Step 1

We’ll walk you through the steps and help you enroll in your new Medicare Advantage plan.

To start, please have these 3 things ready:

  • Your Medicare Number (You can find this on your government-issued Medicare ID card.)
  • The date you became eligible for Medicare Part A & Part B. This is typically your 65th birthday or the month your disability benefits began.
  • Names and addresses of your current doctors

*Required field

Customer & Medicare information

Medical information

Check your Medicare card or your letter from the Social Security Administration or Railroad Retirement Board.

 

Hospital (Part A) effective date

Hospital (Part B) effective date

Medicare Card Example Image

Step 2

Paying Your Plan Premium

If we determine that you owe a late enrollment penalty (or if you currently have a late enrollment penalty), we need to know how you would prefer to pay it. You can pay by mail each month. 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 RRB. DO NOT pay Clarion Health 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 800-772-1213. TTY users should call 800-325-0778. You can also apply for extra help online at www.socialsecurity.gov/prescriptionhelp. If you qualify for Extra Help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn’t cover. If you don’t select a payment option, you will get a bill each month.

 

(The Social Security/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.)

  1. Do you have End-Stage Renal Disease (ESRD)?

    If you have had a successful kidney transplant and/or you don't need regular dialysis any more, you will receive a letter and form asking you to provide documentation from your doctor showing you have had a successful kidney transplant or you don't need dialysis.

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

    Please list your other coverage and your identification (ID) number(s) for this coverage:

  3. Are you a resident in a long-term care facility, such as a nursing home?

    Please provide the following information:

  4. Are you enrolled in your State Medicaid program?

    Please provide your Medicaid number:

  5. Do you or your spouse work?
  6. Please choose the name of a Primary Care Physician (PCP) from our Provider Plan Directory. Click here to find your provider, then enter the Provider ID and (if applicable) the zip code to the office of your choice below
  7. Please check one of the boxes below if you would prefer us to send you information in a language other than English or in an accessible format.
  8. Please provide your emergency contact information.

Please contact Clarion Health at 844-824-8771 if you need information in an accessible format or language other than what is listed above. Our office hours are 8 a.m. - 8 p.m. local time, seven days a week from October 1 - March 31, except for Thanksgiving and Christmas. However, from April 1 - September 30, our hours are 8 a.m. - 8 p.m. local time, five days a week. You will have to leave a message on Saturdays, Sundays and Federal holidays. We will return your call within one business day. TTY users should call 711.

Step 3

Please Complete This Section To Help Determine Which Election Period You Qualify For.

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 please 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 none of these statements apply to you or you’re not sure, please contact Clarion Health at 844-824-8771 (TTY users should call 711) to see if you are eligible to enroll. Our office hours are 8 a.m. - 8 p.m. local time, seven days a week from October 1 - March 31, except for Thanksgiving and Christmas. However, from April 1 - September 30, our hours are 8 a.m. - 8 p.m. local time, Monday - Friday.

Please Read This Important Information

If you currently have health coverage from an employer or union, joining this plan could affect your employer or union health benefits. You could lose your employer or union health coverage, if you join this plan. 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 isn’t any information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.

Please Read and Sign

By completing this enrollment application, I agree to the following:

Clarion Health Medicare HMO plans are Medicare Advantage plans and have a contract with the Federal Government. I will need to keep my Medicare 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 7 of every year), or under certain special circumstances.

 

Clarion Health Medicare HMO serves a specific service area. If I move out of the area that these plans serve, 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 this plan, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from Clarion Health Medicare HMO 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 Clarion Health Medicare HMO coverage begins, I must get all of my health care from Clarion Health Medicare HMO, except for emergency or urgently needed services or out-of-area dialysis services. Services authorized by Clarion Health Medicare HMO and other services contained in my Clarion Health Medicare HMO Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR Clarion Health 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 Clarion Health, he/she may be paid based on my enrollment in an Clarion Health Medicare HMO plan.

 

Release of Information: By joining this Medicare health plan, I acknowledge that the Clarion Health Medicare HMO will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that Clarion Health 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.

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If you are the authorized representative, you must sign above and provide the following information: