Who can use this form?
People with Medicare who want to join a Medicare Advantage Plan.
To join a plan, you must:
• Be a United States citizen or be lawfully present in the U.S.
• Live in the plan's service area
To join a Medicare Advantage Plan, you must also have both:
• Medicare Part A (Hospital Insurance)
• Medicare Part B (Medical Insurance)
When do I use this form?
You can join a plan:
• Between Oct 15 - Dec 7 each year (for coverage starting Jan. 1)
• Within three months of first getting Medicare
• In certain situations where you're allowed to join or switch plans
Visit Medicare.gov to learn more about when you can sign up for a plan.
What do I need to complete this form?
• Your Medicare Number (the number on your red, white, and blue Medicare card)
• Your permanent address and phone number
Note: You must complete all items in Section 1. The items in Section 2 are optional - you can't be denied coverage because you don't fill them out.
• If you want to join a plan during fall open enrollment (Oct 15 - Dec 7), the plan must get your completed form by Dec 7.
• Your plan will send you a bill for the plan's premium. You can choose to sign up to have your premium payments deducted from your bank account or your monthly Social Security (or Railroad Retirement Board) benefit.
What happens next?
Send your completed and signed form to:
Upper Peninsula Health Plan
853 West Washington Street
Marquette, MI 49855
Once they process your request to join, they'll contact you.
How do I get help with this form?
Call Upper Peninsula Health Plan at 1-877-349-9324. TTY users can call 711.
Or, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.
En español: Llame a Upper Peninsula Health Plan al 1-877-349-9324 (TTY 711) o a Medicare gratis al 1-800-633-4227 y oprima el 2 para asistencia en español y un representante estará disponible para asistirle.
|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.|
|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.|
Medicare Advantage Online Enrollment Form
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.
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 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.
My plan is ending its contract with Medicare, or Medicare is ending its contract with my plan.
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 disaster.
I already have Hospital (Part A) and recently signed up for Medical (Part B). I want to join a Medicare Advantage Plan.
I'm new to Medicare, and I was notified about getting Medicare after my Part A and/or Part B coverage started.
I have had Medicare prior to now, but am now turning 65.
I joined a Medicare Advantage Plan with drug coverage when I turned 65. It's been less than 12 months since I joined this plan. I want to switch to Original Medicare, and I'm joining a Drug Plan.
I am enrolling in a 5-star Medicare plan.
I'm in a plan that was recently taken over by the state because of financial issues. I want to switch to another plan.
If none of these statements apply to you or you are not sure, you can call UPHP Customer Service at 1-877-349-9324 (TTY: 711), Monday through Friday from 8 a.m. to 9 p.m. Eastern Time, with weekend hours Oct. 1 through March 31. The call is free.
Page Last Updated: 10/05/2020