2022 South Central MA Kit

Who can use this form? People with Medicare who want to join a Medicare Advantage Plan To join a plan, you must: • Be a United States citizen or be lawfully present in the U.S. • Live in the plan’s service area. Important: To join a Medicare Advantage plan, you must also have both: • Medicare Part A (hospital insurance). • Medicare Part B (medical insurance). When do I use this form? You can join a plan: • Between Oct. 15–Dec. 7 each year (for coverage starting Jan. 1). • Within 3 months of first getting Medicare. • In certain situations where you’re allowed to join or switch plans. Visit medicare.gov to learn more about when you can sign up for a plan. What do I need to complete this form? • Your Medicare number (the number on your red, white, and blue Medicare card) • Your permanent address and phone number Note: You must complete all items in Section 1 and sign the last page of the application. The items in Section 2 are optional—You can’t be denied coverage because you don’t fill them out. Reminders: • If you want to join a plan during fall open enrollment (Oct. 15–Dec. 7), the plan must get your completed form by Dec. 7. • Your plan will send you a bill for the plan’s premium. You can choose to sign up to have your premium payments deducted from your bank account or your monthly Social Security (or Railroad Retirement Board) benefit. What happens next? Send your completed and signed form to: UPMC for Life PO Box 2967 Pittsburgh, PA 15230 Once they process your request to join, they’ll contact you. How do I get help with this form? Call UPMC for Life at 1-877-381-3765. TTY users can call 711. Or, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. En español: Llame a UPMC for Life al 1-877-381-3765 (TTY:711) o a Medicare gratis al 1-800-633-4227 y oprima el 2 para asistencia en español y un representante estará disponible para asistirle. OMB No. 0938-1378 Expires:7/31/2023 112