Enrollment Form

Need Help?  How to fill out the enrollment form

Please select the state you live in:

Please choose the plan you want to enroll in:

If you get Extra Help from Medicare, your monthly plan premium will be lower than what it would be if you didn’t get Extra Help from Medicare. Depending on your level of Extra Help, your premium may be anywhere between $0 and $ 0.00. If you are full-dual eligible, with Extra Help, your premium may be lower.

SECTION 1

To Enroll, all fields in this section are required (unless marked optional)

* Indicates required field.

Application Information

Sex*
Salutation*

Are you enrolled in your State Medicaid program?

Will you have other prescription drug coverage in addition to Simpra Advantage?

Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal employee health benefits coverage, VA benefits, or State pharmaceutical assistance program.

IMPORTANT: Read and sign below

  • I must keep both Hospital (Part A) and Medical (Part B) to stay in Simpra Advantage.
  • By joining this Medicare Advantage Plan or Medicare Prescription Drug Plan, I acknowledge that Simpra Advantage 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.
  • I understand that Simpra Advantage does not cover me while I’m out of the country, except for limited coverage near the U.S. border.
  • I understand that I can be enrolled in only one Medicare Advantage plan at a time and that enrollment in this plan will automatically end my enrollment in another Medicare Advantage plan (exceptions apply for MA PFFS, MA MSA plans).
  • I understand that when my Simpra Advantage coverage begins, I must get all of my medical and prescription drug benefits from Simpra Advantage. Benefits and services provided by Simpra Advantage and contained in my Simpra Advantage “Evidence of Coverage” document (also known as a member contract or subscriber agreement) will be covered. Neither Medicare nor Simpra Advantage will pay for benefits or services that are not covered.
  • 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 my signature or the signature of my Authorized Representative (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 below), 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.

Signature

Applicant Contact Information

Permanent Residence Address (P.O. Box not allowed)

⁺⁺ By providing your email address, you are opting in to receive electronic communications at this email address, when available. If you do not wish to receive electronic communications at this email address, check this box:

Is this your or

⁺⁺ By providing your cell phone number, you are opting in to receive electronic communications via SMS/text message, when available. If you do not wish to receive electronic communications via SMS/text message at this cell number, check this box:

Please list a second phone number of a family member or friend who can be contacted if we are not able to reach you at your preferred phone number above. We will not text them. We will not share Protected Health Information with this person without your approval.

Mailing Address, if different from permanent address. (P.O. Box allowed)

Are you an Authorized Representative?

Authorized Representative Contact information (as applicable)

If you're the Authorized Representative, you must sign above and fill out these fields:

⁺⁺ By providing your email address, you are opting in to receive electronic communications at this email address, when available. If you do not wish to receive electronic communications at this email address, check this box:

Is this your or
Is this your or

⁺⁺ By providing your cell phone number, you are opting in to receive electronic communications via SMS/text message, when available. If you do not wish to receive electronic communications via SMS/text message at this cell number, check this box:

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.

Do you work?
Does your spouse work?

List your Primary Care Physician (PCP), clinic, or health center:

Is this your current provider?

Please tell us the language you would like to speak when talking with Simpra representatives.

Select one choice below:

We send required documents to members in English. Please tell us if you need to receive documents in another language.

Select one choice below:

Please tell us if you need documents in an accessible format.

Are you Hispanic, Latino/a, or Spanish origin? Select all that apply:

What’s your race? Select all that apply.

Asian:
Native Hawaiian and Pacific Islander:

Please contact Simpra Advantage at 1-844-637-4770 (TTY/TDD 1-833-312-0044) if you need information in an accessible format or language other than what is listed above.

Our office hours are 8:00 am to 8:00 pm local time.

TTY/TDD users can call 1-833-312-0044.

Paying Your Plan Premium

For plans with a premium, 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). DON’T pay Simpra Advantage the Part D-IRMAA.

PRIVACY ACT STATEMENT The Centers for Medicare & Medicaid Services (CMS) collects information from Medicare plans to track beneficiary enrollment in Medicare Advantage (MA) Plans, improve care, and for the payment of Medicare benefits. Sections 1851 of the Social Security Act and 42 CFR §§ 422.50 and 422.60 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.

SECTION 3 - Attestation of Eligibility

This is a required section.

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.

If none of these statements applies to you or you’re not sure, please contact Simpra Advantage at 1-844-637-4770 (TTY/TDD users can call 1-833-312-0044) to see if you are eligible to enroll. We are open 8am to 8pm local time, 7 days a week from October 1st – March 31st and 5 days a week from April 1st – September 30th. We are closed on the following holidays: Memorial Day, Independence Day, Thanksgiving and Christmas.

ENROLLEE OR AUTHORIZED REPRESENTATIVE: Please skip this section and continue to the end of the application to send it to Simpra Advantage.

AGENT: Please complete this section before continuing to the end of the application.

Send Enrollment Request to Simpra Advantage

Please be advised that by proceeding you are sending an actual enrollment request to Simpra Advantage. All information you'll provide here is strictly confidential, secure, and will only be used to enroll you in your chosen plan.