-
By clicking the "I accept" button and completing the application you will be
completing an actual enrollment request to Senior Care Plus.
-
Please choose only one plan to enroll in.
Refer to the Summary of Benefits or Evidence of Coverage (EOC) documents for
information and costs associated with the plan. You may pay copayments or
coinsurance for most services. These copayments or coinsurances are due at the
time of service. Out-of-network providers may request full payment
in advance for services.
-
Please sign
and date at the bottom of the application. If someone assisted you in completing
this application, you both must sign and date the application and the person
assisting you must indicate their relationship to you.
-
Please
include your first month's premium if you do not choose to have your premium
deducted from your Social Security check. If you wish to have your future
premiums deducted automatically from your bank account, complete and sign the
Electronic Funds Transfer form along with your first month's premium. (Please do
not send cash.)
-
Return all
completed forms to Senior Care Plus at the address on the bottom of this
application. Please keep the member copy of the application for your records.
Your copy can be used as proof of coverage under this plan when you see network
providers, prior to receiving your membership card. Remember that your effective
date is subject to approval by the Centers for Medicare and Medicaid Services
(CMS). Upon confirmation from CMS, Senior Care Plus will send you a written
notice of your effective date.
-
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 Senior Care Plus 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 drug cost 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. 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, the
State or Medicare will pay all or part of your plan premium. If the State or
Medicare pays only a portion of this premium, selection of a payment method is
still necessary for the amount the State or Medicare doesn't cover or if we
determine that you owe a late enrollment penalty.
-
You can change health plans only at certain times during the year. From October
15 - December 7, you can join, switch or drop a Medicare health or drug plan for
the following year. In addition, from January 1 - March 31, anyone enrolled in a
Medicare Advantage Plan (except an MSA plan) can switch plans or return to
Original Medicare (and join a stand-alone Medicare Prescription Drug Plan).
Generally, you can't make changes at other times except in certain situations,
such as if you move out of your plan's service area, want to join a plan in your
area with a 5-star rating, or qualify for (or lose) Extra Help paying for
prescription drug coverage.
By completing this enrollment application, I agree to the following:
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Senior Care
Plus is a Medicare Advantage plan and has a contract with the Federal
government. I will need to keep my Medicare Parts A and B and reside in Carson City,
Clark, Nye, or Washoe Counties, Nevada.
-
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. I understand that if I don't have Medicare prescription
drug coverage, or creditable prescription drug coverage (as good as Medicare's),
I may have to pay a late enrollment penalty if I enroll in Medicare prescription
drug coverage 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: AEP is Oct 15 - Dec 7) or under special
circumstances.
-
If you
currently have health coverage from an employer or union, joining Senior Care
Plus could affect your employer or union health benefits. You could lose your
employer or union health coverage if you join Senior Care Plus. 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.
-
Senior Care
Plus serves a specific service area. If I move out of the area that Senior Care
Plus serves, I need to notify the plan so I can disenroll and find a new plan in
my new area. Senior Care Plus serves Carson City, Clark, Nye, and Washoe Counties, Nevada.
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Once I am a
member of Senior Care Plus, I have the right to appeal plan decisions about
payment or services if I disagree. I will read the Evidence of Coverage document
from Senior Care Plus 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.
Senior Care Plus does offer Worldwide Emergency Care benefits.
-
For Value
(HMO) members, I understand that beginning on the date Senior Care Plus coverage
begins, I must get all of my health care from Senior Care Plus, except for
emergency or urgently needed services or out-of-area dialysis services. If
medically necessary, Senior Care Plus provides refunds for
all covered benefits, even if I get services "out-of-network".
-
Services
authorized by Senior Care Plus and other services contained in my Senior Care
Plus Evidence of Coverage document (also known as a member contract or
subscriber agreement) will be covered. Without authorization,
NEITHER MEDICARE NOR SENIOR CARE PLUS
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 Senior Care Plus, he/she may be paid based on my
enrollment in Senior Care Plus.
-
Counseling
services may be available in my state to provide advice concerning medical
assistance through the state Medicaid program and the Medicare Saving Program.
If you feel that you may qualify for "Extra Assistance", contact Senior Care
Plus.
Release of Information:
-
By joining
this Medicare health plan, I acknowledge that Senior Care Plus will release my
information including my prescription drug event to Medicare, other plans as is
necessary for treatment, payment and health care operations and 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 Hometown Health Plan may disclose, to the extent permitted by law, my
personal information within Renown Health's family of companies. Hometown Health
Plan may disclose transaction and experience information to affiliated third
parties and/or other entities within Renown Regional Medical Center only to the
extent that it is required for treatment, payment, or healthcare operations or
that is permitted by law (such as for compliance with a subpoena, fraud
prevention or inquiries from state or federal agencies).
If you have
any questions, please call us! Thank you for joining Senior Care Plus.
We are located at 10315 Professional Circle, Reno, Nevada 89521
Senior Care Plus is an HMO plan with a Medicare contract. Enrollment in
Senior Care Plus depends on contract renewal.
-
By clicking the "I accept" button and completing the application you will be
completing an actual enrollment request to Senior Care Plus.
-
Please choose only one plan to enroll in.
Refer to the Summary of Benefits or Evidence of Coverage (EOC) documents for
information and costs associated with the plan. You may pay copayments or
coinsurance for most services.
-
Please sign
and date at the bottom of the application. If someone assisted you in completing
this application, you both must sign and date the application and the person
assisting you must indicate their relationship to you.
-
Please
include your first month's premium if you do not choose to have your premium
deducted from your Social Security check. If you wish to have your future
premiums deducted automatically from your bank account, complete and sign the
Electronic Funds Transfer form along with your first month's premium. (Please do
not send cash.)
-
Return all
completed forms to Senior Care Plus at the address on the bottom of this
application. Please keep the member copy of the application for your records.
Your copy can be used as proof of coverage under this plan when you see network
providers, prior to receiving your membership card. Remember that your effective
date is subject to approval by the Centers for Medicare and Medicaid Services
(CMS). Upon confirmation from CMS, Senior Care Plus will send you a written
notice of your effective date.
-
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 Senior Care Plus 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 drug cost 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. 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, the
State or Medicare will pay all or part of your plan premium. If the State or
Medicare pays only a portion of this premium, selection of a payment method is
still necessary for the amount the State or Medicare doesn't cover or if we
determine that you owe a late enrollment penalty.
-
You may only enroll in a Medicare Advantage plan during the Annual Enrollment
Period (AEP) between October 15 and December 7. In addition, you can disenroll
from a Medicare Advantage plan during the Annual Disenrollment Period between
January 1 and February 14 as long as
you add a prescription drug plan. Additionally, there are exceptions that may
allow you to enroll in a Medicare Advantage plan outside of these periods,
called a Special Enrollment Period (SEP).
If you are a member of a Medicare Advantage Plan (like an HMO or PPO), you may already
have prescription drug coverage from your Medicare Advantage Plan that will meet your needs.
By joining Senior Care Plus Prescription Drug Plan, 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.
By completing this enrollment application, I agree to the following:
-
Senior Care Plus is a stand-alone Prescription 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. It is my responsibility to inform Senior Care Plus PDP of
any prescription drug coverage that I have or may get in the future. I will need
to reside in a county of Nevada: Carson City, Clark, Nye, or Washoe.
-
I can be in only one Medicare Prescription Drug Plan at a time. If I am currently in a Medicare
Prescription Drug Plan, my enrollment will automatically 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.
-
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 late enrollment penalty
in addition to my premium for Medicare prescription drug coverage in the future.
-
Senior Care Plus PDP serves a specific service area. If I move out of the area that Senior Care
Plus PDP 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
Senior Care Plus PDP network pharmacies. Once I am a member of Senior Care Plus PDP, I have the right
to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage
document from Senior Care Plus PDP when I get it to know which rules I must follow to get coverage.
-
I understand
that if I am getting assistance from a sales agent, broker, or other individual
employed by or contracted with Senior Care Plus, he/she may be paid based on my
enrollment in Senior Care Plus.
-
Counseling services may be available in my state to provide advice concerning Medicare
supplement insurance or other Medicare Advantage or Prescription Drug Plan options, medical
assistance through the state Medicaid program and the Medicare Saving Program.
Release of Information:
-
By joining this Medicare prescription drug plan, I acknowledge that Senior Care Plus will release my
information to Medicare and other plans as is necessary for treatment, payment and health care operations.
I also acknowledge that Senior Care Plus 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 Hometown Health Plan may disclose, to the extent permitted by law, my
personal information within Renown Health's family of companies. Hometown Health
Plan may disclose transaction and experience information to affiliated third
parties and/or other entities within Renown Regional Medical Center only to the
extent that it is required for treatment, payment, or healthcare operations or
that is permitted by law (such as for compliance with a subpoena, fraud
prevention or inquiries from state or federal agencies).
If you have
any questions, please call us! Thank you for joining Senior Care Plus.
We are located at 10315 Professional Circle, Reno, Nevada 89521
Senior Care Plus is a stand-alone Prescription Drug Plan with a Medicare contract. Enrollment in Senior Care Plus depends on contract renewal.
-
You can pay your monthly plan premium (including any late enrollment penalty you
have or may owe) by mail, Electronic Funds Transfer (EFT), credit card (must be
done at a Senior Care Plus Office) each month. You can also choose to pay your
premium by automatic deduction from your Social Security or Railroad Retirement
Board 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 the Railroad Retirement Board. Do NOT pay Senior Care Plus the Part
D-IRMAA.
-
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 www.socialsecurity.gov/prescriptionhelp.
-
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, Electronic Funds Transfer (EFT), credit card (at Senior Care Plus,
10315 Professional Circle) each month. You can also pay your premium by
automatic deduction from your Social Security or Railroad Retirement Board (RRB)
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 the RRB. Do NOT pay Senior Care Plus.
-
If you qualify for extra help with your Medicare prescription drug coverage costs,
Medicare will pay all or part of your plan premium for this benefit. If Medicare pays
only a portion of this premium, we will bill you for the amount that Medicare doesn't
cover.
Senior Care Plus complies with applicable Federal civil rights laws and does not
discriminate on the basis of race, color, national origin, age, disability, or sex.
If you have
any questions, please call us! Thank you for joining Senior Care Plus.
We are located at 10315 Professional Circle, Reno, Nevada 89521
Senior Care Plus is an HMO plan with a Medicare contract. Enrollment in Senior Care Plus depends on contract renewal.