Instuctions to help you complete you enollment fom fo HPHC's Medicae Supplemental Plan Thank you fo applying fo membeship to HPHC s Medicae Supplement plan. Pio to submitting you enollment fom fo pocessing, please take the time to complete the entie enollment fom. If the enollment fom eceived is incomplete, it will not be pocessed and will be etuned to you fo additional infomation. If you would like to enoll ove the telephone with a plan epesentative, please call 877-906-HPHC (4742). You ae eligible to apply fo HPHC s Medicae Supplement plan if you meet all of the following equiements: You legal esidence is in the State of Maine. You ae eligible fo Medicae Pat A and Medicae Pat B and enolled in Medicae Pat B. If you ae unde age 65 and you qualify fo Medicae coveage because of a disability. Instuctions: 1. Please choose a plan and effective date fo coveage to begin (i.e. 9/1/2010). You effective date cannot be pio to the date we eceive you application. 2. Please fill in you pesonal infomation. 3. You Medicae infomation: In ode fo you enollment to be complete, you must eithe copy infomation fom you ed, white & blue Medicae cad, o attach a copy of you Medicae cad o you lette of Veification fom the Social Secuity Administation o Raiload Retiement Boad. If you don t have you Medicae infomation o have not been assigned a Medicae claim numbe at this time, call you local Social Secuity Office to enoll o to obtain poof of enollment. 4. Read and answe all questions in section 4. 5. Detemine you Eligibility. Eligibility Categoies (If none of the below applies, you must complete Section 5.) You ae eligible fo open enollment if: You have enolled in Medicae Pat B with in the last 6 months. You wee enolled in Medicae Pat B pio to age 65 based upon disability and tuned 65 within the last 6 months. You Medicae Pat B will become effective within the next 60 days. You ae eligible fo Guaantee Issue if: You have been involuntaily teminated o lost coveage fom a Medicae Advantage Plan, employe etiee plan o a Medicae Supplement plan in the past 90 days. You ae eplacing a Medicae Supplement policy of equal o lesse coveage and have not had a gap in coveage of moe than 90 days. You voluntaily disenolled fom you Medicae Advantage plan with in the fist 36 months of enollment, and ae applying within 90 days of temination. You ae eligible fo Annual one month guaantee issue if: You ae applying fo Plan "A" duing the month of Decembe fo a Januay 1st effective date fo coveage. 6. Read Impotant Infomation in Section 7. 7. Sign and date the enollment fom. 8. If you eceived a notice fom you pio insue saying you wee eligible fo guaanteed issue of a Medicae supplement Insuance Policy, o that you had cetain ights to buy such a Policy, please include a copy. Detach the yellow copy of this fom fo you legal ecods and mail the white enollment fom to: Havad Pilgim Health Cae 1600 Cown Colony Dive, Quincy, MA 02169-9777 Fom No. 1235 If you need assistance o have questions, please call us at: Pospective Membes: 877-909-HPHC (4742), TTY 1-888-259-8276 Cuent Membes: 877-907-HPHC (4742), TTY 1-800-421-3599
Maine Residents HPHC Medicae Supplement Enollment Fom The Plan is undewitten by HPHC Insuance Company, an affiliate of Havad Pilgim Health Cae. SECTION 1. Plan Choice: Plan A Plan F Plan M Plan N Plan Effective Date SECTION 2. Pesonal Infomation: Fist Name Middle Initial Last Name Social Secuity Numbe Pemanent Addess (Numbe & Steet) City/State/Zip/Code Billing Addess (if diffeent fom you pemanent addess) City/State/Zip Code Cuent Insuance Caie Gende Male Female Date of Bith Month Day Yea Telephone Numbe ( ) Email Addess SECTION 3. Medicae Infomation Please take out you ed, white & blue Medicae Cad to complete this section. MEDICARE HEALTH INSURANCE NAME MEDICARE CLAIM NUMBER SEX IS ENTITLED TO EFFECTIVE DATE HOSPITAL (PART A) MEDICAL (PART B) SECTION 4. Replacement o othe Coveage If you lost o ae losing othe health insuance coveage and eceived a notice fom you pio insue saying you wee eligible fo guaanteed issue of a Medicae supplement insuance policy, o that you had cetain ights to buy such a policy, you may be guaanteed acceptance in one o moe of ou Medicae supplement plans. Please include a copy of the notice fom you pio insue with you application. If you wee involuntaily teminated fo nonpayment of pemium, please also include documentation demonstating payment of outstanding pemiums. Fom No. 1234 Yellow - Applicant - Please keep fo you ecods
SECTION 4. continued Please Answe All Questions [Please check Yes o No] To the best of you knowledge, 1. (a) Did you tun age 65 in the last six months? Yes No (b) Did you enoll in Medicae Pat B in the last six months? Yes (c) If yes, what is the effective date? No 2. Ae you coveed fo medical assistance though the state Medicaid pogam? [NOTE TO APPLICANT: If you ae paticipating in a Spend-Down Pogam and have not met you Shae of Cost, please answe NO to this question.] Yes If yes, (a) Will Medicaid pay you pemiums fo this Medicae supplement policy? Yes (b) Do you eceive any benefits fom Medicaid OTHER THAN payments towad you Medicae Pat B pemium? Yes No (c) Did you lose o will you be losing Medicaid eligibility? Yes No Medicaid temination date No No 3. (a) If you had coveage fom any Medicae plan othe than oiginal Medicae within the past 90 days (fo example, a Medicae Advantage plan, o a Medicae HMO o PPO), fill in you stat and end dates below. If you ae still coveed unde this plan, leave END blank. START / / END / / (b) If you ae still coveed unde the Medicae plan, do you intend to eplace you cuent coveage with this new Medicae supplement policy? Yes No (c) Was this you fist time in this type of Medicae plan? Yes No (d) Did you dop a Medicae supplement policy to enoll in the Medicae plan? Yes No 4. (a) Do you have anothe Medicae supplement policy in foce? Yes No (b) If so, with what company, and what plan do you have? (c) If so, do you intend to eplace you cuent Medicae supplement policy with this policy? Yes No 5. Have you had coveage unde any othe health insuance within the past 90 days? Yes No (Fo example, an employe, union, o individual plan) (a) If so, with what company and what kind of policy? (b) What ae you dates of coveage unde the othe policy? START / / END / / (If you ae still coveed unde this plan, leave END blank.) Yellow - Applicant - Please keep fo you ecods
SECTION 5. IF YOU ARE ELIGIBLE FOR OPEN ENROLLMENT OR GUARANTEE ISSUE (SEE #5 ON THE INSTRUCTION PAGE TO DETERMINE WHETHER THIS SECTION APPLIES TO YOU), DO NOT ANSWER THE QUESTIONS IN THIS SECTION. If the answe to any question in this section is YES the Applicant is not eligible fo coveage. This does not apply to applicants applying fo Medicae supplement coveage unde Plan A duing the annual one month guaantee issue. Height (feet/inches) Weight (pounds) Ae you now confined in a hospital o nusing home, o, within the past 60 days, have you been advised by a docto to seek medical cae o teatment in a hospital o in a nusing home? Yes No Ae you bedidden? Yes No Do you equie the use of a wheelchai? (if YES, please give details) Yes No Ae you eceiving kidney dialysis? Yes No Have you, due to mental o physical disability, authoized any peson o institution to legally act in you behalf and take ove you pesonal tansactions? Yes No In the past 12 months, have you been advised to have sugey but it has not yet been done? Yes No In the past 12 months, have you been hospitalized thee o moe times? Yes No Do you outinely visit the same medical povide moe than monthly fo medical advice o teatment? Yes No Do you now have any of the following conditions o have you eceived medical advice o teatment fo the following conditions within the past 12 months? Cance (except skin) o Leukemia Chonic Lung Disease Cihosis of the Live Diabetes (insulin dependent) Stoke Angina Pectois, Heat Attack, Congestive Heat Failue, o Valvula Heat Disease Alzheime s Disease, memoy loss o impaiment, dementia o cognitive impaiment Pakinson s Disease Multiple Scleosis Chonic Kidney Disease Any fom of Athitis o Degeneative Bone Disease causing cippling, factues, limitation of motion o equiing joint eplacement Yellow - Applicant - Please keep fo you ecods
SECTION 6. Impotant Infomation A. You do not need moe than one Medicae supplement policy. B. If you puchase this policy you may want to evaluate you existing health coveage and decide if you need multiple coveages. C. You may be eligible fo Medicaid benefits and may not need a Medicae supplement policy. D. If, afte puchasing this policy, you become eligible fo Medicaid, the benefits and pemiums unde you Medicae supplement policy can be suspended, if equested, duing you entitlement to benefits unde Medicaid fo 24 months. You must equest this suspension within 90 days of becoming eligible fo Medicaid. If you ae no longe entitled to Medicaid, you suspended Medicae supplement policy (o, if that is no longe available, a substantially equivalent policy) will be einstituted if equested within 90 days of losing Medicaid eligibility. If the Medicae supplement policy povided coveage fo outpatient pesciption dugs and you enolled in Medicae Pat D while you policy was suspended, the einstituted policy will not have outpatient pesciption dug coveage, but will othewise be substantially equivalent to you coveage befoe the date of the suspension. E. If you ae eligible fo, and have enolled in a Medicae supplement policy by eason of disability and you late become coveed by an employe o union-based goup health plan, the benefits and pemiums unde you Medicae supplement policy can be suspended, if equested, while you ae coveed unde the employe o union-based goup health plan. If you suspend you Medicae supplement policy unde these cicumstances, and late lose you employe o union-based goup health plan, you suspended Medicae supplement policy (o, if that is no longe available, a substantially equivalent policy) will be einstituted if equested within 90 days of losing you employe o union-based goup health plan. If the Medicae supplement policy povided coveage fo outpatient pesciption dugs and you enolled in Medicae Pat D while you policy was suspended, the einstituted policy will not have outpatient pesciption dug coveage, but will othewise be substantially equivalent to you coveage befoe the date of the suspension. F. Counseling sevices may be available in you state to povide advice concening you puchase of Medicae supplement insuance and concening medical assistance though the state Medicaid pogam, including benefits as a Qualified Medicae Beneficiay (QMB) and a Specified Low-Income Medicae Beneficiay (SLMB). Yellow - Applicant - Please keep fo you ecods
I o my authoized epesentative cetify that the statements made and answes given ae complete and tue. I o my authoized epesentative have ead and caefully consideed all of the infomation on this fom. I o my authoized epesentative also cetify that I eceived the Outline of Medicae Supplement Coveage. I o my authoized epesentative undestand that no employe, fome employe, health cae povide, o pivate o govenment agency may sponso, puchase o contibute to the cost of this Havad Pilgim Medicae Supplement Plan. I o my authoized epesentative undestand that to enoll in coveage, and fo as long as I am coveed, I must be entitled to Medicae Pat A and enolled in Medicae Pat B. I o my authoized epesentative undestand that membeship will become effective upon the fist day of the month following acceptance by the Plan. Benefits unde this Plan will be explained unde a sepaate document. I o my authoized epesentative authoize all of my health cae povides, othe health plans, and insuance companies to elease all of my medical ecods and othe infomation to the Plan o to Plan affiliated health cae povides fo the pupose of detemining my coveage and administeing my benefits. I o my authoized epesentative authoize the use by the Plan and its agents, of any infomation obtained heeunde fo the delivey of health sevice, to detemine eligibility and entitlement to benefits (including eimbusement by thid paties) fo education and eseach in accodance with govenment egulations and fo the othe plan pofessional activities such as utilization eview, quality assuance, case management, efeal and authoization, disease management, faud detection, and cetain ovesight activities, such as acceditation and egulatoy audits. I o my authoized epesentative undestand that the benefits fo which I am eligible ae those descibed in the applicable subscibe policy. I o my authoized epesentative undestand that HPHC s Medicae Supplement Insuance pemium ates ae subject to change as allowed by state law. I o my authoized epesentative undestand that enollment in this plan is contingent upon payment of pemium. I o my authoized epesentative is entitled to eceive a copy of this authoization fom. The subogation povision outlined in the Policy, pemits subogation payments on a just and equitable basis. This authoization is valid though the tem of coveage unde the plan o any enewals theeof. You may evoke this authoization at any time by contacting the Plan at the above addess o telephone numbe, povided that such evocation may be a basis fo denying benefits unde the Plan. All statements and infomation in this fom shall be deemed epesentations and not waanties. I undestand that a copy of this fom will be given to me, o my authoized epesentative, upon equest. It is a cime to knowingly povide false, incomplete o misleading infomation to an insuance company fo the pupose of defauding the company. Penalties may include impisonment, fines o a denial of insuance benefits. Failue to sign this fom may impai the Plan s ability to evaluate o pocess an application o claim and may be a basis fo denying an application o a claim fo benefits. Signatue of Applicant, o Authoized Repesentative (if applicable)* Date *If signed by an Authoized Repesentative, a copy of the authoity to epesent applicant must be attached to the application (such as a Powe of Attoney). Sales Agent ID Yellow - Applicant - Please keep fo you ecods