Before we start the online enrollment process, we would like to collect your permanent residency zip code in order to provide a better assistance of choosing the right plan option for you.
Please enter your permanent residency zip code below:
If you have any question when filling out this form. please contact us at 1-800-353-3765 (toll free). Persons with hearing impairments, please call TTY at 711. We are available to take your call from 8:00am to 8:00pm 7 days a week.
By clicking the I Agree button below, you agree to enroll in an Elderplan Medicare Advantage Prescription Drug Plan and agree to the release and authorization language stated in the application. You also agree that the information that you are providing is accurate.
I understand that if I intentionally provide false information on this application, I will be disenrolled from the plan.
Please note: When you fill out this form, you will be issued a confirmation number. Please save this number AND print out a copy of the completed form for reference. THIS IS YOUR PROOF OF ENROLLMENT.
If you have any question when filling out this form. please contact us at 1-800-353-3765 (toll free). Persons with hearing impairments, please call TTY 711. We are available to take your call from 8:00am to 8:00pm 7 days a week.
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 Elderplan at 1-800-353-3765 (TTY users should call 711) to see if you are eligible to enroll. We are open 8 a.m. – 8 p.m., 7 days a week for more information.
Please call 866-384-3508 for more information and assistance in enrolling in this plan.
Llame al 866-384-3508 para obtener más información y ayuda para inscribirse en este plan.
Note: You will be able to review and confirm your entries before they are submitted.To Enroll in an Elderplan, Please Provide the Following Information.
Permanent Residence Street Address (Don't enter a PO Box):
To enroll in Elderplan Special Need Plan you must meet the criteria listed below and live in our plan service areas:
Elderplan for Medicaid Beneficiaries (HMO D-SNP), you must be entitled to Medicare and New York State Medicaid program, you must be eligible for Medicaid coverage and meet the enrollment eligibility requirements for Elderplan for Medicaid Beneficiaries. The kind of Medicaid benefits you receive are determined by New York State and may vary based upon your income and resources.
Elderplan Plus Long Term Care (HMO D-SNP) you must be entitled to Medicare and New York State Medicaid program, you must be eligible for full benefits from Medicaid and meet the enrollment eligibility requirements for Elderplan Plus Long Term Care. The kind of Medicaid benefits you receive are determined by New York State and may vary based upon your income and resources.
Please indicate if you meet all the following requirements. 1) You are eligible for full New York State Medicaid coverage, 2) you are 18 years or older, and 3) you believe you are eligible for a nursing home level of care, are capable of safely remaining in your home, and require care management and home care or day care services for 120 continuous days or longer?
Elderplan Advantage for Nursing Home Residents (HMO I-SNP) you must live in an institutional nursing home contracted with Elderplan Special Needs Plan.
If “yes,” please provide the following information:
Elderplan Assist (HMO IE-SNP) your current residence should be an assisted living facility while also getting nursing home level of care.
If the answer is "yes" please provide the following information:
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 the information in a language other than English.
Select one if you want us to send you information in an accessible format.
Please contact Elderplan 1-800-353-3765 if you need information in an accessible format other than what’s listed above. Our office hours are 8 AM to 8 PM, 7 days a week. TTY users can call 711.
You can pay your monthly plan premium (including any late enrollment penalty that you currently have or may owe) by mail “Electronic Funds Transfer (EFT)”, “credit card” 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 Elderplan the Part D-IRMAA.
(The Social Security or 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.)
If you are the authorized representative, you must sign below and fill out these fields:
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.