Note: If you complete and submit the following form,
you will be requesting enrollment in a SelectHealth Advantage plan.
Please tell us about your current Medicare coverage and related benefits information.
Please take out your Medicare card to complete this section. In the spaces provided, enter your Medicare Claim Number and the Effective Dates for your Part A and Part B coverage. You must have Medicare Part A and Part B to join a Medicare Advantage plan.
SPECIAL ENROLLMENT PERIOD
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.
If none of these statements applies to you or you're not sure, please contact SelectHealth at 1-855-442-9940 (TTY users should call 711) to see if you are eligible to enroll. We are open Monday through Sunday from 8:00 a.m. to 8:00 p.m.
Other Enrollment Options
Electronic Opt Out: You may elect to receive some post-enrollment materials electronically, including your
Evidence of Coverage (EOC), which details your coverage under the plan, and Abridged Formulary, which provides a list of most commonly used, covered drugs and your Annual Notice of Changes document (ANOC) which details changes to the plan each year. To make this election, provide your email address above. You may change this election or request these items be mailed to you at any time by calling us. You can request other documents/materials be delivered electronically once you are a member of the plan.
Please enter your permanent residence address below. P.O. Box is not allowed. If you have more than one residence, enter your primary residence.
If different from above, please provide the address where you would like to
If we determine that you owe a late enrollment penalty (or if you currently have a late enrollment penalty), we need to know how you would prefer to pay it. You can pay by mail or Electronic Funds Transfer (EFT) each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board 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 Railroad Retirement Board. DO NOT pay SelectHealth the Part D-IRMAA.
You can pay your monthly plan premium (including any late enrollment penalty you have or may owe) by mail or Electronic Funds Transfer (EFT) each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board benefit check each month.
People with limited incomes may qualify for extra help to pay for their prescription drug costs. If you qualify, 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 won't have a coverage gap or a late enrollment penalty. Many people qualify 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 http://www.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.
If you don't select a payment option, you will get a bill each month.
(The Social Security/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.)
Some individuals may have additional prescription drug coverage, including other private insurance, TRICARE, federal employee health benefits, VA benefits, or state pharmaceutical assistance programs.
If you have had a successful kidney transplant and/or you no longer need
regular dialysis, please mail 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.
PO Box 30196
Salt Lake City, UT 84130
Monday through Sunday, 8:00 a.m. to 8:00 p.m.
OPTIONAL SUPPLEMENTAL BENEFITS
If you have been authorized to fill out this form on behalf of another individual, under the laws
of the State where that individual resides, you must provide the following information. Upon request,
you must be able to present SelectHealth Advantage (HMO) and/or Medicare with documentation of your
authority to represent the individual listed on this application
READ THIS IMPORTANT INFORMATION
If you currently have health coverage from an employer or union, joining SelectHealth Advantage (HMO) could affect your employer or union health benefits. You could lose your employer or union health coverage if you join SelectHealth Advantage (HMO). Read the communications your employer or union sends you. If you have questions, visit their website, or contact the office listed in their communications. If there isn’t any information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help. By completing this enrollment application, I agree to the following:
SelectHealth Advantage (HMO) 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 may get 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 15 – December 7 of every year), or under certain special circumstances.
SelectHealth Advantage (HMO) serves a specific service area. If I move out of the area that SelectHealth Advantage (HMO) 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 SelectHealth Advantage (HMO), I have the right to appeal plan decisions about payment or services if I disagree. I will read either the Member Handbook or Evidence of Coverage document from SelectHealth Advantage (HMO) when I get it to know which rules I must follow to get coverage with this Medicare Advantage plan. I understand that people with Medicare aren’t usually covered under Medicare while out of the country except for limited coverage near the U.S. border.
I understand that beginning on the date SelectHealth Advantage (HMO) coverage begins, I must get all of my health care from SelectHealth Advantage (HMO), except for emergency or urgently needed services or out-of-area dialysis services. Services authorized by SelectHealth Advantage (HMO) and other services contained in my SelectHealth Advantage (HMO) Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization,NEITHER MEDICARE NOR SelectHealth Advantage (HMO) WILL PAY FOR THE SERVICES.
I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or contracted with SelectHealth Advantage (HMO), he/she may be paid based on my enrollment in SelectHealth Advantage (HMO).
Release of Information:
By joining this Medicare health plan, I acknowledge that SelectHealth Advantage (HMO) will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that SelectHealth Advantage (HMO) 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.
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.
Review the Agent information below and signify your acceptance
of this attestation to continue.