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Enrollment Form

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How to fill out the enrollment form

2026 Resources

2026 Pre-Enrollment Checklist

2026 Nursing Home Plan (PPO I-SNP) Summary of Benefits

2026 Dual Care (PPO D-SNP) Summary of Benefits

2026 Assist (PPO I-SNP) Summary of Benefits

2026 Medicare Star Ratings

SSBCI Questionnaire for DSNP Enrollees Only

* Indicates required field.

Please select the state you live in:*

Select the plan you want to join:*

Extra Help is a federal program that helps individuals with limited income pay for Part D prescription drugs. Eligibility is determined based on income and asset limits set by the Social Security Administration.

SECTION 1

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

Application Information

Sex*

Are you enrolled in your State Medicaid program?*

Applicant Contact Information

Applicant Permanent Residence Address (Do not enter a PO Box. Note: For individuals experiencing homelessness, a PO Box may be considered your permanent residence address.)

County of residence*

Applicant Mailing Address, if different from permanent address. (P.O. Box 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:

Will you have other prescription drug coverage (like VA, TRICARE) in addition to Simpra Advantage?*

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 (MA) 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 I can be enrolled in only one MA plan at a time – and that enrollment in this plan will automatically end my enrollment in another MA 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 my Simpra Advantage plan. Benefits and services provided by Simpra Advantage and contained in my Simpra Advantage plan’s “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 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.

Signature

Are you the Authorized Representative (the person legally authorized to act on behalf of the enrollee to complete this enrollment under State law)?*

SECTION 2

Answering these questions is your choice. You can’t be denied coverage because you don’t fill them out.

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

Please contact Simpra Advantage Member Services at 1-844-637-4770 (for accommodations, TTY users can call 1-833-312-0044) if you need information in an accessible format other than what’s listed above. Our office hours are 8 a.m. to 8 p.m. local time, 7 days a week from October 1st to March 31st, and 5 days a week from April 1st to September 30th. Member Services is closed on Memorial Day, Juneteenth, Independence Day, Labor Day, Thanksgiving, and Christmas.

Do you work?
Does your spouse work?

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

Is this your current provider?

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.

I would like my premium to be taken out of my (choose one):

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.

If you are enrolling in the Dual Care PPO D-SNP

Please answer the question below to help determine if you are eligible for Dual Care Special Supplemental Benefits for the Chronically Ill (SSBCI). These benefits would provide you a monthly allowance to spend on groceries, rent and utilities. Completion of this form does not affect your enrollment in this plan. More information about benefits can be found in the Dual Care Summary of Benefits and the Dual Care Evidence of Coverage.

Q: Have you been diagnosed with and treated for one or more of the chronic conditions listed below?

  • Autoimmune disorders
  • Cancer
  • Cardiovascular disorders
  • Chronic alcohol use disorder and other substance abuse disorders (SUDs)
  • Chronic and disabling mental health conditions
  • Chronic conditions that impair vision, hearing (deafness), taste, touch, and smell
  • Chronic gastrointestinal disease
  • Chronic heart failure
  • Chronic kidney disease (CKD)
  • Chronic lung disorders
  • Conditions associated with cognitive impairment
  • Conditions that require continued therapy services in order for individuals to maintain or retain functioning
  • Conditions with functional challenges
  • Dementia
  • Diabetes mellitus
  • HIV/AIDS
  • Immunodeficiency and immunosuppressive disorders
  • Neurologic disorders
  • Overweight, obesity, and metabolic syndrome
  • Post-organ transplantation
  • Severe hematologic disorders
  • Stroke

IMPORTANT – Complete only if you are helping an enrollee fill out this form.

Complete this section if you’re an individual (i.e., agents, brokers, SHIP counselors, family members, or other third parties) helping an enrollee fill out this form.

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.

OFFICE USE ONLY

COMPLETE ONLY IF YOU ARE AN AGENT/BROKER OR A PLAN REP.

THIS PAGE MUST BE SUBMITTED WITH THE APPLICATION.

How was this information collected?

Enrollment Eligibility

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.

IMPORTANT:

  • If the SEND button does not work, you may not have completed all required fields. Please review the form and enter any missing information.
  • If you need help, please contact Simpra Advantage at 1-844-637-4770 (TTY/TDD 1-833-312-0044). 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, Labor Day, Thanksgiving and Christmas.

OMB No. 0938-1378 Expires: 12/31/2026

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