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2015 Gateway HealthSM Enrollment FormMedicare Assured DiamondSM (HMO SNP)Medicare Assured RubySM (HMO SNP)Medicare Assured GoldSM (HMO SNP)Medicare Assured PlatinumSM (HMO SNP)Medicare Assured SelectSM (HMO)Medicare Assured ChoiceSM (HMO)Medicare Assured PrimeSM (HMO)Need Help to Enroll? Contact your local sales agent to help you choose the best plan for you and complete thisindividual enrollment form, or Call Gateway Health to help you enroll over the phone. Toll-free: 1-888-905-1302(TTY 711), 8 a.m. – 8 p.m. local time, 7 days a week.You may also complete the enrollment form, sign and date it, and mail or fax the enrollment copy to:Gateway HealthAttn: Medicare Process Administration444 Liberty Avenue, Suite 2100Pittsburgh PA 15222Fax: 1-888-551-9101 (toll-free)I understand the person who is discussing plan options with me is asales agent, broker or other person employed by or contracted withGateway Health. The person may be paid based on my enrollment in a plan.Medicare Assured Diamond and Medicare Assured Ruby are HMO plans with a Medicare contract anda contract with Ohio Medicaid. Enrollment in these Plans depends on contract renewal.Medicare Assured Gold, Medicare Assured Platinum, Medicare Assured Select, Medicare AssuredChoice and Medicare Assured Prime are HMO plans with a Medicare contract. Enrollment in thesePlans depends on contract renewal.Y0097 425 OH Approved
Instructions to complete the enrollment form for:Medicare Assured DiamondSMMedicare Assured RubySMMedicare Assured GoldSMMedicare Assured PlatinumSMMedicare Assured SelectSMMedicare Assured ChoiceSMMedicare Assured PrimeSMPlease PRINT NEATLY on the entire form.Please check which plan you want to enroll in then fill out the remainder of the form.SECTION 1 – INFORMATION ABOUT YOUThis section tells us basic information about you such as your name, address, and phone number. Allfields are required. Please print neatly.SECTION 2 – MEDICARE INFORMATIONYou must complete this section EXACTLY as it appears on your MEDICARE HEALTHINSURANCE identification card. You may attach a copy of your card. Your Medicare number iscalled the “Medicare Claim Number” and it is located on your MEDICARE HEALTH INSURANCEidentification card. If you do not include all of the information in this section, your application cannotbe processed.SECTION 3 M – MEDICAID INFORMATION(Medicare Assured Diamond and Medicare Assured Ruby only)Please enter your Medicaid identification number and social security number in the spaces provided.-or –SECTION 3 C – CHRONIC CONDITION INFORMATION(Medicare Assured Gold and Medicare Assured Platinum only)Please read over each question carefully and answer ‘Yes’ to all that apply.SECTION 4 – SELECT A PRIMARY CARE PHYSICIANPlease write the name of the Primary Care Physician (PCP) that you want to choose in this section. ThePCP must be in our network. You must give us as much information about the PCP as you can, such asthe doctor’s first and last name and if he/she belongs to a group practice, if applicable. For example:John Q. Smith, M.D. – Greater Medical Associates.Y0097 425 OH Approved
SECTION 5 – OTHER INSURANCE INFORMATIONIt is very important that you tell us about any other health insurance or prescription drug coverage thatyou will have in addition to this Plan. This includes coverage that you may have on your own, throughyour spouse, or his/her employer, or through the state Medicaid program.SECTION 6 – PLEASE READ AND ANSWER THESE QUESTIONS1. Check ‘YES’ or ‘NO’ if you have a special kidney disease called End Stage Rena1 Disease (ESRD).2. Check ‘YES’ or ‘NO’ if you have ever received a Medicare covered transplant. (If you checkedYES, please provide the date of transplant)3. Check ‘YES’ or ‘NO’ if you would like to receive your information in Spanish or other formats.SECTION 7 – PAYING YOUR PLAN PREMIUM and/or LATE ENROLLMENT PENALTYIf you are required to pay a premium and/or required to pay the Part D Late Enrollment Penalty, youwill need to read this section carefully and select how you would like our Plan to collect this premium.Select only one: Automatic deduction from your monthly Social Security or Railroad RetirementBoard (RRB) benefit check OR get a bill monthly.STATEMENTS OF UNDERSTANDINGThis portion of the form requires you to read several Statements of Understanding PAGE 4 OF THEENROLLMENT FORM to be sure that you understand the terms of participating in our Plan. Youmust read and understand those statements.AUTHORIZATIONThen sign your name and fill in today’s date in this section. If you cannot sign and you have anauthorized representative fill out this enrollment form on your behalf, then he/she must sign and datewhere indicated. Documentation of the authority to act on your behalf must be made available uponrequest by Gateway Health or Medicare.If anyone helped you fill out this enrollment form, such as a sales representative or community leader,then he/she must sign and date the form, and specify his/her relationship to you.IMPORTANT REMINDERS You may include a copy of your MEDICARE HEALTH INSURANCE identification card. IF APPLICABLE, attach a copy of medical notes indicating that you do not need regulardialysis anymore or that you had a successful kidney transplant. IF APPLICABLE, attach a copy of the legal representative’s proof of authorization by statelaw if someone signs on behalf of the applicant.Y0097 425 OH Approved
2015 Enrollment Form TRACKING # Please check which plan you want to enroll in: Medicare Assured Select (HMO) 0 per month Medicare Assured Choice (HMO) Part C - 0 per month Part D - 57.80 per month* Medicare Assured Prime (HMO) Part C - 21.60 per month Part D - 61.20 per month*For Medicare beneficiaries who also qualify for Medicaid or receive assistance from theState – Dual Eligible Special Needs Plan (D-SNP): Medicare Assured Diamond (HMO SNP) 0 per month* Medicare Assured Ruby (HMO SNP) Part C – 0 per month Part D - 28.60 per month*For Medicare beneficiaries living with diabetes, cardiovascular disorders or chronic heart failure– Chronic Condition Special Needs Plan (C-SNP): Medicare Assured Gold (HMO SNP)Part C - 0 per month Part D - 39.80 per month* Medicare Assured Platinum (HMO SNP) Part C - 26.40 per month Part D - 51.40 per month** Your premium will be determined by the amount of Extra Help you may receiveLast NameSECTION 1 – INFORMATION ABOUT YOU (Please print neatly)First NameMiddle InitialDate of Birth (month/day/year)Phone Number( - - ) Home Phone Cell Phone Other PhoneFor the cell phone checked above, I consent to receive recordedand electronic messages from Gateway. Yes NoPermanent Residence Address (Number, Street, Apartment)/ /CityStateZip CodeCountyMailing Address (Number, Street, Apartment-if different from above)CityPAGE 1 of 6Y0097 425 OH ApprovedStateZip CodeCounty
2015 Enrollment FormSECTION 2 – MEDICARE INFORMATIONPlease take out your Medicare card to complete this section. 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 the SocialSecurity Administration or Railroad Retirement Board.MEDICARE HEALTH INSURANCENAME (Exactly as it appears on Medicare Card)MEDICARE CLAIM NUMBERSEX: M F- - -IS ENTITLED TOEFFECTIVE DATEHOSPITAL (PART A)- -MEDICAL (PART B)- -You must have MedicarePart A and Medicare Part Bto join a MedicareAdvantage PlanSECTION 3 M– MEDICAID INFORMATIONNOTE: This section is to be completed only if applying for Medicare Assured Diamond or MedicareAssured Ruby. To be eligible for these Plans, you must have Medicaid or be receiving assistance from theState.Social Security Number - -Please take out your Medicaid identification card to complete this section. Print your identification numberas it appears on your Medicaid card.Recipient#SECTION 3 C– CHRONIC CONDITION INFORMATIONNOTE: This section is to be completed only if applying for Medicare Assured Gold or Medicare AssuredPlatinum. To be eligible these for Plans, you must have one of these conditions: Diabetes, Chronic HeartFailure (CHF), or Cardiovascular Disorder (CVD). Please answer the questions below. Yes No Have you ever been told by a doctor or clinic that you have diabetes (sugar)? Yes No Have you ever been told by a doctor or clinic that you have Congestive Heart Failure(such as fluid in the lungs or a weak heart)? Yes No Have you ever been told by a doctor or clinic that you have Cardiac Arrhythmias(an irregular heart beat or that your heart flutters or races)? No Have you ever been told by a doctor or clinic that you have Coronary ArteryDisease (blocked arteries – had stents or heart bypass surgery – or a heart attack)? No Have you ever been told by a doctor or clinic that you have Peripheral VascularDisease (poor blood flow to the legs; pain, burning or achiness in your legs whenyou walk, but goes away when you sit down)? No Have you ever been told by a doctor or clinic that you have Chronic VenousThromboembolic Disorder (been told that you have blood clots or are you takingMedicine for blood clots)? Yes Yes YesPAGE 2 of 6Y0097 425 OH Approved
2015 Enrollment FormSECTION 4– SELECT A PRIMARY CARE PHYSICIANPrint the name and phone number of your chosen Primary Care Physician (PCP), group practice.Name:Group PracticePhone: ( ) -SECTION 5– OTHER INSURANCE INFORMATIONSome individuals may have other coverage including other private insurance, TRICARE, Federalemployee health benefits coverage, VA benefits, or State pharmaceutical assistance programs.Will you, on your own or through your spouse, have any health insurance or prescription drug coverageother than Medicare? Yes NoSECTION 6 – PLEASE READ AND ANSWER THESE QUESTIONSDo you have End Stage Renal Disease (ESRD)? Yes NoESRD is permanent kidney failure and requires regular kidney dialysis or a transplant to stay alive.Note: If you have ESRD, you cannot enroll in this plan. If you do not need regular dialysis anymore orhave had a successful kidney transplant, please attach a note or records from your doctor.Have you ever received a Medicare covered transplant? Yes NoIf yes, date of transplant: - -If you want us to send your information in a language other than English, please check one of these boxes Spanish Other, please list the languageSECTION 7– PAYING YOUR PLAN PREMIUM and/or LATE ENROLLMENT PENALTYIf you must pay a premium or if you owe a late enrollment penalty (or if you currently have a lateenrollment penalty), you can choose to pay your premium by automatic deduction from your SocialSecurity or Railroad Retirement Board (RRB) benefit check each month, or you can pay by check eachmonth. If you don’t select a payment option, you will get a bill each month for any premiums owed.If you are assessed a Part D-Income related Monthly Adjustment Amount (Part D-IRMAA), you will benotified by the Social Security Administration. You will be responsible for paying this extra amount inaddition to your plan premium. You will either need to have the amount withheld from your SocialSecurity benefit check or be billed directly by Medicare or the RRB. DO NOT pay Gateway Health thePart 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 co-insurance. Additionally, those who qualify will not be subject to the coveragegap or late enrollment penalty. Many people are eligible for these savings and don’t even know it. Formore information about this extra help, contact your local Social Security office, or call Social Security at1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for extra help online atwww.socialsecurity.gov/prescriptionhelp.PAGE 3 of 6Y0097 425 OH Approved
2015 Enrollment FormSECTION 7– PAYING YOUR PLAN PREMIUM and/or LATE ENROLLMENT PENALTY(CONTINUED)If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all orpart of your plan premium. If Medicare pays only a portion of this premium, we will bill you for theamount that Medicare doesn’t cover.Please select a premium payment option: Automatic deduction from your monthly Social Security or Railroad Retirement Board (RRB)benefit check. (The Social Security / RRB deduction may take two or more months tostart after Social Security or RRB approves the deduction. We will send you a bill until SocialSecurity or RRB accepts your request for automatic deduction. If Social Security or RRB does notapprove your request for automatic deduction, we will send you a paper bill for your premiums.)Get a bill monthly.Please Read This Important InformationIf you currently have health coverage from an employer or union, joining a Medicare Assured plancould affect your employer or union health benefits. You could lose your employer or union healthcoverage if you join a Medicare Assured plan.Read the communications your employer or union sends you. If you have questions, visit their website, orcontact the office listed in their communications. If there isn’t any information on whom to contact, yourbenefits administrator or the office that answers questions about your coverage can help.STATEMENTS OF UNDERSTANDINGYour signature on this application means you agree to the following:1. I can be in only one Medicare Advantage plan at a time. My enrollment in this Plan willautomatically end my enrollment in any other Medicare health plan or Prescription Drug Plan that Iam currently in.2. I will need to keep Medicare Part A and Part B. By enrolling in this Plan, I do not need to enroll ina separate Prescription Drug Plan (PDP).3. This health plan serves a specific service area. If I move out of the service area, I need to tellGateway Health so I can disenroll and find a new plan in my new area.4. I will read my Evidence of Coverage document to know which rules I must follow in order toreceive coverage with this plan. As a member of this Plan, I have the right to appeal plan decisionsabout payment or services if I disagree.PAGE 4 of 6Y0097 425 OH Approved
2015 Enrollment FormSTATEMENTS OF UNDERSTANDING (CONTINUED)5. Lock-In: On the date my coverage begins, I must get all of my prescription drugs and all of myhealth care from this health plan, except for emergency or urgently needed services or out-of-areadialysis services. Services contained in my Plan Evidence of Coverage document and othermedically authorized services authorized by the plan will be covered. Without authorization,NEITHER MEDICARE NOR GATEWAY HEALTH WILL PAY FOR THE SERVICES. Iunderstand that people with Medicare are not usually covered under Medicare while out ofthe Country.6. Release of Information: Gateway Health will release my information to Medicare, other plans,medical providers, or other entities as is necessary for treatment, payment and health careoperations. Information, such as, prescription drug event data could be released to Medicare, whomay release it for research and other purposes which follow all applicable Federal Statutes andRegulations.7. Recorded Healthcare Messages: Gateway Health may, from time to time, want to send recordedand electronic healthcare messages to me. If I check the YES box under my cell phone number onthe front of this form, I understand that I have given Gateway Health my permission to sendrecorded and electronic healthcare messages to my cell phone. I may withdraw my permission atany time by calling the Member Services number located on the back of my ID card.8. I am enrolling in a Medicare Advantage plan and the plan has a contract with the Federalgovernment.9. I understand that if I am getting assistance from a sales agent, broker, or other individual employed by orcontracted with the plan, he/she may be paid based on my enrollment in the plan.10. It is my responsibility to inform you of any prescription drug coverage that I have or may get in thefuture11. Enrollment in this Plan is generally for the entire year. Once I enroll, I may leave this plan or makechanges only at certain times of the year when an enrollment period is available (Example: October15 – December 7 of every year), or under certain special circumstances.12. The information on this enrollment form is correct to the best of my knowledge. I understand that ifI intentionally provide false information on this form, I will be disenrolled from the plan.PAGE 5 of 6Y0097 425 OH Approved
2015 Enrollment FormAUTHORIZATIONI understand that my signature (or the signature of the person authorized to act on my behalfunder the laws of the State where I live) on this application means that I have read andunderstand the contents of this application including the Statements of Understanding on page 4and 5.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 and2. Documentation of this authority is available upon request by Gateway Health.Your Signature:X Date:AUTHORIZED REPRESENTATIVE: You must sign next to the “X” on the previous page, andprovide the following information:Name:Relationship to Enrollee:Address:Phone: ( ) -FOR INTERNAL USE ONLYICEP/IEP AEP SEP (type)To be filled out by Sales Agent:Signature:Agent Writing Number:Referring Agent Number:Date Application Received by Sales Agent:Proposed Effective Date:PAGE 6 of 6Y0097 425 OH Approved- -Medicare ProcessAdministration Use Only
Gateway Health. The person may be paid based on my enrollment in a plan. Medicare Assured Diamond and Medicare Assured Ruby are HMO plans with a Medicare contract and a contract with Ohio Medicaid. Enrollment in these Plans depends on contract renewal. Medicare Assured Gold, Medicare Assured Platinum, Medicare A
