Fillable Form 2022: Aetna Medicare Individual Enrollment Form Medicare

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Form 2022: Aetna Medicare Individual Enrollment Form Medicare

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The Form 2022: Aetna Medicare Individual Enrollment Form Medicare form is 21 pages long and contains:

  • 3 signatures
  • 17 check-boxes
  • 123 other fields

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File type: PDF

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Aetna Medicare
2022
Medicare Prescription Drug Plan (Part D)
Individual Enrollment Form
OMB No. 0938-1378 Expires 7/31/2023
Confirm your enrollment eligibility
Typically, you may enroll in a Medicare Prescription Drug Plan only during the Annual Enrollment
Period (AEP) from October 15 through December 7 of each year. There are exceptions that may
allow you to enroll in a Medic
are Prescription Drug Plan outside of this period.
Please read the following statements carefully and check the box if the statement applies to you.
By c
hecking any of the following boxes you are certifying that, to the best of your knowledge, you are
eligible for that reason, which will help us to determine your enrollment period. If we later determine
that this information is incorrect, you may be disenrolled.
Reasons for Annual Enrollment Period Eligibility
I am enrolling between 10/15/21 – 12/7/21 during the current Annual Enrollment Period.
Reasons for Initial Enrollment Period Eligibility
I am new to Medicare. I previously had Medicare but am now turning 65.
Reasons for Special Enrollment Period Eligibility (Sel
ect reason and enter date if applicable)
I am enrolled in a Medi
care Advantage plan
and want to make a change during the
Medicare Advantage Open Enrollment Period
(MA OEP).
I recently moved outsi
de of the service area for
my current plan or I recently moved and this
plan is a new option for me. I moved on
(date).
I recently
was released from incarceration.
I was released on
__ (date).
I recently returned to the United States after
living permanen
tly outside of the U.S. I
returned to the U.S. on (date).
I recently obtained law
ful presence status in
the United States. I got this status on
(date).
I recently had a change in my Medicaid (new
ly
got Medicaid, had a change in level of
Medicaid assistance, or lost Medic
aid) on
__ __ (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 Hel
p, or lost Extra Help) on
(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 cover
age, but I haven’t had a
change.
I 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 facil
ity on
(date).
I recently left a PACE program on
(date).
I recently involuntarily lost my creditable
prescription drug coverage (as good as
Medicare’s). I lost my drug coverage on
(date).
I am l
eaving employer or union coverage on
(date).
I belong to a pharmacy assistance program
provided by
my state.
My plan is ending its contract with Medicare,
or Medicare is e
nding its contract with my
plan.
I was enrolled in a plan by Medicare (or my
stat
e) and I want to choose a different plan.
My enrollment in that plan started on
(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
request because of the natural disaster.
If none of these statements applies to you, call us at 1-833-526-2210 (TTY: 711) to see if you can
enroll. We're here 8 AM to 8 PM, seven days a week, from October 1 to March 31 and 8 AM to 8 PM,
Monda
y through Friday, from April 1 to September 30.
PLEASE RETURN TO COMPANY
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2022 2 22-EF-UNIV
Section 1: Choose your plan
Please check the plan you want to
enroll in:
SilverScript SmartRx (PDP)
SilverScript Choice (PDP)
SilverScript Plus (PDP)
Proposed effective date of coverage:
__ __ /__ __ /__ __ __ __
M M / D D / Y Y Y Y
The effective date for enrollees in their Initial
Enroll
ment Period will either be the first of the month
following enrollment submission or the first of the
month the enrollee is eligible for Part D, whichever is
later.
Section 2: Your information
Last name First name Middle initial
Birth date
__ __ / __ __ / __ __ __ __
M M / D D / Y Y Y Y
Sex
M
F
Primary phone number
( __ __ __ )
__ __ __ - __ __ __ __
Secondary phone number ( __ __ __ )
__ __ __ - __ __ __ __
Permanent residence / long-term care facility address (a PO Box is not allowed)
Street number Street name
Apt./Suite/Unit (please specify)
City County State ZIP Code
Long-term care facility name
Mailing address (only if different from your permanent residence address)
Street number Street name
Apt./Suite/Unit (please specify)
City County State ZIP Code
Email address
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2022 3 22-EF-UNIV
Section 3: Provide your Medicare insurance information
Medicare Number: __ __ __ __ - __ __ __ - __ __ __ __
Is Entitled To: Effective Date:
HOSPITAL (Part A) __ __ / __ __ / __ __ __ __
MEDICAL (Part B) __ __ / __ __ / __ __ __ __
You must have either Medicare Part A or Part B (or both) to join a Medicare Prescription Drug (Part D)
Plan.
Section 4: Please read and answer these important questions
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 Aetna Prescription Drug Plan (Aetna
PDP) during the 2022 calendar year?
Yes No
If “yes,” please list your other coverage and your identification (ID) number(s) for this coverage:
Name of other coverage:
Member number: Group number:
Indicate your preferred language (if not English):
Spanish Other
If you need information in an alternate language or accessible format, such as Braille, audio tape, or
large print, please contact us at 1-855-771-9286 (TTY: 711), 24 hours a day, 7 days a week.
Would you like to receive paperless Explanation of Benefit (EOB) statements?
We’ll send you a monthly email letting you know how to access and view your secure EOB statement.
You will need to provide us with your email address. You can opt out at any time.
Yes, I want to receive my EOB statements electronically.
Please be sure to include your email address in Section 2.
No, I want to receive my EOB statements in the mail.
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2022 4 22-EF-UNIV
Section 5: Paying your plan premium
You can pay your monthly plan premium (including any Part D late enrollment penalty you may owe)
by Electronic Funds Transfer (EFT), automatic deduction from your monthly Social Security or Railroad
Retirement Board (RRB) benefit check, monthly payment by invoice, credit card, or by mail.
Please select a premium payment option. If you don’t select a payment option, we’ll automatically
send you an invoice each month.
Electronic Funds Transfer from Checking or Savings account
You won’t need to remember to send in a check each month.
The money is automatically taken from your account on or around the 9
th
of each month.
We will withdraw the total amount due on your account. This includes your current monthl
y
premium payment, as well as any past due payments at the time of the monthly draft.
To sign up, please include a VOIDED check or savings account direct deposit form from your
bank with your enrollment form.
Signature of account holder: (if different than enrollee)
I agree that this authorization will remain in effect until I provide written notification terminating
this service.
Automatic deduction from Social Security or Railroad Retirement Board (RRB) benefit check
I get monthly benefits from:
Social Security
RRB
We will deduct your monthly premium from your Social Security check (or RRB for those who
qualify) automatically. Your request for automatic deduction will be submitted for the next
available payment cycle.
It can take several months for this option to begin once approved by Centers for Medicare &
Medicaid Services, and it will not cover any premiums for which we have already sent you an
invoice, so please continue to pay your premium as long as you receive an invoice.
Do not select this option if another entity (such as an Employer Group or State Pharmaceutical
Assistance Program) is paying part of your premium.
If Social Security or the RRB does not approve your request for automatic deduction, we will
send you an invoice to pay your monthly premium.
Monthly payments by invoice
You can mail us a check with your payment slip each month.
You can pay using a debit or credit card after your enrollment in the plan is active.
You can bring your invoice to any retail CVS Pharmacy® and pay with cash, credit card, or debit
card. (This service is not available at CVS Pharmacy Target® or Schnucks Pharmacy locations.)
Continued
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signature
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2022 5 22-EF-UNIV
Section 5: Paying your plan premium (continued)
People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you
qualify, Medicare could pay for 75 percent or more of your drug costs, including monthly prescription
drug premiums, annual deductibles, and coinsurance. Additionally, those who qualify won’t have a
coverage gap or a Part D late enrollment penalty.
Many people are eligible for these savings and don’t ev
en
know it.
For
m
o
r
e infor
m
a
tion abou
t this
E
x
t
ra
He
lp, co
n
t
a
ct
y
o
u
r local Social Security office, or call Social Security at 1-800-772-1213
(TTY: 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 does not cover.
Social Security will contact you if you have to pay a Part D-Income Related Monthly Adjustment
Amount (Part D IRMAA). You’ll have to pay this extra amount as well as your plan premium. You will
either have the amount withheld from your Social Security or RRB benefit check, or be billed directly by
Medicare or the RRB. Do not send your Part D IRMAA payment to us.
Section 6: Please read this important information
If you are a member of a Medicare Advantage Plan (such as an HMO or PPO), you may already have
prescription drug coverage from your Medicare Advantage Plan that will meet your needs.
By joining Aetna PDP, your membership in your Medicare Advantage Plan may end. This will affect
both your doctor and hospital coverage as well as your prescription drug coverage. Read the
information that your Medicare Advantage Plan sends you and if you have questions, contact your
Medicare Advantage Plan.
If you currently have health coverage from an employer or union, joining Aetna PDP could affect
yo
ur em
plo
yer o
r unio
n healt
h be
nefi
ts.
Yo
u
co
uld lo
se
yo
ur em
plo
yer o
r unio
n healt
h co
verage if
yo
u jo
i
n Aetna PDP. 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
information on whom to contact, your benefits administrator or the office that answers questions about
your coverage can help.
Section 7: Please read terms and sign below
By completing this enrollment application, I agree to the following: Aetna PDP is a Medicare drug
plan and has a contract with the Federal government. I understand that this prescription drug
coverage is in addition to my coverage under Medicare; therefore, I will need to keep my Medicare
Part A or Part B coverage to stay in Aetna PDP. It is my responsibility to inform you of any prescription
drug coverage that I have or may get in the future. I can only be enrolled in one Medicare Prescription
Drug Plan at a time – if I am currently enrolled in a Medicare Prescription Drug Plan, my enrollment in
Aetna PDP will end that enrollment. Enrollment in this plan is generally for the entire year. Once I enroll,
I may leave this plan or make changes if an enrollment period is available, generally during the Annual
Enrollment Period (October 15 – December 7), unless I qualify for certain special circumstances.
Continued
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2022 6 22-EF-UNIV
Section 7: Please read terms and sign below (continued)
Aetna serves a specific service area. If I move out of the area that Aetna serves, I need to notify the
plan so I can disenroll and find a new plan in my new area. I understand that I must use network
pharmacies, except in an emergency when I cannot reasonably use Aetna network pharmacies. Once I
am a member of Aetna, I have the right to appeal plan decisions about payment or services if I
disagree. I will read the Evidence of Coverage document from Aetna when I get it to know which rules I
must follow to get coverage.
I understand that if I leave this plan and don’t have or get other Medicare prescription drug coverage
or creditable prescription drug coverage (as good as Medicare’s), I may have to pay a Part D late
enrollment penalty in addition to my premium for Medicare prescription drug coverage in the future.
I understand that if I am getting assistance from a sales agent, broker, or other individual employed by
or contracted with Aetna, he or she may be paid based on my enrollment in Aetna.
Counseling services may be available in my state to provide advice concerning Medicare supplement
insuranc
e or other Medicare Advantage or Prescription Drug Plan options, medical assistance through
the state Medicaid program, and the Medicare Savings Program.
Release of Information
By joining this Medicare Prescription Drug Plan, I acknowledge that Aetna PDP will release my
information to Medicare, who may use it to track beneficiary enrollment, for payment and other
purposes applicable to Federal statutes that authorize the collection of this information (see Privacy
Act Statement below).
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 affect 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
c
ountry except for limited coverage near the U.S. border.
I understand that my signature (or the signature of the person authorized to act on my behalf
under state law 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 by Medicare.
SilverScript is a Prescription Drug Plan with a Medicare contract marketed through Aetna Medicare.
Enrollment in SilverScript depends on contract renewal.
Signature Today’s date
/ __ __ __ __/__ __ __ __
Print name (please print)
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Section 8: Power of Attorney / Authorized Representative
If you’re an authorized representative helping someone fill out this form, you must sign the
previous page and provide the following information (not for agent use).
Name
Address
City State ZIP Code
Phone number - -
Relationship to enrollee child friend spouse other
When you’ve completed this Enrollment Form, sign, date, and mail it in the enclosed postage-paid
envelope. If you do not use the postage-paid envelope, include the proper postage and mail to:
SilverScript Insurance Company
PO Box 30001
Pittsburgh, PA 15222-0330
Note: This mailing address is not applicable for agent-submitted applications.
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8
__ __/__ __/__ __ __ __
To be completed by Agent / Prescription Drug Plan only
AGENT INSTRUCTIONS
Complete Steps 1 and 2 below for successful enrollment:
Step 1: You
must enter the enrollment application into the agent portal within 24 hours of receiving the
application from the beneficiary. Instructions on how to enter enrollments are located in the
Reference Materials section of the agent portal. Failure to complete this step can result in your
enrollment not being processed.
Step 2: Please send all pages of the signed, completed application and the Scope of Appointment to
SilverScript Insurance Company within 24 hours of portal entry. Choose one of the following options:
Upload: Upload a scanned copy of the documents via the agent portal s
ecure mailroom
Email: enrollmentverification@CVScaremark.com
Fax: 1-866-552-6205
Mail: SilverScript Insurance Company
Attn: Age
nt Processing
PO Box 30002
Pittsburgh, PA 1
5222-0330
Application received date
Agent ID number
Agent na
m
e
(pl
ea
se pr
int)
Agent sig
n
ature
Agent po
rt
al applic
ati
o
n co
nfi
r
m
atio
n n
umb
er
Sco
pe o
f
Appo
int
me
n
t (yo
u m
ust
che
ck o
ne
)
A Scope of Appointment is included w
ith this enrollment form.
Scope of Appointment was NOT completed because the agent did not have an individual or
one-on-one marketing appointment (whether in person, telephonically
, or otherwise) with the
applicant.
2022
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Form 2022: Aetna Medicare Individual Enrollment Form Medicare

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Completed 21 October 2021

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