brand new day To Enroll in Brand New Day Health Maintenance Organization or Special Needs Plan (SNP), please provide the following information:

Transcription

1 To Enroll in Brand New Day Health Maintenance Organization or Special Needs Plan (SNP), please provide the following information: brand new day Proposed Effective Coverage Date: To Enroll in Brand New Day, Please Provide the Following Information: 1a.Do you have Medi-Cal? Yes No If yes, please provide your Medi-Cal (BIC) number 1b. Does your Medi-Cal include a Share of Cost? Yes No 1c. Are you currently a member of an HMO? Yes No If yes, name of the plan If enrollment is not between October 15th to December 7th Please fill out. 1.d. Have a diagnosis that qualifies for a Brand New Day Special Needs Plan Have Medicare and Medi-Cal coverage Is or has just turned 65 years old Recently moved into service area Recently released from prison Was involuntarily dis-enrolled from another plan Loss of Dual Status or SNP Eligibility Other Please Select a Plan: If you have Medi-Cal with no Share of Cost and the State pays your premium, the plans with a Premium may be your best choice *Please contact Brand New Day if you need information in another language or format (Braille)* Standard Plans 024 Dual Coverage (HMO D-SNP for Medi-Medi Coverage) $36.30 paid by State of CA for Members with Medi-Cal 025 Classic Care (HMO) $0 Copays 033 Classic Choice for Medi-Medi (HMO) $36.30 paid by State of CA for Members with Medi-Cal Diabetes Plans If you have been diagnosed with Diabetes or High Blood Sugar then select: Plans 026 or Diabetes-In Control Drug Savings (HMO Special Needs Plan) $0 Premium 027 Diabetes-In Control Dual Access (HMO Special Needs Plan) $36.30 paid by State of CA for Members with Medi-Cal Dementia Plans (Available in all counties except Kings) If you have been diagnosed with Dementia, Parkinson s Disease, Alzheimer s Disease, Mild Cognitive Impairment, Dementia With Lewy bodies, Creutzfeld-Jakob Disease or Huntington s Disease then select: Plans 028 or Dementia - Bridges Drug Savings (HMO Special Needs Plan) $0 Premium 029 Dementia -Bridges Dual Access (HMO Special Needs Plan ) $36.30 paid by State of CA for Members with Medi-Cal Congestive Heart Plans If you have been diagnosed with Congestive Heart failure, Coronary Artery Disease, Stroke, Hypertension, Atrial fibrillation or History of Heart Attack then select: Plans 030 or CHF-Healthy Heart Drug Savings (HMO Special Needs Plan ) $0 Premium 031 CHF-Healthy Heart Dual Access (HMO Special Needs Plan ) $36.30 paid by State of CA for Members with Medi-Cal Chronic Mental Illness Plans If you have been diagnosed with mental illness such as Schizophrenia, Schizoaffective Disorder, Bipolar Disorder or Paranoid Disorder then select Plans 032 or Mental Illness-Hope Drug Savings (HMO Special Needs Plan ) $0 Premium 020 Mental Illness-Harmony Dual Access (HMO Special Needs Plan $36.30 paid by State of CA for Members with Medi-Cal Page 1 of 5

2 Last Name: Birth Date: ( / / ) (MM/DD/YYYY) First Name: M F Home Phone Number: Cell Phone Number: Permanent Residence Street Address: Apt# or Space: City: State: Zip Code: (Optional County) Mailing Address if different then Permanent Address: Emergency contact name: (optional) Apt# or Space: Phone Number (optional) Are you a resident in a long-term facility, such as a nursing home? (e.g. nursing facility rest home, rehabilitation hospital, convalescent home, etc.)? Yes No Do you live in in a group home, Assisted Living or Board and Care? Yes No If yes, please provide the following information: Name of Institution or Home: Address & Phone Number of Institution (number and street: Name of Facility Manager: Primary Care Language: English Spanish Chinese Korean Khmer Vietnamese Other Race /Ethnic Group : White-Non Hispanic Black-Non Hispanic Hispanic or Latino Asian American Indian/Alaskan Native Native American/Pacific Islander Two or more races(not Hispanic or Latino) Do you or your Spouse work? Yes No If yes name of employer or Union name and Group Do you, on your own or through your spouse, have any other Health Insurance other than Medicare such as private insurance, Worker s Compensation, third party liability or VA benefits? Yes No (2h) If yes what kind of insurance do you Please Provide Your Medicare Insurance Information Please take your Medicare card to complete this Section; Please fill in these blanks so they match your red, white or blue Medicare card -OR- Attach a copy of your Medicare card or your letter from Social Security or Railroad Retirement Board Page 2 of 5 MEDICARE HEALTH INSURANCE Sample Only Name: Medicare Claim Number Sex - _ - Is Entitled To: Effective Date HOSPITAL (Part A) MEDICAL (Part B)

3 Please Provide your Doctor Choices: Name of Chosen Primary Care Physician (PCP, Clinic or Health Center) PCP Provider Code or IPA # Name of Psychiatrist ( For Mental Health Plans only) Provider Code Contracting Dentist you have chosen Dental Facility # Brand New Day (health plan) has my permission to send information to me by Yes No This includes sending my personal health information by Yes No I understand I may change my mind and revoke this permission by calling (TTY ) anytime My address is: PLEASE READ AND ANSWER THESE IMPORTANT QUESTIONS: 1. Do you have End-Stage Renal Disease (ESRD)? Yes No 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. 2. Some individuals may have other medical or drug coverage, including work, other private insurance, TRICARE, Federal employee health benefits coverage, VA benefits, or State pharmaceutical assistance programs. Will you have other medical or prescription drug coverage in addition to Brand New Day? Yes No If yes, please list your other coverage and your identification (ID) number(s) for this coverage: Name of other medical coverage: ID# for this medical coverage: Group # for this medical coverage: Name of other drug coverage: ID# for this drug coverage: Group# for this drug coverage: Page 3 of 5

4 I am new to Medicare ATTESTATION of ELIGIBILITY FOR AN ENROLLMENT PERIOD 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 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) / / I recently left a PACE program on (insert date) / / I recently involuntarily lost my creditable prescription drug coverage (coverage as good as Medicare s) I lost my drug coverage on (insert date) / / I am leaving my employer or union coverage on (insert date) / / 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 dis-enrolled from the SNP on (insert date) / / If none of these statements applies to you or you re not sure, please contact Brand New Day at TDD/TYY users call PAYING YOUR PLAN PREMIUM You do not need to fill out this section if you chose a plan with no Part D premium or if you have Medi-Cal and no Share of Cost. Check this box if this section is not applicable EXTRA HELP FOR MEDICATION COVERAGE 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 co-insurance. 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 (800) TYY users should call (800) You can also apply for extra help on-line at 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. If you don t select a payment option, you will get a coupon book. Page 4 of 5

5 PREMIUM PAYMENT You can pay your monthly premium (including any late enrollment penalty that you currently have or may owe) by mail each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month. If you are assessed a Part D-Income related monthly adjustment amount, 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 the RRB. DO NOT PAY Brand New Day the Part D-IRMAA. Pease select a premium payment option: Get a bill Get a coupon book Automatic deduction from your Social Security Railroad Retirement Board (RRB) benefit check. (The Social Security/RRB) deduction may take two or more months to begin after Social Security or RRB approves 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. Signature: PLEASE READ AND SIGN BELOW 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: Documentation Type: DPOA DPAHC Written Advance Directive Legal Guardian SALES AGENT/OFFICE USE ONLY If Anyone helped the individual fill out this form or assisted in enrollment ( with the exception of the effective date) she/he must sign the following line: Name of Staff/Agent/Broker: Signature: Date: Relationship to applicant: Agent Phone # Agent # FMO: Enroll by: Phone-Tracking # Web-Tracking # Grp Seminar In-Home BRAND NEW DAY HOME OFFICE USE ONLY: Date of Receipt: Date Entered: Plan ID#: Initials of Verification Rep: Date E4 Letter Sent Out: Date E6 Letter Sent Out: Effective Date of Coverage: Name of Staff Member / Agent / Broker (if assisted enrollment): Group #: Part D Premium: ICEP / IEP: AEP: SEP (type): LIS: Not Eligible: Notes: Page 5 of 5