Customer Care Center Hours: October 15, February 14, :00 a.m. to 8:00 p.m. Monday - Sunday

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1 ENROLLMENT APPLICATION FOR DEANCARE MEDICARE COST PLAN Customer Care Center: 1277 Deming Way, Madison, WI (888) TTY users dial 711 Fax (608) February 15, October 14, :00 a.m. to 8:00 p.m. Monday - Friday Customer Care Center Hours: October 15, February 14, :00 a.m. to 8:00 p.m. Monday - Sunday February 15, October 14, :00 a.m. to 8:00 p.m. Monday - Friday A TO ENROLL IN DEANCARE GOLD (Cost), PLEASE PROVIDE THE FOLLOWING INFORMATION 1. Please check the plan you are applying for: See the enclosed Summary of Benefits document for benefit information. You must continue to pay your Part B premium. q Dean Care Gold (Cost) Enhanced: $113 per month q Dean Care Gold (Cost) Shared Value: $68 per month q Dean Care Gold (Cost) Basic: $108 per month 2. Please indicate your requested enrollment effective date: / 01 / MM YYYY 3. Name (Last, First, Middle Initial) 4. Sex q M q F 6. Permanent Residence Address City 5. Date of Birth State ZIP 7. Home Phone Number 8. County 9. Mailing Address, City, State, ZIP (only if different from your Permanent Residence Address) PLEASE PROVIDE YOUR MEDICARE INSURANCE INFORMATION 10. Please take out your Medicare card to complete this section B 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 the Social Security Administration or Railroad Retirement Board You must have Medicare Part B to join a Medicare cost plan NAME: MEDICARE CLAIM NUMBER SEX: IS ENTITLED TO HOSPITAL (Part A) MEDICAL (Part B) EFFECTIVE DATE / / / / C PLEASE READ AND ANSWER THESE IMPORTANT QUESTIONS TO THE BEST OF YOUR KNOWLEDGE 11. Your chosen DeanCare Gold (Cost) primary care physician/clinic: Please see our DeanCare Gold (Cost) provider directory enclosed with the pre-enrollment materials. 12. Do you have end-stage renal disease (ESRD)? If you answered Yes to this question and you do not need regular dialysis any more, or have had a successful kidney transplant, please attach a note or records from your doctor showing you do not need dialysis or have had a successful kidney transplant. For DHP Use Only Member Number Division Effective Date Processed By: H5264_EN2064_0814v2 CMS Approved page 1 of 5 q TL q Q q M q ACH Form A

2 QUESTIONS CONTINUED 13. Did you turn age 65 in the last six months? 14. Did you enroll in Medicare Part B in the last 6 months? If Yes please answer question What is the effective date? / / 16. Are you covered for medical assistance through the state Medicaid program? Please Note: If you are participating in a Spend-Down Program and have not met your Share of Cost, please answer No to this question and skip to question 17. If you answered Yes, please answer questions 16a and 16b. 16a. Will Medicaid pay your premiums for this DeanCare Gold (Cost) plan? 16b. Do you receive any benefits from Medicaid other than payments toward your Medicare Part B premium? 17. If you had coverage from any Medicare health plan other than original Medicare within the past 63 days (e.g. Medicare Advantage or a Medicare HMO or PPO), please list your effective and termination dates. If you are still covered under that Medicare plan, leave Termination blank. Effective Date / / Termination Date / / Please note: Enrolling in DeanCare Gold (Cost) automatically disenrolls you from any other Medicare health plan in which you are enrolled. These plans do not include Medicare supplement plans (or Medigap) which is addressed in question a. Was this your first time in that type of Medicare health plan? D 17b. Did you drop a Medicare supplement policy to enroll in the Medicare plan? 18. Do you have a Medicare supplement policy in force? If Yes, please answer questions 18a and 18b. If No, skip to question a. If Yes to having another Medicare supplement policy, with what company is your plan through? Company: 18b. Do you intend to replace your current Medicare supplement policy with this DeanCare Gold (Cost) plan? 19. Have you had coverage under any other health insurance (e.g. an employer, union, or individual plan) including through you or your spouse s employer, within the past 63 days? If Yes please answer question 19a and 19b. 19a. If Yes with any other health insurance coverage, please state: Company: Kind of Policy: 19b. If Yes with you, or your spouse s employer, please state: Employer Name: Employer Address: Policy Holder Name: Policy Number: 19c. If you answered questions 19a and 19b above, what are your dates of coverage under the other policy? If you are still covered under the other policy, leave Termination blank. Effective Date / / Termination Date / / page 2 of 5

3 STATEMENTS You do not need more than one Medicare supplement, select or cost policy. If you purchase DeanCare Gold (Cost), you may want to evaluate your existing health coverage and decide if you need multiple coverages. You may be eligible for benefits under Medicaid and may not need a Medicare Supplement, Select or Cost policy. If, after purchasing DeanCare Gold (Cost), you become eligible for Medicaid, this plan s benefits and premiums can be suspended, during your entitlement to Medicaid benefits, for 24 months. You must request this suspension within 90 days of becoming eligible for Medicaid. If you are no longer entitled to Medicaid, your DeanCare Gold (Cost) plan (or a substantially equivalent policy) will be reinstituted, if you request reinstitution, within 90 days of losing Medicaid eligibility If you are eligible for and have enrolled in a Medicare Cost policy by reason of disability and you later become covered by an employer or union-based group health plan, the benefits and premiums under your Medicare Cost policy can be suspended, if requested, while you are covered under the employer or union based group health plan. If you suspend your Medicare Cost policy under these circumstances, and later lose your employer or union based group health plan, your suspended Medicare Cost policy or, if that is no longer available, a substantially equivalent policy will be reinstituted if requested within 90 days of losing your employer or union based group health plan. If the Medicare supplement, Select or Cost policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy will not have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of suspension. Counseling services may be available in your state or provide advice concerning your purchase of Medicare Cost insurance and medical assistance through the state Medicaid program, including benefits as a Qualified Medicare Beneficiary (QMB) and a Specified Low-Income Medicare Beneficiary (SLMB). Please see the booklet Wisconsin Guide to Health Insurance for People with Medicare enclosed with the pre-enrollment materials. TERMS AND CONDITIONS I acknowledge that premium and cost-sharing amounts were stated to me and that I can find this information in the preenrollment materials provided to me. I agree to abide by DeanCare Gold (Cost) rules as outlined in the pre-enrollment and benefit materials provided to me. I know what my proposed or requested effective date of coverage is, which is when I should begin receiving care through DeanCare Gold (Cost). I understand DeanCare Gold (Cost) will send me written notification of my effective date of enrollment. I understand that it is my responsibility to notify Dean Health Plan before I permanently move or leave the service area for more than 90 continuous days, and that my absence means Dean Health Plan may take action to disenroll me and return me to traditional Medicare coverage. I understand that no insurance agent or broker can modify, waive or change in any way this application, any requirement imposed by Dean Health Plan, nor bind coverage or guarantee approval of this application. page 3 of 5

4 PLEASE READ By completing this enrollment application, I agree to the following: DeanCare Gold (Cost) is a Medicare health plan and I will need to keep my Medicare Part B. I can be in only one Medicare health plan at a time. It is my responsibility to inform you of any prescription drug coverage that I have or may get in the future. I know I may disenroll from this plan at any time by sending a written request to DeanCare Gold (Cost) or by calling (800) MEDICARE ( ). TTY users should call (877) You can call 24 hours a day, seven days a week. DeanCare Gold (Cost) serves a specific service area. If I move out of the area that DeanCare Gold (Cost) 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 DeanCare Gold (Cost), I have the right to appeal plan decisions about payments or services if I disagree. I will read the Evidence of Coverage document from DeanCare Gold (Cost) when I receive it to know which rules I must follow in order to receive coverage with this Medicare health plan. I understand that beginning on the date my DeanCare Gold (Cost) plan coverage starts, in order for DeanCare Gold (Cost) to fully cover my medical services (except for emergency or urgently-needed services) all of my health care must be provided or arranged by DeanCare Gold (Cost). If I obtain services not provided or arranged by the plan, I will be responsible for all Medicare deductibles and co-insurance, as well as any additional charges as prescribed by the Medicare program. I may also be liable for charges not covered by Medicare. Medicare beneficiaries are generally not covered under Medicare while out of the country except for limited coverage in Canada and Mexico. Services authorized by DeanCare Gold (Cost) and other services contained in my DeanCare Gold (Cost) Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. 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. 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 behalf of the individual under the laws of the State where the individual resides) 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 DeanCare Gold (Cost) or by Medicare. DeanCare Gold (Cost) is a Medicare health plan and I will need to keep my Medicare Part B. I can only be in one Medicare health plan at a time. It is my responsibility to inform you of health coverage that I have or may get in the future. I know I may disenroll from this plan at any time by sending a written request to DeanCare Gold (Cost) or by calling (800) MEDICARE ( ). TTY users should call (877) page 4 of 5

5 PAYMENT INFORMATION Your DeanCare Gold (Cost) premium can be billed directly to you monthly or you may choose Automatic Transfer of Funds to have your premium withdrawn monthly. Please submit payment for the first month of coverage with the completed application. Please indicate your choice of billing method: Direct Billing: q Monthly (You may also prepay up to 12 months in advance.) Automatic Transfer of Funds: q Monthly (Please complete the Authorization for Automatic Transfer of Funds form and return with this application if you wish to pay your monthly premium through a checking or savings account.) APPLICANT SIGNATURE AND SIGNATURE DATE Applicant s Signature: Date: / / If the applicant cannot sign, a court-appointed legal guardian, power of attorney (POA) or other person who has legal authority to procure insurance must sign the below signature line. (Please attach the guardianship papers, POA or other proof of legal authority to procure insurance, as well as the guardian/poa s address and phone number.) If the guardian/poa represents the member, all documents and correspondence will go to the guardian/poa. Guardian/POA s Signature: Date: / / For Agent Use Only By signing the below, I represent that I have asked this applicant all of the questions on this application and the answers are recorded as given to me. Writer Agent s Name: License No.: Writer Agent s Signature: Date: / / DeanCare Gold (Cost) is an HMO plan with a Medicare contract. Enrollment in DeanCare Gold (Cost) depends on contract renewal Dean Health Plan, Inc 2064_0814 page 5 of 5

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