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Providence Medicare Sycamore + Rx (HMO)

H9047-066

Plan Premiums

Price: $0.00, 0

$ 0 00 /month

Tell us about yourself

Personal Information

First Name

First Name is required

Middle Initial

Last Name is required

Last Name

Last Name is required

Sex

Male

Female

Please select your gender

Your Birthday

Your Birthday is requiredPlease enter a valid date

Phone

Phone is required.Please enter a valid phone number formatted without dashes or spaces (ex. 7130008888)

Required Information

Where do you live?

Permanent Residence Street Address (Don’t enter a PO Box)

Address 1

Address 1 is required

Apartment/Unit #

City

City is required.

State

State is required.

ZIP

ZIP is required.Please enter a valid ZIP Code.

County

Mailing address, if different from your permanent address (PO Box allowed)

Mailing Address 1

Mailing address is required.

Apartment/Unit #

Mailing City

Mailing city is required.

Mailing State

Mailing state is required.

Mailing ZIP

Mailing ZIP Code is required.Please enter a valid ZIP Code.

Mailing County

Required Information

Who is your primary doctor?

List your Primary Care Physician (PCP), clinic, or health center:

Provider First Name

Provider First Name is required

Provider Last Name

Provider Last Name is required

Provider Lookup

Your Medicare information

Medicare Insurance Information

You must have Medicare Part A and Part B to join a Medicare Advantage Plan. Using the information on your Medicare card, please complete the section below.

Medicare Number

Please enter a valid Medicare Number.Please enter a valid Medicare Number.Medicare Number has been verified.

Hospital Part A Effective Date

Please enter a date later than 07/01/1966 (mm/dd/yyyy) AND within the next year.Please enter a valid date.Hospital Part A Effective Date has been verified.

Medical Part B Effective Date

Please enter a date later than 07/01/1966 (mm/dd/yyyy) AND within the next year.Please enter a valid date.Medical Part B Effective Date has been verified.

Please click the Verify button before proceeding to next step.Verifying Medicare Claim Number...We are unable to verify your number at this time. Please check your number and press Verify to re-verify.To verify please enter required information on personal information tab.

Required Information

What is your current Medicare situation?

Typically, you may enroll in a Medicare Advantage plan only during the Annual Enrollment Period from October 15 through December 7 of each year. There are exceptions that may allow you to enroll in a Medicare Advantage plan outside of this period.

Please read the following statements carefully and check the box if the statement applies to you. By checking any of the following boxes you are certifying that, to the best of your knowledge, you are eligible for an Enrollment Period. If we later determine that this information is incorrect, you may be disenrolled.

Please select an election period

I am newly eligible for Medicare and this is my first entitlement to enrollment.Initial Coverage Election Period (ICEP) – Your ICEP begins the first three months before your entitlement to BOTH Part A and Part B and typically ends after the third month of eligibility. (Typically this relates to either your 65th birthday or your 25th month of disability)

I am newly eligible for Medicare Part D (Prescription Drug Coverage).Initial Election Period for Part D (IEP for Part D) – You may be eligible for IEP for Part D if you are entitled to Part A OR you are enrolled in Part B, AND permanently reside in the service area of a Part D plan. You may also be eligible if you previously had Medicare due to disability and are now turning 65.

My situation falls under one of the Special Election Period circumstances.Special Election Period (SEP) – You may use an SEP outside of the usual ICEP, IEP, or AEP.

Required Information

Special Election Period Options

If none of these statements applies to you or you’re not sure, please contact Providence Medicare Advantage Plans at 1-800-603-2340 or 503-574-8000 (TTY users should call 711) to see if you are eligible to enroll. We are open seven days a week, 8 a.m. to 8 p.m. (Pacific Time).

I am new to Medicare.

I am leaving employer or union coverage on

Please enter a date. (mm/dd/yyyy)Please enter a valid date

I recently had a change in my Medicaid (newly got Medicaid, had a change in level of Medicaid assistance or lost Medicaid) on

Please enter a date. (mm/dd/yyyy)Please enter a valid date

I recently had a change in my Extra Help paying for Medicare prescription drug coverage (newly got Extra Help, had a change in the level of Extra Help or lost Extra Help) on

Please enter a date. (mm/dd/yyyy)Please enter a valid date

I belong to a pharmacy assistance program provided by my state.

I recently left a PACE program on

Please enter a date. (mm/dd/yyyy)Please enter a valid date

I am enrolling during the Annual Enrollment Period (October 15-December 7).

I have both Medicare and Medicaid (or my state helps pay for my Medicare premiums) or I get Extra Help paying for my Medicare prescription drug coverage, but I haven’t had a change.

I am moving into, live in, or recently moved out of a Long-Term Care Facility (for example, a nursing home or long term care facility). I moved/will move into the facility on

Please enter a date. (mm/dd/yyyy)Please enter a valid date

I moved/will move out of the facility on

Please enter a date. (mm/dd/yyyy)Please enter a valid date

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

Please enter a date. (mm/dd/yyyy)Please enter a valid date

I recently was released from incarceration. I was released on

Please enter a date. (mm/dd/yyyy)Please enter a valid date

I recently involuntarily lost my creditable prescription drug coverage (coverage as good as Medicare’s). I lost my drug coverage on

Please enter a date. (mm/dd/yyyy)Please enter a valid date

I recently returned to the United States after living permanently outside of the U.S. I returned to the U.S. on

Please enter a date. (mm/dd/yyyy)Please enter a valid date

My plan is ending its contract with Medicare, or Medicare is ending its contract with my plan.

Please enter a date. (mm/dd/yyyy)Please enter a valid date

I recently obtained lawful presence status in the United States. I got this status on:

Please enter a date. (mm/dd/yyyy)Please enter a valid date

I was enrolled in a plan by Medicare (or my state) and I want to choose a different plan. My enrollment in that plan started on

Please enter a date. (mm/dd/yyyy)Please enter a valid date

I was affected by an emergency or major disaster (as declared by the Federal Emergency Management Agency (FEMA) or by a Federal, State or local government entity). One of the other statements here applied to me, but I was unable to make my enrollment because of the disaster.

Name of the disaster impacted by:

Name of the disaster impacted by is required.

Eligibility Period that was missed due to the disaster (for example, the Initial Enrollment Period, Annual Enrollment Period, Open Enrollment Period, or a Special Enrollment Period):

Eligibility Period that was missed due to the disaster is required.

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 disenrolled from the SNP on

Please enter a date. (mm/dd/yyyy)Please enter a valid date

I was impacted by a significant network change with my current plan and was notified on

Please enter a date. (mm/dd/yyyy)Please enter a valid date

I recently received notice of a Medicare entitlement determination for a retroactive effective date. I was notified on

Please enter a date. (mm/dd/yyyy)Please enter a valid date

I am enrolled in a Medicare Advantage plan and want to make a change during the Medicare Advantage Open Enrollment Period (MA OEP) (January 1-March 31).*Please select an SEP option

Answer these important questions

Important Questions - Please answer the following questions

Will you have other coverage in addition to Providence Medicare Advantage Plans?

Yes

Some individuals may have other coverage, including other private insurance, TRICARE, Federal employee health benefits coverage, VA benefits, or State pharmaceutical assistance programs.

Please list your other coverage and your identification (ID) number(s) for this coverage:

Name of Other CoveragePlease provide coverage name.

ID Number for this Coverage

Please provide coverage ID.

Group Number for this Coverage

Please provide coverage group number.

Check all that apply

Medical

Vision

Dental

Prescription

Please answer the required important questions.

Required Information

The following questions will help us to better serve all communities. Answering these questions is your choice. You can’t be denied coverage because you don’t fill them out.

Which of the following describes your racial or ethnic identity?
Please check all that apply.
Are you Hispanic, Latino/a, or Spanish origin? Select all that apply.

No, not of Hispanic, Latino/a, or Spanish origin

Yes, Mexican, Mexican American, Chicano/a

Yes, Puerto Rican

Yes, Cuban

Yes, another Hispanic, Latino/a, or Spanish origin

I choose not to answer.

What’s your race? Select all that apply.

American Indian or Alaska Native

Asian Indian

Black or African American

Chinese

Filipino

Guamanian or Chamorro

Japanese

Korean

Native Hawaiian

Other Asian

Other Pacific Islander

Samoan

Vietnamese

White

I choose not to answer.

For Washington and California Plans: Cottonwood, Pine and Sycamore

Select this box if you would like to receive information in Spanish.

For California Plan: Sycamore

Select this box if you would like to receive information in Vietnamese.

Select one if you want us to send you information in an accessible format.

Braille

Large Print

Audio CD

Please contact Providence Medicare Advantage Plans at 503-574-8000 or 1-800-603-2340 if you need information in an accessible format other than what’s listed above. Our office hours are seven days a week, 8 a.m. to 8 p.m. (Pacific Time). TTY users can call 711.

Do you work?

Yes

Does your spouse work?

Yes

Information Authorization

Disclosure Overview

Who is Authorized to Disclose Information

By joining this Medicare Advantage plan, I acknowledge that Providence Medicare Advantage Plans will release my information to Medicare and other plans as is necessary for treatment, health care operations. I also acknowledge that Providence Medicare Advantage Plans will release my information including my prescription drug event data if I am on a prescription drug plan 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. I understand that my signature (or the signature of the person authorized to act on my behalf under the laws of the State where I live) 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 from Medicare.

Statements of Understanding

Providence Medicare Advantage Plans is a Medicare Advantage plan and has a contract with the Federal government. I will need to keep my Medicare Parts A and B. I can be in only one Medicare Advantage plan at a time, and I understand that my enrollment in this plan will automatically end my enrollment in another Medicare health plan or prescription drug plan. It is my responsibility to inform you of any prescription drug coverage that I have or maybe get in the future. I understand that if I don't have Medicare prescription drug coverage, or a creditable prescription drug coverage plan (as good as Medicare's), I may have to pay a late enrollment penalty if I enroll in Medicare prescription drug coverage in the future. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes only at certain times of the year, when an enrollment period is available (Example: October 15th-December 7th of every year), or under certain special circumstances.

Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan.

Providence Medicare Advantage Plans serves a specific service area. If I move out of the area that Providence Medicare Advantage Plans 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 Providence Medicare Advantage Plans, I have the right to appeal plan decisions about payment or service if I disagree.

I will read the Evidence of Coverage from Providence Medicare Advantage Plans when I get it to know which rules I must follow to get coverage with this Medicare Advantage plan.

I understand that selecting a Providence Medicare (HMO) plan means that on the date coverage begins, I must get all of my health care from Providence Medicare Advantage Network Providers, except for emergency or urgently needed services or out-of-area dialysis services.

Services authorized by Providence Medicare Advantage Plans and other services contained in my Providence Medicare Advantage Plans Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered provided plan rules are followed. If plan rules are not followed, NEITHER MEDICARE NOR PROVIDENCE MEDICARE ADVANTAGE PLANS WILL PAY FOR THE SERVICES.

Privacy Act Statement

The Centers for Medicare & Medicaid Services (CMS) collects information from Medicare plans to track beneficiary enrollment in Medicare Advantage (MA) plans to improve care and for the payment of Medicare benefits. Section 1851 of the Social Security Act and 42 CFR §§ 422.50 and 422.60 authorize the collection of this information. CMS may use, disclose and exchange enrollment data from Medicare beneficiaries as specified in the System of Records Notice (SORN) “Medicare Advantage Prescription Drug (MARx)”, System No. 09-70-0588. Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan.

Producer Compensation

I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or contracted with Providence Medicare Advantage Plans, he/she may be paid based on my enrollment in Providence Medicare Advantage Plans.

Authorization

I authorize the use and disclosure of health information about me as described herein.

Signature of Applicant

Please sign your name.

Signature Date

Signature Date is requiredPlease enter a valid date

Check here if there is a paper application associated with this enrollment.

Required Information

Please select the statement below that best describes your relationship to the person with Medicare listed on this enrollment form

Relationship

What is the relationship to the person with Medicare listed on this enrollment form?

I am the person listed on this enrollment form

I am the person authorized to act on behalf of the individual

Authorized Representative

If you are the authorized representative, provide the following information

First Name

First Name is required.

Last Name

Last Name is required.

Relationship to Enrollee

Please enter relationship.

Phone

Phone cannot be empty.Please enter a valid phone number formatted without dashes or spaces (ex. 7130008888)

Address 1

Address is required.

Apartment/Unit #

City

City is required.

State

State is required.

ZIP

ZIP is required.Please enter a valid ZIP Code

County

Required Information

Plan Payment

PAYING YOUR PLAN PREMIUM

Please select a payment method

Get a monthly bill – Once you receive your first bill, you can choose a different payment option.

You can pay by credit/debit card or checking/savings account: One-time or recurring payments can be made via your myProvidence account at myProvidence.com or through the Providence website at providence.org/premiumpay.

You can pay by phone: Self Service is available 24 hours a day, 7 days a week, at 1-844-791-1468, TTY: 711.

Automatic deduction from your monthly Social Security or Railroad Retirement Board (RRB) benefit check

Paying by Credit CardWellcare Healthcare will bill you directly. Please go to Pay with Credit Card and click the pay button to process your credit card payment on or after January 1st.

Please answer additional questions for setting up Electronic Funds Transfer (EFT).

Financial Institution or Bank

Financial Institution is required

Account Type

Checking

Savings

Please select "Checking" or "Savings"

Transit/Routing Number

Transit/Routing Numbers is required

Account Number

Account Number is requiredPlease enter a valid Bank Account Number.

Account Holder's Name

Account Holder's Name is required

Date:

Date is requiredPlease enter a valid date

Required Information

Please answer additional questions for deducting from your monthly benefits.

I get monthly benefits from

Social Security

RRB

Please select "Social Security" or "RRB"

(The Social Security/RRB deduction may take two or more months to begin after Social Security/RRB approves the deduction. You may receive an invoice for the first few months before the withholding begins. If Social Security or RRB does not approve your request for automatic deduction, we will send you a letter and paper bills for your monthly premiums.)

Required Information

Payment Overview

Extra Help

People with limited incomes may qualify for Extra Help to pay 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 1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for Extra Help online at socialsecurity.gov/prescriptionhelp.

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.

Late Enrollment Penalty

Some members are required to pay a Part D late enrollment penalty because they did not join a Medicare drug plan when they initially became eligible or because they went a continuous period of 63 days or more without “creditable” prescription drug coverage. (“Creditable” means the drug coverage is generally expected to pay at least as much as Medicare's standard prescription drug coverage.) For these members, the Part D late enrollment penalty is added to the plan's monthly premium. Their premium amount will be the monthly plan premium plus the amount of their Part D late enrollment penalty.

If you are assessed a Part D-IRMAA, 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 RRB. DO NOT pay Providence Medicare Advantage Plans the Part D-IRMAA.

Send Partial Application for Signature

Beneficiary First Name

Beneficiary Last Name

Email Address

Please enter valid email address.

Beneficiary Phone

Please enter valid phone number.

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