(Optional)

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IS Entitled To Effective Date

If we determine that you owe a late enrollment penalty (of if you currently have a late enrollment penalty), we need to know how you would like to pay it. You can pay by mail each month or quarterly. 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, you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security benefit check or be billed directly by Medicare or the RRB. DO NOT pay Liberty Health Advantage 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 co-insurance. 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 help online at www.socialsecurity.gov/prescriptionhelp

Please contact Liberty Health Advantage at 1.866.542.4269 if you need information in another format or language than what is listed above. Our office hours are Sunday to Saturday 8am to 8pm. After February 15, 2012, Member Service will be operated by alternate technology. TTY users call 1.800.662.1220.

If you currently have health coverage from an employer or union, joining Liberty Health Advantage could affect your employer or union health benefits. You could lose your employer or union heath coverage if you join Liberty Health Advantage HMO. Read the communications your employer or union sends you. If you have questions, visit their website, or contact the office listed in their communications. If there is no information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.

By completing this enrollment application, I agree to the following:
Liberty Health Advantage is a Medicare Advantage plan and has a contract with the Federal government. I will need to keep my Parts A and B. I can be in only one Medicare Advantage plan at a time and I understand that my enrollment in this plan will automatically end my enrollment in another Medicare health plan or prescription drug plan. It is my responsibility to inform you of any prescription drug coverage that I have or may get in the future. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes only at certain times of the year when an enrollment period is available (Example: October 15 – December 07 of every year), or under certain special circumstances.

Liberty Health Advantage serves a specific service area. If I move out of the area that Liberty Health Advantage serves, I need to notify the plan so I can disenroll and find a new plan in my new area. Once I am a member of Liberty Health Advantage, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from Liberty Health Advantage when I get it to know which rules I must follow to get coverage with this Medicare Advantage plan. I understand that people with Medicare aren’t usually covered under Medicare while out of the country except for limited coverage near the U.S. border.

I understand that beginning on the date Liberty Health Advantage coverage begins, I must get all of my health care from Liberty Health Advantage, except for emergency or urgently needed services or out-of-area dialysis services. Services authorized by Liberty Health Advantage and other services contained in my Liberty Health Advantage Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR LIBERTY HEALTH ADVANTAGE WILL PAY FOR THE SERVICES.

I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or contracted with Liberty Health Advantage, he/she may be paid based on my enrollment in Liberty Health Advantage.

Release of Information:By joining this Medicare health plan, I acknowledge that Liberty Health Advantage HMO will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that Liberty Health Advantage will release my information including my prescription drug event data to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations. 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 authorized to act on my behalf under the laws of the State where I live) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (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 from Medicare.

If you are the authorized representative, please provide the following information. Proof of this authorty must be available upon request by Liberty Health Advantage HMO or CMS.

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 Liberty Health Advantage at 1-866-542-4269 (TTY users should call) 1.800.662.1220 to see if you are eligible to enroll. We are open Sunday to Saturday, 8am to 8pm. After February 14, 2012, Member Services hours on Saturday & Sunday will be operated by alternate technology.

The information that I have given in my application is true to the best of my knowledge.

I understand enrollment in Medicaid Advantage is voluntary. I have been told the rights and benefits that I will have as a member of Medicaid Advantage and the conditions of participation. I know that I must be enrolled in the same health plan’s Medicare Advantage product to enroll or stay enrolled in Medicaid Advantage.

I consent to the release of any medical information about me:

• By my primary care provider (PCP), by any other health care provider, or by the New York State Department of Health (SDOH) to my health plan and any health care providers involved in caring for me, as reasonably necessary for my health plan or my providers to carry out treatment, payment or health care operations. This may include pharmacy and other medical claims information needed to help manage my care;
• By my health plan and any health care providers to SDOH and other authorized federal, state and local agencies for purposes of administration of the Medicaid and/or Medicare programs; and
• By my health plan to other persons or organizations, as reasonably necessary for my health plan to carry out treatment, payment or heath care operations.

I also agree that HIV/AIDS, mental health or alcohol and substance abuse information about me may be released, to the extent permitted by law, for as long as I remain enrolled in this Medicaid Advantage plan. I know that I can revoke this consent at any time by notifying the health plan in writing, except that this would not apply to information that has already been released.

I understand that other federal, state and local laws may also protect the confidentiality of my personal health information.