2022 Lycoming Tioga MA Kit

Page 4 of 5 Attestation of Eligibility for an Enrollment Period Typically, you may enroll in a Medicare Advantage plan only during the annual enrollment period from Oct. 15 through Dec. 7 of each year. If you are filling out this application during the annual enrollment period, you do not need to complete this section. If you are enrolling outside of the annual election period, 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 this information is incorrect, you may be disenrolled.  I am new to Medicare.  I am enrolled in a Medicare Advantage plan and want to make a change during the Medicare Advantage Open Enrollment Period (MA OEP).  I recently moved outside of the service area for my current plan, or I recently moved, and this plan is a new option for me. I moved on (insert date) _______________________.  I recently was released from incarceration. I was released on (insert date) _______________________.  I recently returned to the United States after living permanently outside of the U.S. I returned to the U.S. on (insert date) _______________________.  I recently obtained lawful presence status in the United States. I got this status on (insert date) _______________________.  I recently had a change in my Medicaid (newly got Medicaid, had a change in level of Medicaid assistance, or lost Medicaid) on (insert date) __________________.  I recently had a change in my 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 (insert date) __________________.  I have both Medicare and Medicaid (or my state helps pay for my Medicare premiums), or I get Extra Help paying for my Medicare prescription drug coverage, but I haven’t had a change.  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 (insert date) ________________.  I recently left a PACE program on (insert date) _______________________.  I recently involuntarily lost my creditable prescription drug coverage (coverage as good as Medicare’s). I lost my drug coverage on (insert date) _______________________.  I am leaving my employer or union coverage on (insert date) _____________________.  I belong to a pharmacy assistance program provided by my state.  My plan is ending its contract with Medicare, or Medicare is ending its contract with my 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 (insert date) _________________.  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 (insert date) ____________________.  I was affected by a weather-related emergency or major disaster (as declared by the Federal Emergency Management Agency (FEMA). One of the other statements here applied to me, but I was unable to make my enrollment because of the natural disaster.  I am dropping a Part D plan (Medicare Advantage prescription drug plan or Part D prescription drug plan) in order to maintain my other creditable coverage. The coverage I currently have is _________________. If none of these statements applies to you or you’re not sure, please contact UPMC for Life at 1-877-381-3765 (TTY users should call 711 ) to see if you are eligible to enroll. We are open Oct. 1 through Dec. 7 seven days a week from 7 a.m. to 9 p.m., Dec. 8 through Dec. 31 seven days a week from 8 a.m. to 8 p.m., and Jan.1 through Sept. 30 Monday through Friday from 8 a.m. to 8 p.m. and Saturday from 9 a.m. to 3 p.m. Enrollment 127 1010101010101010101010 1100100001001000011001 1000100100001001000000 1010000100100001111111 1010010000100100001000 1000010010000000101011 1001000001010101101000 1001001000010101101101 1100001010101000110000 1100100001111011111011 1000100101110010101110 1010000101100110011101 1010010000001111000000 1000000001011011101011 1001011000100010011000 1001000100111110101101 1100001110111010101000 1100101010000010000011 1000100101011100110010 1010110100101011000001 1100011000100100001000 1111111111111111111111