Fillable 2021 Johns Hopkins Advantage MD (HMO and PPO) (John Hopkins Medicine Medicare Plan)

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2021 Johns Hopkins Advantage MD (HMO and PPO) (John Hopkins Medicine Medicare Plan)

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1
OMB No. 0938-1378
Expires:7/31/2023
2021 Johns Hopkins Advantage MD (HMO and PPO)
Enrollment Request Form
Who can use this form?
People with Medicare who want to join a Medicare
Advantage Plan or Medicare Prescription Drug Plan
To join a plan, you must:
• Be a United States citizen or be lawfully present
in the U.S.
• Live in the plan’s service area
Important: To join a Medicare Advantage Plan,
you must also have both:
• Medicare Part A (Hospital Insurance)
• Medicare Part B (Medical Insurance)
When do I use this form?
You can join a plan:
• Between October 15–December 7 each year (for
coverage starting January 1)
• Within 3 months of rst getting Medicare
• In certain situations where you’re allowed to join
or switch plans
Visit Medicare.gov to learn more about when you
can sign up for a plan.
What do I need to complete this form?
• Your Medicare Number (the number on your
red, white, and blue Medicare card)
• Your permanent address and phone number
Note: You must complete all items in Section 1.
The items in Section 2 are optional — you can’t be
denied coverage because you don’t ll them out.
Reminders:
• If you want to join a plan during fall open
enrollment (October 15–December 7), the plan
must get your completed form by December 7.
• Your plan will send you a bill for the plan’s
premium. You can choose to sign up to have
your premium payments deducted from your
bank account or your monthly Social Security
(or Railroad Retirement Board) benefit.
What happens next?
Send your completed and signed form to:
Johns Hopkins Advantage MD
P.O. Box 3538
Scranton, PA 18505
Fax: 1-855-825-7723
Once they process your request to join, they’ll
contact you.
How do I get help with this form?
Call Johns Hopkins Advantage MD at
1-888-403-7662. TTY users can call 711.
Or, call Medicare at 1-800-MEDICARE
(1-800-633-4227). TTY users can call
1-877-486-2048 24 hours a day/7 days a week.
En español: Llame a Johns Hopkins Advantage MD al
1-888-403-7662/TTY 711 o a Medicare gratis al 1-800-
633-4227 y oprima el 2 para asistencia en español y un
representante estará disponible para asistirle 24 horas
del día, los 7 días de la semana.
White – Enrollment Copy
Pink – Customer Copy
Y0124_2021App0820_M Approved
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless
it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-NEW. The time
required to complete this information is estimated to average 20 minutes per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have any comments concerning the accuracy of the time estimates or suggestions for improving this form, please write to:
CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
IMPORTANT Do not send this form or any items with your personal information (such as claims, payments, medical
records, etc.) to the PRA Reports Clearance Office. Any items we get that aren’t about how to improve this form or its
collection burden (outlined in OMB 0938-1378) will be destroyed. It will not be kept, reviewed, or forwarded to the plan.
See “What happens next?” on this page to send your completed form to the plan.
2
Section 1 – All fields on this page are required (unless marked optional)
Select the plan you want to join:
HMO Plans Plan Premium
Plan Premium + Optional
Supplemental Benefit
*
Johns Hopkins Advantage MD (HMO)
(Baltimore City only)
$20 per month
$50 per month
Includes fitness and
comprehensive dental
Johns Hopkins Advantage MD (HMO)
(Available throughout our service area)
$40 per month
$70 per month
Includes fitness and
comprehensive dental
PPO Plans Plan Premium
Plan Premium + Optional
Supplemental Benefit *
Johns Hopkins Advantage MD (PPO)
(Not available in Montgomery County)
$91 per month
$121 per month
Includes fitness and
comprehensive dental
Johns Hopkins Advantage MD Plus (PPO)
(Not available in Montgomery County)
$121 per month
Includes fitness benefit
at no extra cost
$149 per month
Includes comprehensive dental
(Fitness included in plan premium)
Advantage MD Premier (PPO)
(Montgomery County only)
$351 per month
Includes fitness and comprehensive dental at no extra cost.
*
Please see the Summary of Benefits for more information about Optional Supplemental Benefits.
FIRST name: LAST name: Middle Initial [Optional]:
Birth date: (MM/DD/YYYY)
(
__/__/____
)
Sex:
Male Female
Phone number:
( )
Home phone Cell phone
Alternate phone number [Optional]:
Cell phone ( )
Email address [Optional]:
Permanent Residence Street Address (Don’t enter a PO Box):
City: [Optional County]: State: ZIP Code:
Mailing address, if dierent from your permanent address (PO Box allowed):
Street address: City: State: ZIP Code:
Your Medicare information:
Medicare Number:
Answer these important questions:
Will you have other prescription drug coverage (like VA, TRICARE) in addition to Advantage MD? Yes No
Name of other coverage: Member number for this coverage: Group number for this coverage:
____-___-____
3
IMPORTANT: Read and sign below:
• I must keep both Hospital (Part A) and Medical (Part B) to stay in Advantage MD.
• By joining this Medicare Advantage Plan or Medicare Prescription Drug Plan, I acknowledge that
Advantage MD will share my information with Medicare, who may use it to track my enrollment, to
make payments, and for other purposes allowed by Federal law that authorize the collection of this
information (see Privacy Act Statement on page 4).
• Your response to this form is voluntary. However, failure to respond may aect enrollment in the plan.
• 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 people with Medicare are generally not covered under Medicare while out of the
country, except for limited coverage near the U.S. border.
• I understand that when my Advantage MD coverage begins, I must get all of my medical and prescription
drug benefits from Advantage MD. Benefits and services provided by Advantage MD and contained in
my Advantage MD “Evidence of Coverage” document (also known as a member contract or subscriber
agreement) will be covered. Neither Medicare nor Advantage MD will pay for benefits or services that
are not covered.
• I understand that my signature (or the signature of the person legally authorized to act on my behalf) on
this application means that I have read and understand the contents of this application. If signed by an
authorized representative (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 by Medicare.
Signature: Today’s date:
If you’re the authorized representative, sign above and fill out these fields:
Name: Address:
Phone number: Relationship to enrollee:
Section 2 – All fields on this page are optional
Answering these questions is your choice. You can’t be denied coverage because you don’t fill them out.
Select one if you want us to send you information in a language other than English.
Spanish
Select one if you want us to send you information in an accessible format.
Braille Large print Audio CD
Do you work? Yes No Does your spouse work? Yes No
List your Primary Care Physician (PCP), clinic, or health center:
Please contact Advantage MD at 1-888-403-7662 if you need information in an accessible format other
than what’s listed above. Our office hours are 8 a.m. to 8 p.m., 7 days a week from October 1 to March
31. From April 1 – September 30, you will need to leave a message on weekends and holidays. TTY users
can call TTY 711.
4
Please select a premium payment option. If you do not select a payment option, you will
receive a monthly bill.
Electronic funds transfer (EFT) from your bank account each month.
• The EFT enrollment process usually takes 4-5 weeks. While you are waiting for EFT, you will receive
monthly statements. You must pay your premium directly to Johns Hopkins Advantage MD at
P.O. Box 419169, Boston, MA 02241-9169.
Please enclose a VOIDED check or provide the following:
Account holder name
Bank routing number Bank account number
Account type:
Checking
Savings
Continues on next page...
PRIVACY ACT STATEMENT
The Centers for Medicare & Medicaid Services (CMS) collects information from Medicare plans to track
beneficiary enrollment in Medicare Advantage (MA) or Prescription Drug Plans (PDP), improve care, and for
the payment of Medicare benefits. Sections 1851 and 1860D-1 of the Social Security Act and 42 CFR §§ 422.50,
422.60, 423.30 and 423.32 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 aect enrollment in the plan.
Paying your plan premiums
You can pay your monthly plan premium (including any late enrollment penalty that you currently have or may
owe) by mail or “Electronic Funds Transfer (EFT)”, each month. You can also choose to pay your
premium by having it automatically taken out of your Social Security or Railroad Retirement
Board (RRB) benefit each month.
If you have to pay a Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA),
you must pay this extra amount in addition to your plan premium. The amount is usually taken out
of your Social Security benefit, or you may get a bill from Medicare (or the RRB). DON’T pay Johns Hopkins
Advantage MD the Part D-IRMAA.
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.
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. 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 www.socialsecurity.gov/prescriptionhelp.
As a Maryland resident, you may also qualify for the Senior Prescription Drug Assistance
Program (SPDAP). For more information, call 1-800-551-5995 (TTY 1-800-877-5156) Monday – Friday
from 8:00 am to 5:00 p.m. Visit them online at http://marylandspdap.com/.
5
Automatic deduction from your monthly Social Security or Railroad Retirement Board
(RRB) benefit check.
I get monthly benefits from: Social Security RRB
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 eective 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.
Get a monthly bill.
Payments are due on the first of each month. Make your check, cashier’s check or money order
payable to Johns Hopkins Advantage MD and mail directly to Johns Hopkins Advantage
MD, P.O. Box 419169, Boston, MA 02241-9169.
Attestation of eligibility for an 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.
I am new to Medicare.
I am enrolled in a Medicare Advantage plan and want to make a change during the Medicare Advantage
Open Enrollment Period (MA OEP).
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 was released from incarceration. I was released 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 recently obtained lawful presence status in the United States. I got this status on (insert date)
I recently had a change in my Medicaid (newly got Medicaid, had a change in level of Medicaid assistance,
or lost Medicaid) on (insert 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 (insert date)
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/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 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 plan by Medicare (or my state) and I want to choose a different plan. My enrollment in
that plan started on (insert date)
I 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 (insert date)
__
I was affected by a weather-related emergency or major disaster (as declared by the Federal Emergency
Management Agency (FEMA). One of the other statements here applied to me, but I was unable to make
my enrollment because of the natural disaster.
If none of these statements applies to you or you’re not sure, please contact Johns Hopkins Advantage
MD at 1-888-403-7662. (TT Y users should call 711) to see if you are eligible to enroll. W e are open 8 a.m.
- 8 p.m., 7 days a week October 1 to March 31. From April 1 to September 30 the hours are 8 a.m. to 8
p.m., Monday - Friday. On weekends and holidays you will need to leave a message.
Agent Use Only:
Name of agent (if assisted in enrollment^
Agent Code:
FMO Name:
Effective Date of Coverage:
ICEP/IEP:
_________
AEP:
__________
SEP (type):__________Not Eligible:
_________
D ate:
______________
Johns Hopkins Advantage MD is a Medicare Advantage Plan with a Medicare contract offering HMO and PPO
products. Enrollment in Johns Hopkins Advantage MD HMO or PPO depends on contract renewal.
_________________________________________
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2021 Johns Hopkins Advantage MD (HMO and PPO) (John Hopkins Medicine Medicare Plan)

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Completed 25 May 2021

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