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EASY CHOICE MEDICARE ADVANTAGE PLANS

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  • 57 check-boxes
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EASY CHOICE MEDICARE ADVANTAGE PLANS
INDIVIDUAL ENROLLMENT FORM
How to Enroll with Easy Choice
Please read this entire enrollment form to make sure you understand the information.
When you’re ready, fill out the entire enrollment form. Where appropriate, write
clearly in all capital letters or place an “X” in the appropriate box.
Once you’re done, don’t forget to sign and date it.
Return the completed/signed form to Easy Choice using the attached postage-paid
business reply envelope.
Contact your Sales Agent with any questions you may have.
Sales Agent: _______________________ Phone: ( ____ ) ____ - ___________
Call Easy Choice Customer Service at 1-866-999-3945.
TTY users should call 1-800-735-2929.
Hours of operation are Monday–Friday, 8 a.m. to 8 p.m.
Between October 1 and February 14, representatives are available Monday–Sunday,
8 a.m. to 8 p.m., or visit us anytime at www.easychoicehealthplan.com.
Enroll online at www.easychoicehealthplan.com.
Enroll online at www.medicare.gov.
3 Other Easy Ways to Enroll with Easy Choice
H5087_CA034206_WCM_APP_ENG CMS Approved 07272016 CA7CCPAPP73561E_0616
©WellCare 2016 CA_06_16_OCR_BRE
This information is available for free in other languages. Please call our Customer Service number at
1-866-999-3945, Monday-Friday, 8 a.m . to 8 p.m. Between October 1 and February 14, representatives
are available Monday-Sunday, 8 a.m. to 8 p.m. TTY users should call 1-800-735-2929.
Esta información está disponible gratis en otros idiomas. Por favor llame a nuestro número de
Servicio al Cliente al 1-866-999-3945, de lunes a viernes, de 8 a.m. a 8 p.m. Entre el 1 de octubre
y el 14 de febrero, los representantes están disponibles de lunes a domingo de 8 a.m. a 8 p.m.
Los usuarios de TTY deben llamar al 1-800-735-2929.
本資訊免費提供其它語言版本。請撥打1-866-999-3945與我們的客戶服務部聯繫，服務時
間為週一至週五，上午8 點至晚上8 點 。在十月1 日至二月1 4 日之間，代表的服務時間
為週一至週日，上午8 點至晚上8 點。 用戶請撥打1-800-735-2929。
이 정보는 다른 언어로 무료로 제공됩니다. 10월 1일부터 2월 14일까지 고객 서비스
전와번호 1-866-999-3945번으로 월요일부터 금요일과지, 오전 8시에서 오후 8시
사이에 전화하면 담당자와 통화하실 수 있습니다. TTY 사용자들은 1-800-735-2929
번에 월요일부터 금요일과지, 오전 8시에서 오후 8시 사이에 전와하십시오.
Thông tin này hiện có miễn phí bằng các ngôn ngữ khác. Xin gọi Dịch Vụ Khách Hàng của chúng
tôi tại số 1-866-999-3945, Thứ Hai-Thứ Sáu, 8 sang tới 8 tối Trong khoảng Ngày 1 Thang Mười va
14 Tháng Hai, các đại diện có sẵn Thứ Hai-Chủ Nhật, 8 sáng tới 8 tối những người sử dụng TTY
nên gọi so 1-800-735-2929.
2017 EASY CHOICE MEDICARE ADVANTAGE PLANS INDIVIDUAL ENROLLMENT FORM
Please contact Easy Choice if you need information in another language or format (Braille).
To Enroll in an Easy Choice Plan, Please Provide the Following Information:
Please select the box for the plan you want to enroll in:
001: Easy Choice Freedom Plan (HMO SNP) - Los Angeles
002: Easy Choice Plus Plan (HMO) - Orange, Riverside, San Bernardino
005: Easy Choice Best Plan (HMO) - Los Angeles, Orange
016: Easy Choice Best Plan (HMO) - Riverside, San Bernardino
017: Easy Choice Plus Plan (HMO) - Los Angeles
$
per month
Mr. Mrs. Ms. Sex: M F Birth Date:
M M D D Y Y Y Y
Last Name:
Middle Initial:
First Name:
Home Phone Number: Alternate Phone Number:
Yellow: Member Copy)
Email Address (optional):
Please know that by providing your email address, you are agreeing to receive emails from us. We will give you the
opportunity to opt in and you may always opt out of future email communications.
Permanent Residence Street Address:
(
P.O. Box is not allowed
)
(White: Office Copy
Street Address:
City: State: ZIP Code:
County:
City: State: ZIP Code:
Mailing Address:
(
only if different from your Permanent Residence Street Address
)
Please Provide Your Medicare Insurance Information:
Please take out your Medicare card to complete this section.
• Please fill in these blanks so they match your red,
white and blue Medicare card.
- OR -
• Attach a copy of your Medicare card or your letter
from Social Security or the Railroad Retirement Board.
You must have Medicare Part A and Part B to join a
Medicare Advantage Plan.
MEDICARE HEALTH INSURANCE
Name:
Medicare Claim Number:
Is Entitled To: Effective Date: (MMDDYYYY)
HOSPITAL (Part A)
MEDICAL (Part B)
SAMPLE ONLY
Sex:
H5087_CA034206_WCM_APP_ENG CMS Approved 07272016
Sales Agent:
©WellCare 2016 CA_06_16_OCR_BRE
PAGE 1 OF 6
CA7CCPAPP73561E_0616
(White: Office Copy Yellow: Member Copy)
Paying Your Plan Premium
Consent to Contact by Phone
If enrolling in a health plan with a $0 monthly premium: 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 each month. You can also choose to pay your premium by automatic deduction from your
Social Security or Railroad Retirement Board (RRB) benefit check each month, if eligible. If you are assessed a
Part D-Income Related Monthly Adjustment Amount (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 the
RRB. DO NOT pay Easy Choice the Part D-IRMAA.
If enrolling in a plan with a monthly premium: You can pay your monthly plan premium (including any late
enrollment penalty that you currently have or may owe) by mail or by automatic deduction from your Social
Security or Railroad Retirement Board (RRB) benefit check each month, if eligible. If you are assessed a Part
D-Income Related Monthly Adjustment Amount (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 the
RRB. DO NOT pay Easy Choice 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 coinsurance. 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 do not 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 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 monthly bill to pay your premiums.
Please select a premium payment option:
Get a bill monthly Social Security Railroad Retirement Board
Automatic deduction from your monthly Social Security or Railroad Retirement Board (RRB) benefit check (if eligible).
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, or
approves deductions to begin after the enrollment effective date, we will send you a bill for your monthly premiums.
Consent for non-telemarketing calls: I agree to receive non-telemarketing calls or text messages from the health plan
using an automated phone dialing system that provides relevant, timely information regarding your health care and
coverage. These calls may be pre-recorded. I may opt out at any time by calling the number on the back of my ID card. I
understand that giving my consent to get calls or texts is not a condition to get the plan’s products or services.
Yes (Agree to Consent) No (Do not Consent) Signature:_________________________________________
Consent for telemarketing calls: I agree to receive phone calls or text messages from the health plan on my cell phone
using an automated phone dialing system or an artificial pre-recorded voice. These calls will provide information about
our services, including marketing information and tips to help you make health care decisions. These calls or texts will
go to the numbers provided on this application. I may opt out at any time by calling the number on the back of my ID
card. I understand that giving my consent to get calls or texts is not a condition to get the plan’s products or services.
Yes (Agree to Consent) No (Do not Consent) Signature:_________________________________________
H5087_CA034206_WCM_APP_ENG CMS Approved 07272016
Sales Agent:
PAGE 2 OF 6
©WellCare 2016 CA_06_16_OCR_BRE CA7CCPAPP73561E_0616
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signature
click to edit
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signature
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Please Read and Answer These Important Questions:
1. Do you have end-stage renal disease (ESRD)? Yes No
If you have had a successful kidney transplant and/or you do not need regular dialysis any more, please attach
a note or records from your doctor showing you have had a successful kidney transplant or you do not need
dialysis; otherwise, we may need to contact you to obtain additional information.
(White: Office Copy Yellow: Member Copy)
2. For MAPD Plans: Some individuals may have other drug coverage, including other private insurance, TRICARE,
federal employee health benefits coverage, VA benefits or State Pharmaceutical Assistance Programs.
Will you have other prescription drug coverage in addition to Easy Choice? Yes No
If “yes’’ please list your other coverage and your identification (ID) number(s) for this coverage:
Name of other coverage:
ID # for this coverage: Group # for this coverage:
3. Are you a resident of a long-term care facility, such as a nursing home? Yes No
If “yes’’ please provide the following information:
Name of Institution:
Address & Phone Number of Institution:
4. Are you enrolled in your State Medicaid program? If “yes” please provide your Medicaid number:
Yes No
5. Do you or your spouse work? Yes No
Please select ONE box for the language in which you prefer to receive information:
English Spanish (where available) Chinese (where available) Korean (where available) Vietnamese (where available)
Please select the box if you prefer to receive information in large print:
Please contact Easy Choice at the Customer Service number listed on the front cover of this booklet regarding the
availability of information in a format or language other than what is listed above.
Please choose a primary care physician (PCP), clinic or health center: (First and Last Name of PCP)
Are you a current patient? Yes No
ID#
H5087_CA034206_WCM_APP_ENG CMS Approved 07272016
Sales Agent:
©WellCare 2016 CA_06_16_OCR_BRE
PAGE 3 OF 6
CA7CCPAPP73561E_0616
Please Read This Important Information:
For MAPD Plans: If you currently have health coverage from an employer or union, joining an Easy Choice plan
could affect your employer or union health benefits. You could lose your employer or union health coverage
if you join an Easy Choice health plan. 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.
(White: Office Copy Yellow: Member Copy)
Please Read and Sign:
By completing this enrollment application, I agree to the following:
Easy Choice Health Plan (HMO), a WellCare company, is a Medicare Advantage organization with a Medicare contract. Enrollment
in Easy Choice (HMO) depends on contract renewal. 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.
Easy Choice serves a specific service area. If I move out of the area that Easy Choice 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 Easy Choice, I have the right to appeal plan decisions
about payment or services if I disagree. I will read the Evidence of Coverage document from Easy Choice when I receive 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 Easy Choice coverage begins, I must get all of my health care from Easy Choice, except
for emergency or urgently needed services or out-of-area dialysis services. Services authorized by Easy Choice and other services
contained in my Easy Choice Evidence of Coverage document (also known as a member contract or subscriber agreement) will be
covered. Without authorization, NEITHER MEDICARE NOR EASY CHOICE 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 Easy
Choice, he/she may be paid based on my enrollment in Easy Choice.
Release of Information: By joining this Medicare health plan, I acknowledge that Easy Choice will release my
information to Medicare, other plans and providers as is necessary for treatment, payment and health care operations.
I also acknowledge that Easy Choice 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.
Today’s Date:
Signature:
M M D D Y Y Y Y
If you are the authorized representative, you must sign above and provide the following information.
Would you like all mail to be sent to the authorized representative? Yes No
Name:
Address:
City: State: ZIP:
Phone Number:
Relationship to Enrollee:
H5087_CA034206_WCM_APP_ENG CMS Approved 07272016
Sales Agent:
©WellCare 2016 CA_06_16_OCR_BRE
PAGE 4 OF 6
CA7CCPAPP73561E_0616
Attestation of Eligibility for an Enrollment Period
(White: Office Copy Yellow: Member Copy)
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 select the box if the statement applies to you. By filling in 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 the statement you select requires a date, please use the following format: MMDDYYYY
I am a new Medicare beneficiary.
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 .
I recently was released from incarceration. I was released on .
I recently returned to the United States after living permanently outside of the U.S.
I returned to the U.S. on .
I recently obtained lawful presence status in the United States. I got this status on .
I have both Medicare and Medicaid or my state helps pay for my Medicare premiums.
I get Extra Help paying for Medicare prescription drug coverage.
I no longer qualify for Extra Help paying for my Medicare prescription drugs.
I stopped receiving Extra Help on .
I am moving into, live in, or recently moved out of a long-term care facility (for example, a nursing home).
I moved/will move into/out of the facility on .
I recently left a PACE program on .
I recently involuntarily lost my creditable prescription drug coverage (coverage as good as Medicare’s).
I lost my drug coverage on .
I am leaving employer or union coverage on .
I belong to a pharmacy assistance program provided by my state or I am losing/recently lost participation in
such a program on .
My plan is ending its contract with Medicare, or Medicare is ending its contract with my plan.
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 .
If none of these statements applies to you or you’re not sure, please contact Easy Choice at 1-866-999-3945 to
see if you are eligible to enroll. We are open 8 a.m. to 8 p.m., 7 days a week. TTY users should call 1-800-735-2929.
H5087_CA034206_WCM_APP_ENG CMS Approved 07272016
Sales Agent:
©WellCare 2016 CA_06_16_OCR_BRE
PAGE 5 OF 6
CA7CCPAPP73561E_0616
Sales Agent/Office Use Only:
Name of Staff Member/Agent/Broker (if assisted in enrollment):
Agent Signature: __________________________________ Date Application Received:
Agent Initials: Agent ID:
Agent Phone #:
M M D D Y Y Y Y
Plan ID #: Effective Date of Coverage:
ICEP/IEP AEP SEP (type): Not Eligible
H
M M D D Y Y Y Y
Cancel
Application
Emergency Contact:
(optional)
Phone Number: Relationship to You:
(optional) (optional)
Emergency Contact Information:
(White: Office Copy Yellow: Member Copy)
73561
H5087_CA034206_WCM_APP_ENG CMS Approved 07272016
Sales Agent:
©WellCare 2016 CA_06_16_OCR_BRE
PAGE 6 OF 6
CA7CCPAPP73561E_0616
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EASY CHOICE MEDICARE ADVANTAGE PLANS

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Completed 28 December 2022

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