 8 a.m. to 8 p.m.
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AGENT USE ONLY
Receipt date_________________________ Released to client on _________________________________
Effective date of coverage __________________-01-2016
Month
ICEP/IEP
AEP
Not eligible
SEP (reason if SEP) ____________________________________________________________________
Appointment type ________________________________ Scope of Appointment attached
Yes
No
Name of Group Health staff member_______________________________________________________
Broker or agent name ____________________________________________________________________
Group Health agent ID number ____________________________________________________________
Company/house name (if applicable)________________________________________________________
Group Health house ID number ____________________________________________________________
Phone number_________________________________________________________________________
Group Health Date-Stamp:
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