Hometown Health - Senior Care Plus

Please review information and make changes if needed.

By submitting this application you will be completing an actual enrollment request to Senior Care Plus. Upon approval by CMS you will receive notice of acceptance or denial of your enrollment into Senior Care Plus. Please fill out your personal information below. When you're finished, please click the Submit button at the bottom.

Note: This tool is entirely confidential. The information you are providing will only be used for the purposes of completing your enrollment in the Senior Care Plus Value Plan that you selected. We will not share the information you provide with anyone for any other purpose.

* - Required Fields

If you want to change plans you are generally limited to making changes between October 15th and December 7th each year. However, there are situations in which you may be able to make changes at other times. If any of the statements below match your current situation, please check the box to the left of the statement(s) and Senior Care Plus will contact you for additional information.

If none of the statements match your current situation, please contact Senior Care Plus to see if you are eligible to enroll.

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.

Please check all that apply I am enrolled in a Medicare Advantage plan and want to make a change during the Medicare Advantage Open Enrollment Period (MA OEP) I am new to Medicare. 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 am leaving employer or union coverage. I recently involuntarily lost my creditable prescription drug coverage (coverage as good as Medicare's). 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) 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 belong to a pharmacy assistance program provided by my state. I recently had a change in my Medicaid (newly got Medicaid, had a change in level of Medicaid assistance, or lost Medicaid). I was enrolled in a Special Need Plan (SNP) but I have lost the special needs qualification required to be in that plan. I recently left a PACE program. I was recently released from incarceration I recently returned to the United States after living permanently outside of the U.S. I recently obtained lawful presence status in the United States 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). 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. 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. I was notified by my plan that it had or will have a significant provider network change.

Title: Mr. Mrs. Miss Ms.

First Name: MI: Last Name:

Birth Date:

Gender: Male Female

Email Address:

Home Phone Number: ( ) -

Cell Phone Number (optional): ( ) -

Street Address Line 1: Street Address Line 2:

City: State: ZIP Code:

Street Address Line 1: Street Address Line 2:

City: State: ZIP Code:

Current Plan

County (Please select):

Please select the Nevada county in which you reside to view your plan options.

Primary Care Physician (required for HMO only; choose from list)

Name: Relationship to you: Phone Number: ( ) -

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.
You must have Medicare Part A and Part B to join Senior Care Plus.

If your card looks like this, fill out the Medicare Claim Number with your number. Medicare Card

Medicare Claim Number - - -

If your card looks like this, fill out the Medicare Beneficiary Identifier with your number. Medicare Card

Medicare Beneficiary Identifier - -

Hospital (Part A) Effective - 1 - Medical (Part B) Effective - 1 -

You can pay your Medicare plan directly for your monthly premium, or have the monthly premium automatically deducted from your Social Security payment. If you choose to pay directly, you can pay by mail or by electronic Funds Transfer (EFT). Generally you must stay with the option you choose for the rest of the year.

If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare may cover all or some portion of your plan premium. Please choose if you want to pay your remaining premium, if there is any, directly to your plan.

I Qualify for Extra Help: Yes No

I elect to pay my future premiums by: Electronic Funds Transfer
Payment Invoice
Social Security Administration (SSA) or Railroad Retirement Board (RRB) Deduction*

*SSA or RRB deduction may take up to two or three months to begin. In most cases, the first deduction from your SSA or RRB benefit check will include all premiums due from your enrollment effective date up to the point withholding begins. If SSA or RRB does not approve your request for automatic deduction, we will send you a paper bill for your monthly premiums.

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 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.

You can pay your monthly plan premium (including any late enrollment penalty that you currently have or may owe) by mail Electronic Funds Transfer (EFT), credit card 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 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 RRB. DO NOT pay Senior Care Plus the Part D-IRMAA.

The information provided is correct to the best of my understanding. I have read and understand the information disclosed on the AUTHORIZATION & DISCLOSURE INFORMATION form.

If you are the person authorized to act on behalf of the individual, you must provide the following information: Name: Relationship: Phone #: State Law requires proof of Legal Guardian, Durable Power of Attorney for Health Care decisions (DPAHC) or written Advance Directive. Please attach copy of documents. If someone other than yourself helped you complete this form, he/she must sign above.

Do you have End Stage Renal Disease (ESRD)? Yes No

Will you have other prescription drug coverage in addition to Senior Care Plus? Some people may have other drug coverage, including other private (Employer Group) insurance, TRICARE, Federal employee group health coverage, VA benefits, or State Pharmaceutical Assistance Programs (Nevada Senior Rx).
Yes No

Are you enrolled in your State Medicaid program? Yes No

Are you a resident in a long-term care facility, such as a nursing home? Yes No

Do you or your spouse work? Yes No

Please read and initial that you understand: (Initial) Senior Care Plus will send me final approval and my permanent membership card when The Centers for Medicare & Medicaid Services (CMS) confirms my enrollment with Senior Care Plus. I should not disenroll from any Medicare supplement plan, Medigap or Medicare Select plan until I get final approval from Senior Care Plus. (Initial) My plan premium is due on the first of every month (if applicable). I may pay by automatic deduction from my Social Security Administration (SSA) or Railroad Retirement Board (RRB) check, Electronic Funds Transfer (EFT) or by sending a monthly payment using the premium-payment slips provided by Senior Care Plus. Failure to pay my monthly premium will result in disenrollment from Senior Care Plus. My monthly premium is $. Full payment of all past-due premiums will be required to re-enroll. (Initial) I understand that I need to pay copayments or coinsurance for most services and that copayments are due at the time of service. Network providers may bill me for coinsurance later. Out-of-network providers may request full payment in advance for services.

What language is spoken mostly at home? English Spanish Other

Material ID: H2960_2020_SCPWebsite_EnrollApp_M (CMS Accepted)
Page Last Updated: 10/15/2019

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

If yes, please provide your Medicaid number:

If "yes" please provide the following information: