Enrollment Application. Senior Blue Traditional Blue Medicare PPO

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1 MEDICARE ADVANTAGE Enrollment Application Senior Blue Traditional Blue Medicare PPO 30 Century Hill Drive, Latham, NY Toll Free TTY/TDD (Hearing Impaired) Monday through Friday, 8:30 a.m. to 5:00 p.m. Internal use only - Date stamps Rep. Corporate business offi ce BS 617R H3384 H5526 ENR003 NENY Member App 09_2008

2 MEDICARE ADVANTAGE Enrollment application? If you would like assistance, please call BlueShield of Northeastern New York at: ; TTY/TDD , Monday through Friday, 8:30 a.m. to 5:00 p.m. If you are a current member, please fill in the shaded areas only. Part 1: Please tell us about yourself Last name First name Initial Date of birth / / Social Security Number / / Gender M F (optional) address (optional) Permanent residence address: Street/Apartment # Telephone ( ) Mailing address (If different from permanent address): Street/Apartment # /PO Box Telephone ( ) In case of emergency, please contact (optional): Last name First name Relationship Telephone ( ) Part 2: Please list a Primary Care Physician (PCP) from the provider directory NOTE: Required for Senior Blue enrollment; optional for Traditional Blue Medicare PPO enrollment Last name First name PCP # Physician s address: Street/Apartment #/Suite Current patient Yes No 1

3 Part 3: Medicare eligibility information Please fi ll in these blanks so they match your Medicare card, or you can attach a copy of your letter of verifi cation from the Social Security Administration or Railroad Retirement Board. Medicare Health Insurance - Social Security Act Medicare claim number Gender M F Is entitled to: Hospital (Part A) Effective date / / Medical (Part B) Effective date / /! We cannot call this enrollment form fi nished until you have given us this information.! You must have Medicare Part A and Part B to join a Medicare Advantage plan. Part 4: Please select the plan in which you want to enroll - please select only one plan Senior Blue 600 (Dual eligibles only) Senior Blue 601 $40 monthly premium Senior Blue 651 with Part D $48 monthly premium Senior Blue 652 with Part D $81 monthly premium Senior Blue 653 with Part D $99 monthly premium Traditional Blue Medicare PPO 701 $95 monthly premium Traditional Blue Medicare PPO 751 with Part D $137 monthly premium Traditional Blue Medicare PPO 752 with Part D $165 monthly premium Desired effective date / / Part 5: Plan premium payment option You can have the monthly premium for this Medicare plan automatically deducted from your Social Security payment. If you don t choose this option, we will send you a bill each month. Generally, you must stay with the option you choose for the rest of the year. Do you want your premium (if any) for this plan withheld from your Social Security payment? Yes No 2

4 Part 6: Please read and answer these questions 1. Do you have End Stage Renal Disease (ESRD)? Yes No ESRD is permanent kidney failure and requires regular kidney dialysis or a transplant to stay alive.! If you have ESRD, you cannot enroll in this plan unless you are already enrolled in another BlueShield of Northeastern New York commercial plan or you were affected by the non-renewal of another Medicare Advantage plan after December 31, 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. 2. Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal Employee Health Benefi ts coverage, VA benefi ts, or EPIC. Will you have other prescription drug coverage in addition to the plan in which you are enrolling? Yes No If yes, please list your other coverage and your identifi cation (ID) number(s) for this coverage: Name of other coverage ID # for this coverage Group # for this coverage 3. Are you currently a resident in an institution (e.g., skilled nursing facility, rehabilitation hospital)? Yes No If yes, please list the institution s phone number and date of admission. Name Street/Suite # Telephone ( ) Date of admission / /! Your answer to this question will not keep you from enrolling in this plan. 4. Do you receive Medicaid benefi ts? Yes No If yes, Medicaid number:! Your answer to this question will not keep you from enrolling in this plan. 5. Do you, on your own or through your spouse, have any health insurance other than Medicare, such as private insurance, Workers Compensation or VA benefi ts? Yes No If yes, what kind of insurance do you have? What is the name of your insurance? Do you or your spouse work? Yes No! Your answer to this question will not keep you from enrolling in this plan. 3

5 Part 7: CMS working-aged survey Section 1 Are you working or self-employed? Yes No If Yes, please answer Section 1, Questions 1-5 and Section 2. If no, skip to Section 2 on page 4 1. Does your employer have 20 or more employees? Yes No 2. Do you have health coverage through your employer? Yes No 3. Have you refused health coverage through your employer? Yes No 4. Tell us about your employer: Company name Telephone ( ) Street/Apartment # 5. Do you plan to leave your employment or retire in the next: 3 months 6 months 1 year No plans Section 2 No, I am not working or self-employed 1. Are you married? Yes If yes, complete questions 2-8 No If No, end of survey 2. Spouse s name: Social Security #: / / 3. Is spouse working or self-employed? Yes No 4. Does your spouse s employer have 20 or more employees? Yes No 5. Does your spouse have health coverage through his/her employer? Yes No If No, end of survey 6. Tell us about your spouse s employer: Company name Telephone ( ) Street/Apartment # 7. Does your spouse s health plan include coverage for you? Yes No 8. Does your spouse plan to leave his/her employment or retire in the next: 3 months 6 months 1 year No plans 4! Please read this important information If you currently have health coverage from an employer or union, joining Senior Blue or Traditional Blue Medicare PPO could affect your employer or union health benefi ts. It may also change how your current coverage works. Read the communications your employer or union sends you. If you have questions, visit their web site, or contact the offi ce listed in their communications. If there is no information on who to contact, your benefi ts administrator or the offi ce that answers questions about your coverage can help.

6 Please read this important information If you currently have health coverage from an employer or union, joining Senior Blue or Traditional Blue Medicare PPO could affect your employer or union health benefi ts. If you have health coverage from an employer or union, joining Senior Blue or Traditional Blue Medicare PPO may change how your current coverage works. Read the communications your employer or union sends you. If you have questions, visit their website, or contact the offi ce listed in their communications. If there is no information on whom to contact, your benefi ts administrator or the offi ce that answers questions about your coverage can help. Senior Blue and Traditional Blue Medicare PPO serve a specifi c service area. If I move out of the area that Senior Blue or Traditional Blue Medicare PPO serves, I need to notify the plan so I can disenroll and fi nd a new plan in my new area. Once I am a member of Senior Blue or Traditional Blue Medicare PPO, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from Senior Blue or Traditional Blue Medicare PPO when I receive it to know which rules I must follow in order to receive coverage with this Medicare Advantage plan. I understand that Medicare benefi ciaries are generally not covered under Medicare while out of the country except for limited coverage near the U.S. border. I understand that beginning on the date Senior Blue or Traditional Blue Medicare PPO coverage begins, I must get all of my health care from Senior Blue or Traditional Blue Medicare PPO, with the exception of emergency or urgently needed services or out-of-area dialysis services. Traditional Blue Medicare PPO members: I understand that beginning on the date Traditional Blue Medicare PPO coverage begins, using services in-network can cost less than using services out-of-network, with the exception of emergency or urgently needed services or out-of-area dialysis services. If medically necessary, Traditional Blue Medicare PPO provides reimbursement for all covered benefi ts, even if received out of network. Services authorized by Senior Blue or Traditional Blue Medicare PPO and other services contained in my Senior Blue or Traditional Blue Medicare PPO Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR SENIOR BLUE / TRADITIONAL BLUE MEDICARE PPO WILL PAY FOR THE SERVICES. I understand that if I am receiving assistance from a sales agent, broker, or other individual employed by or contracted with Senior Blue or Traditional Blue Medicare PPO, he/she may be compensated based on my enrollment in Senior Blue or Traditional Blue Medicare PPO. Counseling services may be available in my state to provide advice concerning Medicare supplement insurance or other Medicare Advantage or Prescription Drug plan options and concerning medical assistance through the state Medicaid program and the Medicare Savings Program. By joining this plan, I attest that I am not receiving any fi nancial support from my current or former employer group or union (or my spouse's current or former employer group or union) intended for the purchase of medical services or medical coverage, prescription drugs or prescription drug coverage or to pay for, in whole or in part, my enrollment in a Medicare Advantage or Medicare drug plan. 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. I also acknowledge that Senior Blue or Traditional Blue Medicare PPO will release my information including my prescription drug event data 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. 5

7 Part 8: Enrollee authorization 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 certifi es that: 1) this person is authorized under State law to complete this enrollment and 2) documentation of this authority is available upon request by BlueShield of Northeastern New York or Medicare. Enrollee s signature* X Date / / * If the individual cannot sign, a court-appointed Legal Guardian or person with Durable Power of Attorney for Healthcare (DPAHC), if authorized by state law or another person who is authorized by state law, must sign the following line. Attach a copy of proof of Legal Guardian, DPAHC, or proof of authorization by state law. Signature X Date / / If you are the authorized representative, you must provide the following information: Last name First name Initial Street/Apartment # Telephone ( ) Relationship to enrollee Notes: (Internal use only) Senior Blue 600 Senior Blue 651 with Part D Traditional Blue Medicare PPO 701 Senior Blue 601 Senior Blue 652 with Part D Traditional Blue Medicare PPO 751 with Part D Senior Blue 653 with Part D Traditional Blue Medicare PPO 752 with Part D Class ID # Plan ID # Group # Effective date Subgroup Type of election Representative name ID # 6

8 ! How to complete the Medicare Advantage Enrollment Application for Senior Blue and Traditional Blue Medicare PPO To enroll as a new member in a Senior Blue or Traditional Blue Medicare PPO health plan, please complete all of the sections on pages 1 through 6. If you wish to allow a third party access to your protected health information, please complete the Authorization to use or disclose Protected Health Information (PHI) on pages 9 and 10. Please use ink and print all information.! Application Checklist: Thank you for your interest in our health plans. Please read the information below to ensure your application is processed in the timeliest manner. This will ensure you can begin taking advantage of your health benefi ts as soon as possible. If you have any questions about our plans or need help fi lling out this application, please call (toll free TTY/TDD ) Monday through Friday, 8 a.m. - 5 p.m. We can walk you through the enrollment process. The following information is necessary to enroll you in your plan of choice. Please make sure you have indicated or completed the following information before you submit your member application. I have included my Medicare Part A & B information (Part 3) I have selected a plan (Part 4) I have indicated an effective date which should be the fi rst day of the month I want to begin my coverage (Part 4) Either you or your Power of Attorney have signed and dated the application (Part 5) If any of the above information has not been included on your application, it will delay your enrollment.

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