Enrollment Form

* Indicates required field.

Please select the state you live in:*

Enrollment for 2022 plans begins on October 15

Please choose the plan you want to enroll in:*

Simpra Advantage Nursing Home Plan (PPO I-SNP) - $40.00 per month ($0 for full dual eligible with Extra Help)

Simpra Advantage Dual Care (PPO D-SNP) - $40.00 per month ($0 for full dual eligible with Extra Help)

Simpra Advantage Assist (PPO I-SNP) - $86.00 per month

Simpra Advantage (PPO I-SNP) - $41.40 per month ($0 for full dual eligible with Extra Help)

Simpra Advantage (PPO D-SNP) - $41.40 per month ($0 for full dual eligible with Extra Help)

Simpra Advantage Premier (PPO I-SNP) - $ 98.00 per month

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).

Application Information

Sex* Male Female

Birth Date*

First Name*

Last Name*

Middle Initial

Salutation* Mr Mrs Ms

Medicare Number (MBI)*

Are you enrolled in your State Medicaid program?*

Yes No

What is your Medicaid Number?*

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

Yes No

Name of the other drug coverage*

ID for this coverage*

Group # for this coverage*

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

Are you a resident of or expect to be a resident of a long-term care facility (LTC) or an assisted living facility (ALF) in the Simpra Advantage network for more than 90 days?

Yes No

Name of Facility*

Street Address*

City*

State*

ZIP*

Phone Number of Facility*

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

Checking this box will serve as your electronic signature*

Full Name*

Today's Date

Applicant Contact Information

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

Street*

City*

State*

ZIP*

Email⁺⁺ (optional)

⁺⁺ 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:

Opt Out

Preferred Phone*

Is this your* Cell Phone⁺⁺ or Home Phone

⁺⁺ 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:

Opt Out

Secondary Phone

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.

Name

Relationship to Enrollee

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

Attn Name

Street

City

State

ZIP

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

Yes No

Authorized Representative Contact information (as applicable)

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

First Name*

Last Name*

Street*

City*

St*

Zip*

Relationship to Enrollee*

Email⁺⁺ (optional)

Opt Out

Preferred Phone*

Is this your* Cell Phone⁺⁺ or Home Phone

Opt Out

Secondary Phone*

Is this your* Cell Phone⁺⁺ or Home Phone

Opt Out

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? Yes No

Does your spouse work? Yes No

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

Is this your current provider? Yes No

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

Select one choice below:

English Spanish Other (Non-English):

I choose not to answer

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

Select one choice below:

English Spanish Other (Non-English):

I choose not to answer

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

Audio File Large Print Braille I do not need accessible formats

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

No, not of Hispanic, Latino/a, or Spanish origin Yes, Puerto Rican Yes, another Hispanic, Latino/a, or Spanish origin

Yes, Mexican, Mexican American, Chicano/a Yes, Cuban. I choose not to answer

What’s your race? Select all that apply.

American Indian or Alaska Native Asian: Asian Indian Chinese Filipino Japanese Korean Vietnamese Other Asian

Black or African American Native Hawaiian and Pacific Islander: Guamanian or Chamorro Native Hawaiian Samoan Other Pacific Islander White I choose not to answer

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.

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.

Yes, I’d like my premium to be taken out of my Social Security benefit. Yes, I’d like my premium to be taken out of my Railroad Retirement Board (RRB) benefit. No, none of the above. I would like a direct bill.

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.

AEP - I am enrolling during the Annual Enrollment Period (October 15 – December 7). IEP - I am new to Medicare. OEP - I am enrolled in a Medicare Advantage plan and want to make a change during the Medicare Advantage Open Enrollment Period (January 1 – March 31). OEPI - I am in an institution like a nursing home and would like to make a change or I recently moved out of an institution. ICEP - I already have Hospital (Part A) and recently signed up for Medical (Part B). I want to join a Medicare Advantage Plan. IEP2 - I am turning 65 and not new to Medicare. SEP - Special Election Period (choose one reason for enrollment below, if this category applies to you)

RESIDENCE: I recently moved outside my service area for my current plan or I recently moved and this plan is a new option for me. I moved on:

Dual Eligible: I am dual eligible (Medicare and Medicaid) and would like to make my quarterly change.

CHANGE 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:

DISASTER: I was affected by an emergency or major disaster as declared by the Federal Emergency Management Agency (FEMA) or a government entity. One of the other statements here applied to me, but I was unable to make my enrollment request because of the disaster.

CHANGE MEDICAID: I recently had a change in my Medicaid (newly got Medicaid, had a change in level of Medicaid assistance, or lost Medicaid) on this date:

CHANGE EXTRA HELP: I recently had a change in 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) on this date:

LTC/MOVE IN OR OUT: 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:

PACE: I recently left a Program of All-inclusive Care for the Elderly (PACE®) on this date:

LOST RX COVERAGE: I recently involuntarily lost my creditable prescription drug coverage (coverage as good as Medicare’s). I lost my drug coverage on:

LOST EMPLOYER/UNION COVERAGE: I am leaving employer or union coverage.

Employer/Union coverage started on:

and coverage ends on:

STATE RX ASSISTANCE: I belong to a pharmacy assistance program provided by my state.

RETURN TO U.S.: I recently returned to the United States after living permanently outside of the U.S. I returned to the U.S. on:

LAWFUL PRESENCE: I recently obtained status in the United States. I got this status on this date:

PLAN CONTRACT END: My plan is ending its contract with Medicare or Medicare is ending its contract with my plan.

LOST SNP ELIGIBILITY: 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:

RELEASED FROM INCARCERATION: I was recently released from incarceration. I was released on:

LOW PERFORMING PLAN: My current plan has been determined to be a Consistently Low Performing Plan and I would like to change plans.

Other SEP:

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.

Other enrollment period:

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.

Agent First and Last Name:

Agent Phone Number:

Agent Email:

AL License:

NPN:

Application received date:

Coverage effective date:

Checking this box will serve as your electronic signature

Signature:

Today's Date:

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.

I agree. Please enroll me.*

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, Thanksgiving and Christmas.

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Last modified: November 21, 2024

Enrollment Form

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SECTION 1

Application Information

Are you enrolled in your State Medicaid program?*

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

Are you a resident of or expect to be a resident of a long-term care facility (LTC) or an assisted living facility (ALF) in the Simpra Advantage network for more than 90 days?

IMPORTANT: Read and sign below

Signature

Applicant Contact Information

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

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

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

Authorized Representative Contact information (as applicable)

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

SECTION 2

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

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

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

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

What’s your race? Select all that apply.

Paying Your Plan Premium

SECTION 3 - Attestation of Eligibility*

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