INDIVIDUAL ENROLLMENT REQUEST FORM TO ENROLL
IN A MEDICARE ADVANTAGE PLAN (PART C) OR
MEDICARE PRESCRIPTION DRUG PLAN (PART D)


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

Important:
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.
Reminders:
• 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.
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.
Upper Peninsula Health Plan

Medicare Advantage Online Enrollment Form

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

*Please check which plan you want to enroll in:


*Last Name:
*First Name:
Middle Initial (optional):
*Birth Date:
*Sex:
*Home Phone Number:
() -
*Permanent Residence Street Address (P.O. Box is not allowed):
*City:
*County:
*State:
*Zip Code:
Mailing Address (only if different from your Permanent Residence Address):
City:
County:
State:
Zip Code:
Please Provide Your Medicare Insurance Information
Medicare Number:
Please read and answer these important questions:

* Will you have other prescription drug coverage (like VA, TRICARE) in addition to Upper Peninsula Health Plan?

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

* Name of other coverage:
* ID # for this coverage:
Group # for this coverage:
Please Read and Sign Below
* I must keep both Hospital (Part A) and Medical (Part B) to stay in Upper Peninsula Health Plan (UPHP).

* By joining this Medicare Advantage Plan, I acknowledge that UPHP 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 UPHP coverage begins, I must get all of my medical and prescription drug benefits from UPHP. Benefits and services provided by UPHP and contained in my UPHP "Evidence of Coverage" document (also known as a member contract or subscriber agreement) will be covered. Neither Medicare nor UPHP will pay for benefits or services that are not covered.

* 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.
Today's Date: 09/28/2021
* Name:
* Address:
* Phone Number: () -
* Relationship to Enrollee:
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.


Language Preference:

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

Please contact UPHP at 1-877-349-9324 if you need information in an accessible format other than what's listed above. Our office hours are 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. TTY users can call TTY 711.

Yes No Yes No
Please choose the name of a Primary Care Physician (PCP), clinic or health center:

How did you hear about us? (Please check all that apply):

Paying Your Plan Premium

If you are enrolling in UPHP Choice (HMO): 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 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 (Part D-IRMAA), you will be notified by the Social Security Administration. You will be responsible for paying 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). DO NOT pay UPHP the Part D-IRMAA. (Note: UPHP Choice (HMO) is a $0 premium plan, however, if you owe a late enrollment penalty or are assessed a Part D-IRMAA, that amount is considered your plan premium.)

If you are enrolling in UPHP Advantage (HMO-POS): You can pay your monthly plan premium (including any late enrollment penalty that you currently have or may owe) by mail 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). DO NOT pay UPHP 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 your drug costs including monthly prescription drug premiums, annual deductibles, and coinsurance. 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 http://www.socialsecurity.gov/prescriptionhelp.

If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn't cover.

If you don't select a payment option, you will get a bill each month.


Please select a premium payment option:

I get monthly benefits from:

(The Social Security/RRB deduction may take two or more months to begin after Social Security or RRB approves the deduction. In most cases, if Social Security or RRB accepts your request for automatic deduction, the first deduction from your Social Security or RRB benefit check will include all premiums due from your enrollment effective date up to the point withholding begins. If Social Security or RRB does not approve your request for automatic deduction, we will send you a paper bill for your monthly premiums.)

Office Use Only
Name of staff member/agent/broker (if assisted in enrollment):
Plan ID #:
Effective Date of Coverage:

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.

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 moved on (insert date)
I was released from incarceration.
- I was released on (insert date)
I recently returned to the United States after living permanently outside of the U.S.
- I returned to the U.S. on (insert date)
I recently obtained lawful presence status in the United States.
- I got this status on (insert date)
I recently had a change in my Medicaid (newly got Medicaid, had a change in level of Medicaid assistance, or lost Medicaid)
- It was changed on (insert date)
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)
- It was changed on (insert date)

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 facility).
- I moved/will move into/out of the facility on (insert date)
I recently left a PACE program.
- I recently left a PACE program on (insert date)
I recently involuntarily lost my creditable prescription drug coverage. (coverage as good as Medicare's)
I lost my drug coverage on (insert date)
I am leaving employer or union coverage.
I am leaving employer or union coverage on (insert date)

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 (insert date)
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 disenrolled from the SNP on (insert date)

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.

Other SEP reason

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.

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Page Last Updated: 10/05/2020