Kaiser Senior Enrollment Form – Fill Out and Use This PDF

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 estimate(s) 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.

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Name

Kaiser Permanente Medical/Health Record Number (for current or past members)

Please contact Kaiser Permanente if you need information in another language or accessible format (Braille).

Section 1 – All fields in this section are required (unless marked optional)

Select the plan you want to join:

Service areas for some plans do not include the full county. Please refer to the Summary of Benefits for detailed information on plan service areas.

SOUTHERN CALIFORNIA:

Senior Advantage Medicare Medi-Cal Plan South (HMO D-SNP) - $30.50 per month

Special Needs Plan (SNP) - For people who are entitled to both Medicare and state Medicaid benefits

Senior Advantage Inland Empire (HMO) - $0 per month Senior Advantage Kern County - Basic (HMO) - $0 per month Senior Advantage Kern County - Enhanced (HMO) - $29 per month

Senior Advantage Los Angeles and Orange Counties (HMO) - $0 per month Senior Advantage San Diego County (HMO) - $0 per month

Senior Advantage Ventura County (HMO) - $0 per month

NORTHERN CALIFORNIA:

Senior Advantage Medicare Medi-Cal Plan North (HMO D-SNP) - $30.50 per month

Special Needs Plan (SNP) - For people who are entitled to both Medicare and state Medicaid benefits

Senior Advantage Alameda County - Basic (HMO) - $24 per month

Senior Advantage Alameda, Napa, and SF Counties (HMO) - $84 per month Senior Advantage Contra Costa County - Basic (HMO) - $24 per month Senior Advantage Contra Costa County - Enhanced (HMO) - $84 per month Senior Advantage Greater Fresno Area - Basic (HMO) - $15 per month Senior Advantage Greater Fresno Area - Enhanced (HMO) - $75 per month Senior Advantage Greater Sac & Sonoma County - Basic (HMO) - $15 per month Senior Advantage Greater Sac & Sonoma County - Enhanced (HMO) - $75 per month Senior Advantage Marin and San Mateo Counties (HMO) - $89 per month

Senior Advantage San Francisco County - Basic (HMO) - $24 per month Senior Advantage San Joaquin County - Basic(HMO) - $15 per month Senior Advantage San Joaquin County - Enhanced (HMO) - $75 per month Senior Advantage Santa Clara County - Basic (HMO) - $15 per month Senior Advantage Santa Clara County - Enhanced (HMO) - $75 per month Senior Advantage Santa Cruz County (HMO) - $79 per month

Senior Advantage Solano County (HMO) - $89 per month

Senior Advantage Stanislaus County - Basic (HMO) - $15 per month Senior Advantage Stanislaus County - Enhanced (HMO) - $75 per month

Name

Advantage Plus (optional supplemental benefits package):

Would you also like to add Advantage Plus to your Kaiser Permanente Senior Advantage plan? The Advantage Plus

package is optional. For an additional $16 per month, you can add more benefits (dental, hearing, and extra vision coverage). The monthly premium for Advantage Plus will be added to your Kaiser Permanente Senior Advantage monthly premium. Note: This option is not available under the Senior Advantage Medicare Medi-Cal (HMO D-SNP) plans.

Yes No

City:

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

Street Address:

E-mail Address:

Your Medicare information:

Medicare Number:

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Answer these important questions:

1.Will you have other prescription drug coverage (like VA, TRICARE) in addition to Kaiser Permanente? Yes No

If “yes,” please list your other coverage and your identification (ID) number(s) for this coverage:

2. Are you enrolled in your State Medicaid program? Yes No If “yes,” please provide your Medicaid number:

STOP Please Read This Important Information

If you currently have health coverage from an employer or union, joining Kaiser Permanente could affect your employer or union health benefits. You could lose your employer or union health coverage if you join Kaiser Permanente Senior Advantage. 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.

IMPORTANT: Read and sign below:

•I must keep both Hospital (Part A) and Medical (Part B) to stay in Kaiser Permanente Senior Advantage.

•By joining this Medicare Advantage Prescription Drug Plan, I acknowledge that Kaiser Permanente 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 below).

•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 country, except for limited coverage near the U.S. border.

•I understand that when my Kaiser Permanente Senior Advantage coverage begins, I must get all of my medical and prescription drug benefits from Kaiser Permanente. Benefits and services provided by Kaiser Permanente and contained in my Kaiser Permanente Senior Advantage “Evidence of Coverage” document (also known as a member contract or subscriber agreement) will be covered. Neither Medicare nor Kaiser Permanente will pay for benefits or services that are not covered.

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•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.

Advantage Plus optional supplemental benefits conditions of enrollment

If you checked “Yes” to add the Advantage Plus optional supplemental benefits package on page 2, please read the information below.

By completing this enrollment application:

•I agree to adding the Advantage Plus optional supplemental benefits package that gives me (dental, hearing, and extra vision coverage) for $16 per month. This amount is in addition to my Medicare and Kaiser Permanente Senior Advantage premiums.

•I understand that the optional supplemental benefits package adds more benefits to my Kaiser Permanente Senior Advantage coverage, and the terms and conditions can be found in the Kaiser Permanente Senior Advantage Evidence of Coverage.

•I understand that the Advantage Plus optional supplemental benefits package is only available to members enrolled in a Kaiser Permanente Senior Advantage Individual Plan.

•I understand that I must get covered care from network providers, except for emergency or urgently needed services.

•I understand that I can stop my Advantage Plus optional supplemental benefits package coverage anytime. If I disenroll, I won’t be eligible to enroll again until the next Advantage Plus optional supplemental benefits package annual election period for coverage that has a start date of January 1 or I have another Special Enrollment Period.

If you are the authorized representative, you must sign above and provide the following information:

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Section 2 – All fields in this section 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.

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

Please contact Kaiser Permanente at 1-800-443-0815 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. TTY users should call 711.

Paying Your Plan Premium

You can pay your monthly plan premium (including any late enrollment penalty that you currently have or may owe) by mail, phone, or online 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 Kaiser Permanente the Part D-IRMAA.

Please select a premium payment option: If you don’t select a payment option, you will get a bill each month. Get a bill

After you receive your first bill, you can choose a different payment option.

•You can have your monthly payment automatically deducted from your bank account. Please call us at

1-888-236-4490 (TTY 711) to request a Medicare Autopay Selection Form or if you have any questions.

•To pay by credit or debit card, visit kp.org/payonline or call us at 1-888-236-4490 (TTY 711). You will need your account information from your bill to make a payment.

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

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.

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

I recently had a change in my Extra Help paying for Medicare prescription drug coverage (newly got Extra Help, had a change

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

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

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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

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

I was affected by an emergency or a major disaster as declared 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 natural disaster.

I am in a plan that was recently taken over by the state because of financial issues. I want to switch to another plan.

I am in a plan that’s had a star rating of less than 3 stars for the last 3 years. I want to join a plan with a star rating of 3 stars or higher.

If none of these statements applies to you or you’re not sure, please contact Kaiser Permanente at 1-800-443-0815 (TTY users should call 711) to see if you are eligible to enroll. We are open seven days a week, from 8 a.m. to 8 p.m.

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