BlueCHiP for Medicare 2016 Plan Selection Form

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1 2016 Plan Selection Form Date: c c / c c / c c c c Instructions: Complete the following sections 1. Provide Demographics 2. Choose your Medical Plan 3. Choose your Optional Supplemental Dental Plan 4. Indicate your Primary Care Physician (PCP) 5. Choose your Payment Option 6. Sign your Application Section 1 Provide Demographics FIRST Name: MIDDLE Initial: LAST Name: Member Number: c Z c B c M c c c c c c c c c c Permanent Residence Street Address (P.O. Box is not allowed): City: State: ZIP Code: Mailing Address (only if different from your Permanent Residence Address): Street Address: City: State: ZIP Code: Billing Address (only if different from your Mailing Address): Street Address: City: State: ZIP Code: Home Phone Number: ( ) Cell Phone Number: ( ) Alternate Phone Number: ( ) Address: What is your primary language spoken: Please contact if you need information in another language or alternate format (large print). Not all materials may be available in alternate formats. 1

2 Section 2 Choose your Medical Plan Put a check above your plan choice: Core (HMO) Advance (HMO)* Value (HMO-POS) Monthly Premium: $0 $0 $16 PCP Office Visit Copayment: $0 PCMH/$10 $5 $0 PCMH/$35 Specialist Office Visit Copayment: Emergency Room Copayment: Inpatient Hospital Copayment: $40 $45 $50 $75 $75 $75 $180 per day; Days 1-5 $285 per day; Days 1-5 $350 per day; Days 1-5 In-Network Out-of-pocket Maximum: $3,950; $4,850; $5,700; Prescription Drug Coverage: Medicare Part B coverage only (20% coinsurance) $2/$10/$47/$100/25% ($200 deductible for tiers 3, 4, 5) $2/$10/$47/$100/25% ($290 deductible for tiers 3, 4, 5) Point-of-service Out-of-network Benefit: Point-of-service Out-of-pocket Maximum: Not Covered Not Covered 20% coinsurance for most covered services $5,700 Section 3 Choose your Optional Supplemental Dental Rider Put a check above your plan choice: Dental Monthly Premium: $23.20 Calendar Year Coverage Limit: $1,000 Please see your Evidence of Coverage (EOC) for full benefit details on the optional Dental plan. c Choose not to have Optional Supplemental Dental Rider 2

3 Standard with Drugs (HMO) Extra (HMO-POS) Plus (HMO) Preferred (HMO-POS) $44 $86 $156 $247 $0 PCMH/$18 $0 PCMH/$10 $0 PCMH/$5 $0 PCMH/$5 $45 $35 $30 $30 $75 $65 $65 $65 $345 per day; Days 1-5 $275 per day; Days 1-5 $190 per day; Days 1-5 $180 per day; Days 1-5 $5,700; $3,750; $2,800; $2,250; $7/$12/$47/$100/25% ($200 deductible for tiers 3, 4, 5) $4/$8/$47/$100/33% (No deductible) $3/$6/$47/$100/33% (No deductible) $3/$6/$47/$100/33% (No deductible) Tier 1 & 2 gap coverage Not Covered 20% coinsurance for most covered services Not Covered 20% coinsurance for most covered services $3,750 $2,250 Section 4 Indicate your Primary Care Physician (PCP) Please write the name of your Primary Care Physician (PCP) below.* * The Advance Plan has a different provider network than our other Plans. Please confirm Plan network participation when choosing providers. 3

4 Section 5 Choose your Payment Option Your Plan Premium You can pay your monthly plan premium (including any late enrollment penalty you have or may owe) using any of the payment options below. People with limited incomes may qualify for extra help to pay for their prescription drug costs. If eligible, Medicare could pay for 75 percent 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 MEDICARE ( ), 24 hours per day, 7 days per week. TTY/TDD users should call If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium for this benefit. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare does not cover. If you don t select a payment option, you will receive a bill each month. c Option 1 - Electronic Funds Transfer (EFT) from your bank account each month. Check Sample 1. Fill out the information below: Account Holder Name: Bank Routing Number: Bank Account Number: Account Type: q Checking q Savings VOID 2. Attach a voided check to this form. Write VOID on a blank check from the account you would like the EFT payments withdrawn from. Do NOT send a deposit slip, blank check or cancelled check. c Option 2 - Automatic deduction from your monthly Social Security or Railroad Retirement Board benefit check. Automatic deduction from your monthly Social Security or Railroad Retirement Board (RRB) benefit check. (The Social Security or 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.) c Option 3 - Direct Bill Please select a premium payment option: c Receive a bill monthly c Receive a bill quarterly 4

5 Section 6 Please sign below Call our Concierge Team at (TTY users should call 711), seven days a week from October 1 to February 14, 8:00 a.m. to 8:00 p.m. From February 15 to September 30, you can call Monday through Friday, from 8:00 a.m. to 8:00 p.m. On Saturday and Sunday, call from 8:00 a.m. to noon. You can use our automated answering system outside of these hours. I want to transfer my current plan to the plan I have selected on this form. I understand that if I make the change as part of the Medicare Annual Enrollment Period and I don t have a Special Election, my new plan will be effective on January 1, If I do have a Special Election, and if this form is received by the end of any month, my new plan will generally be effective on the first of the following month. Member Signature: Today s Date: Authorized Representative: If you are the authorized representative, you must sign above and provide the following information: Name: Address: Phone Number: ( ) - Relationship to Member: Office Use Only: Sales Agent Signature (if assisted in enrollment): Print Sales Agent Name: Broker ID#: Please mail this form to: Blue Cross & Blue Shield of Rhode Island Attn: Membership Department 500 Exchange Street Providence, RI

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8 Blue Cross & Blue Shield of Rhode Island is an HMO plan with a Medicare contract. Enrollment in Blue Cross & Blue Shield of Rhode Island depends on contract renewal. An independent licensee of the Blue Cross and Blue Shield Association. 500 Exchange Street Providence, RI /15 BMED

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