Enrollment Checklist

1) I am aware that the Sales Agent I am working with is a licensed representative of my plan and does not represent Medicare or any branch of the federal or state government. When my enrollment is complete, the Sales Agent may be paid a fee. *

I Agree I Disagree

2) I understand that my plan will now provide all my plan will now provide all my Medicare health and/or prescription drug coverage and that the plan I have chosen in NOT a Medicare Supplemental (Medigap) Plan. *

I Agree I Disagree

3) My Sales Agent has explained that my plan may have copays, coinsurance, or an annual deductible, that I may need a prior authorization for some types of care, and that my plan may have limitations on the care it covers. *

I Agree I Disagree

4) I understand to enroll in this plan I must have Medicare Parts A and B. The plan I choose must serve the area I live in, and I need to live in that plan’s service area for at least 6 months in a row, if I move or choose to live outside the service area for more than 6 months in a row, I may need to change plans. If that happens, I can call Customer Service to help me choose a new plan. *

I Agree I Disagree

5) I know I need to pay my Medicare Part B premium, as well as my monthly plan premium (if my new plan has a premium). I understand I may be able to get Extra Help with my plan costs. *

I Agree I Disagree

6) I have reviewed the benefits, eligibility and rules of the plan. If I need more information, I can refer to the Evidence of Coverage I will receive in my Member Welcome Kit or I can call Customer Service. *

I Agree I Disagree

7) My Sales Agent confirmed that my current doctor and other providers are part of my plan’s network (this may not apply to certain PFFS and PPO Plans). *

I Agree I Disagree

8) If needed, a Power of Attorney (or any other person who helps in my health care decisions) is here today or has been contacted. *

I Agree I Disagree Option 3

9) Once my enrollment is approved by Medicare, I will receive a Member ID card, I must use this Member ID card instead of my Original Medicare card when I need medical services or visit the pharmacy. I may use my Enrollment Receipt, with my proposed membership effective date until my permanent Member ID card arrives. *

I Agree I Disagree

10) For plans that include Prescription Drug Coverage: To help me save on prescription drug costs, my plan has a drug list (also called a formulary) and a network of pharmacies, I understand that I may pay the full cost for drugs that are not on my plan’s drug list, or that are filled at non-network pharmacies. *

I Agree I Disagree

11) My Sales Agent helped me confirm that my current medications are on my plan’s drug list and explained the plan costs, which may include a deductible and copays. *

I Agree I Disagree

12) My Sales Agent explained that I may need to get prior authorization for certain drugs. He/she also explained step therapy, quantity limits and the coverage gap, and how my medication cost are calculated in order to reach the gap. *

I Agree I Disagree

13) I understand that Medicare may assess a Late Enrollment Penalty (LEP), which can be added to my monthly Part D premium if I did not join a Medicare Plan when I was first eligible or did not have creditable coverage. *

I Agree I Disagree

14) I’m aware that I am able to use any provider who is willing to accept payment from the plan I’m enrolling in and is contracted with Medicare (and Medicaid if applicable). Except for emergency or urgent care situations, it may cost more to get care from out-of-network providers. *

I Agree I Disagree

15) For Special Needs (SNP) Plans: These Plans have rules about who can join them. Chronic Special Needs Plan: I can enroll in this type of Plan if I have already been diagnosed with one of these conditions: diabetes and/or heart failure or cardiovascular disorders. Dual Special Needs Plans: I can enroll in this type of plan if I have full Medicaid coverage ($0 cost share Dual Eligible). *

I Agree I Disagree

16) The company I’m enrolling with will call or write to me in 10-15 days. My Sales Agent has explained this process is an Outbound Enrollment Verification (OEV) that is a required confirmation to ensure I understand I have enrolled in a plan. *

I Agree I Disagree

17) If my situation changes and I am no longer eligibility for this plan, I will be disenrolled. My plan will work with me to find a plan that fits my new situation. *

I Agree I Disagree

18) My Sales Agent verified my Medicaid eligibility *

I Agree I Disagree

19) If my plan is unable to confirm my eligibility for this plan prior to enrollment, my application will be denied. *

I Agree I Disagree

20)My Sales Agent explained the enrollment cancellation process to me. *

I Agree I Disagree

21) If my enrollment application is incomplete for any reason, I will receive a letter and/or a call from the health plan asking me to provide the missing information. This may delay my enrollment in the plan. *

I Agree I Disagree

Enrollee Statement: By signing this form, I confirm that my Sales Agent has explained my plan benefits and reviewed the information in the enrollment booklet, including the multi-language insert, Star Ratings program, formulary, disclaimers and important contact information. I have full opportunity to ask questions. I understand that by complementing this application, I am applying to enroll in the plan. I know that if I have additional questions, I may call my Sales Agent or Customer Service. I will receive a copy of my enrollment application within 10 days after enrolling in this plan. *

I Agree I Disagree

Printing your name below, constitutes as your electronic signature and agreement that you agent Dana Gaffney covered each of these areas with you today.

YOUR CART