021586 (01-2020)
An Independent Licensee of the Blue Cross Blue Shield Association 1
• Are eligible for the group’s Medicare supplement plan
• Currently have both Medicare Part A and Part B, and
• Don’t receive Medicaid assistance other than payment of your
Medicare Part B premium.
For Office Use Only
Group Number:
__________________________
Effective Date of Coverage:
__________________________
Enrollee Class (if applicable):
__________________________
Your Information
Applicant
I am eligible for Medicare Part A and B because: Age 65+ Under Age 65
I have Medicare due to: Kidney Dialysis or Kidney Transplant
Last Name
First Name
Middle Initial
Social Security Number (required)
Home Address (cannot be a P.O. Box)
City
County
State
ZIP
Mailing Address (if different from above)
City
County
State
ZIP
Daytime Phone Number
Email Address
Birthdate Month
Day
Year
Gender
Male Female
Dependent
I am eligible for Medicare Part A and B because: Age 65+ Under Age 65
I have Medicare due to: Kidney Dialysis or Kidney Transplant
Relationship to Applicant:
Last Name
First Name
Middle Initial
Social Security Number (required)
Home Address (cannot be a P.O. Box)
City
County
State
ZIP
Mailing Address (if different from above)
City
County
State
ZIP
Daytime Phone Number
Email Address
Birthdate Month
Day
Year
Gender
Male Female
P.O. Box 327, MS 295
Seattle, WA 98111-9220
A
Group Medicare Supplement
Enrollment Application
Washington State Health Care Authority
B
You can become a Washington State Health Care Authority
Medicare Supplement member if you:
Please PRINT, sign and date in blue or black ink. Applications that contain correction fluid or
tape will not be accepted. PLEASE RETURN ALL THE PAGES OF THE APPLICATION EVEN IF
THEY ARE BLANK.
021775 (06-2020)
2
What Plan Do You Want?
Your Other Health Coverage
Please answer all the questions below as best you know how.
Applicant
Tell Us About Your Medicare Coverage (You have to have Medicare Parts A and B to Enroll)
1.
a.
Did you turn age 65 in the last 6 months? Yes No
b.
Did you enroll in Medicar
e Part B in the last 6 months? Yes No
c.
If
Yes, what is the effective date? (month and year)
/
01
/
(See your Medicare card to find this date.)
Your Medicare Information Here
Please fill in your Medicare
number and effective dates in
the box to the right.
You can
copy from your Medicare card.
Or, it
's OK to include a copy of
your Medicare card instead.
We need these numbers to
enroll you.
MEDICARE HEALTH INSURANCE
1-800-MEDICARE (1-800-633-4227)
NAME OF BENEFICIARY
MEDICARE CLAIM NUMBER
-
-
-
IS ENTITLED TO
EFFECTIVE DATE
Part A Hospital Insurance
/
01
/
Part B Medical Insurance
/
01
/
Tell Us About Your Medicare Advantage Coverage, If Any
If you didn't have this kind of coverage, just check "No" to 2.a., b., c. and d.
2
.
a.
Have you had coverage from any Medicare plan other than original
Medicare w
ithin the last 63 days (for example, a Medicare Advantage
plan, or a Medicare HMO or PPO)?
Yes No
If Yes
, fill in your
start
and
end
dates below. (OK to put in just the month and year.)
If you are still covered under this plan
, leave “End” blank.
Start:
/
/
End:
/
/
C
B
Plan G
Yes No
Which Medicare supplement plan do you want to enroll in?
Did you receive a copy of the Premera Blue Cross “Outline of Coverage”?
Did you receive a copy of Medicare’s “Choosing A Medigap Policy” guide? Yes No
3
b.
If you are still covered under the Medicare plan, do you intend
to replace your current coverage with this new Medicare
Supplement pl
an? (You can't keep both.) Yes No
c.
Was this your first time in this type of Medicare plan?
Yes No
d.
Did you drop a Medicare Supplement policy to enroll in the Medicare plan? Yes No
Tell Us About Your Medicare Supplement Coverage, If Any
If you didn't have this kind of coverage, just check "No" to 3.a. and c. Leave 3.b. blank.
3.
a.
Do you have another Medicare Supplement policy in force? (These plans
are called Plan A, B, C, D, F, G, K, L, M or N)
Yes No
b.
If
Yes, with what company, and what plan do you have? (If you know, put the
insurance company name and the plan name (such as Plan F) in the b
lanks.)
Company:
Plan:
c.
If
Yes, do you intend to replace your current Medicare Supplement policy
with this plan? (You can't keep both.)
Yes No
Tell Us About Any Other Individual Or Group Health In
surance Coverage, If Any
If you didn't have this kind of coverage, just check "N
o" to 4.a., and leave b. and c. blank.
4
.
a.
Have you had coverage under any other health insurance within the past 63 days?
(For example, an employer, union or individual pl
an). Yes No
b.
If Yes, with what company and what kind of policy? (If you know, put in the insurance company
name and the type of policy, such as group coverage through your spouse or individual coverage.)
Company
:
Policy:
c.
What are your dates of coverage under the other policy?
If you are still covered under the same
policy
, leave “End” blank. (It's OK to put just the month and year or just the year.)
Start:
/
/
End:
/
/
Tell Us About Any Help With Your Medical Bills You Receive
From Your State's Medicaid Programs
This doesn't mean Social Security
benefits or food stamps. It can include payment for
nursing home care. If you didn't have this kind of help from State Medicaid, just check
"N
o" to 5.a., b. and c.
5.
a.
Are you covered for any medical assistance through the state Medicaid program?
N
ote To Applicant:
If you are participating in a “Spend-Down Program” and have
not met your “Share of Cost,” please answer
No
to this question. Yes No
b.
If
Yes
, will Medicaid pay your premiums for this Medicare Supplement plan? Yes No
c.
Do you receive any benefits from Medicaid OTHER THAN payments toward your
Medicare Part B Premium?
Yes No
4
Dependent
Tell Us About Your Medicare Coverage
(You have to have Medicare Parts A and B to Enroll)
1.
a.
Did you turn age 65 in the last 6 months?
Yes No
b.
Did you enroll in Medicare Part B in the last 6 months?
Yes No
c.
If Yes, what is the effective date? (month and year)
/
01
/
(See your Medicare card to find this date.)
Dependent’s Medicare Information Here
Please fill in your Medicare
number and effective dates in
the box to the right.
You can
copy from your Medicare card.
Or, it's OK to include a copy of
your Medicare card instead.
We need these numbers to
enroll you.
MEDICARE HEALTH INSURANCE
1-800-MEDICARE (1-800-633-4227)
NAME OF BENEFICIARY
MEDICARE CLAIM NUMBER
-
-
-
IS ENTITLED TO
EFFECTIVE DATE
Part A Hospital Insurance
/
01
/
Part B Medical Insurance
/
01
/
Tell Us About Your
Dependent’s Medicare Advantage Coverage, If Any
If you didn't have this kind of coverage, just check "No" to 2.a., b., c. and d.
2
.
a.
Have you had coverage from any Medicare plan other than original
Medicare within the last 63 days (for example, a Medicare Advantage
plan, or a Medicare HMO or PPO)
? Yes No
If Yes
, fill in your
start
and
end
dates below. (OK to put in just the month and year.)
If you are still co
vered under this plan
, leave “End” blank.
Start:
/
/
End:
/
/
b.
If you are still covered under the Medicare plan, do you intend to replace your current
coverage with this new Medica
re Supplement plan? (You can't keep both.) Yes No
c.
Was this your first time in this type of Medicare plan?
Yes No
d.
Did you drop a Medicare Supplement policy to enroll in the Medicare plan? Yes No
Tell Us About Your
Dependent’s Medicare Supplement Coverage, If Any
If you didn't have this kind of coverage, just check "No" to 3.a. and c. Leave b. blank.
3.
a.
Do you have another Medicare Supplement policy in force? (These plans
are called Plan A, B, C, D, F, G, K, L, M or N)
Yes No
b.
If Yes, with what company, and what plan do you have? (If you know, put the insurance company
name and the plan name (
such as Plan F) in the blanks.)
Company:
Plan:
c.
If
Yes, do you intend to replace your current Medicare Supplement
policy with this plan? (You can't keep both.)
Yes No
Tell Us About Any Other
Dependent Individual Or Group Health Insurance Coverage, If Any
If you didn't have this kind of coverage, just check "N
o" to 4.a., and leave b. and c. blank.
4
.
a.
Have you had coverage under any other health insurance within the past 63 days?
(For example, an employer, union or ind
ividual plan). Yes No
b.
If
Yes, with what company and what kind of policy? (If you know, put in the
insurance company name and the type of policy, such as group coverage
through your spouse or individual coverage.
)
Company:
Policy:
c.
What are your dates of coverage under the other policy?
If you are still covered under the same
policy
, leave “End” blank. (It's OK to put just the month and year or just the year.)
Start:
/
/
End:
/
/
Tell Us About Any Help With Your
Dependent’s Medical Bills You Receive
From Your State's Medicaid Programs
This doesn
't mean Social Security benefits or food stamps. It can include payment for
nursing home care. If you didn't have this kind of help from State Medicaid, just check
"N
o" to 5.a., b. and c.
5.
a.
Are you covered for any medical assistance through the state Medicaid program?
Note To Applicant:
If you are participating in a “Spend-Down Program” and have
not met your “Share of Cost,” please answer
No
to this question. Yes No
b.
If
Yes
, will Medicaid pay your premiums for this Medicare Supplement plan? Yes No
c.
Do you receive any benefits from Medicaid OTHER THAN payments toward
your Medicare Part B Premium?
Yes No
Proceed to section D
5
Conditions of Enrollment/Signatures
I, the undersigned, apply for enrollment with Premera Blue Cross (Premera). I represent that all
statements and answers on this application are complete and true.
1. I am an eligible member of the group.
2. I have both Medicare Parts A and B in force today.
3. I understand that my coverage does not start until Premera accepts this application and assigns
an effective date.
4. I authorize Premera, at its option, to pay doctors and other providers directly for health care I
receive.
5. I understand that it is a crime to knowingly provide false, incomplete, or misleading information
to an insurance company for the purpose of defrauding the company. Penalties include
imprisonment, fines, and denial of insurance benefits.
6. I also understand and agree that Premera may cancel this coverage back to its start date as if I
never had coverage at all, if it is found that I have supplied false information, or any information
was omitted by me or for me, on this application, and that information is material enough to
affect my eligibility for coverage. (Please note: After coverage has been in force for two years,
coverage may no longer be canceled for this reason.)
7. I understand that Premera may collect, use, and disclose personal information about me as
required or permitted by law or to perform routine business functions. Examples are to
determine my eligibility for enrollment or to pay claims. If Premera discloses my personal
information for any other reason, Premera will first take out any data that can be used to easily
identify me, or will get my signed permission.
Be sure to sign and date this application, include all pages of the application and
provide any proof required for “yes” answers in section C, when submitting to Premera
for processing.
Signature of Applicant Today’s Date
X
Signature of Dependent Today’s Date
X
Please Note: If you have a Medicare supplement or Medicare Advantage policy today (including a
Medicare HMO or PPO), you cannot be enrolled unless you intend to replace your current coverage.
Please complete the “Notice to Applicant Regarding Replacement of Medicare Supplement or
Medicare Advantage Coverage” form.
If you have any questions, please contact your benefit department or Premera at 1-800-817-3049 or
TDD for the Deaf or Hard of Hearing at 1-800-842-5357.
D
6
Important Notes
1. You do not need more than one Medicare Supplement policy. If you currently have a Medicare
Supplement policy or Medicare Advantage policy (including a Medicare HMO or PPO), you
cannot be enrolled unless you intend to replace your current coverage. Please complete a
replacement form. If you purchase this contract, you may want to evaluate your existing health
coverage and decide if you need multiple coverages.
2. You may be eligible for benefits under Medicaid and may not need a Medicare Supplement
policy. Medicaid is a public aid program for people with low income. It is not the same as
Medicare.
3. If, after purchasing this plan, you become entitled to Medicaid, the benefits and subscription
charges under your Medicare Supplement contract can be suspended, if requested, during your
entitlement to benefits under Medicaid for 24 months. You must request this suspension within 90
days of becoming eligible for Medicaid. If you are no longer entitled to Medicaid, your suspended
Medicare Supplement plan (or, if that is no longer available, a substantially equivalent plan) will
be re-instituted if requested within 90 days of losing Medicaid eligibility.
4. Counseling services may be available in your state to provide advice concerning your purchase
of Medicare Supplement coverage and concerning medical assistance through the state
Medicaid program, including benefits as a “Qualified Medicare Beneficiary” (QMB) or a “Specified
Low-Income Medicare Beneficiary” (SLMB).
5. If you are eligible for, and have enrolled in a Medicare supplement policy by reason of disability
and you later become covered by an employer or union-based group health plan, the benefits
and premiums under your Medicare supplement policy can be suspended, if requested, while you
are covered under the employer or union based group health plan. If you suspend your Medicare
supplement policy under these circumstances, and later lose your employer or union based
group health plan, your suspended Medicare supplement policy (or, if that is no longer available,
a substantially equivalent policy) will be reinstituted, if requested within 90 days of losing your
employer or union based group health plan.
8
HCA Eligibility Attachment
Group Medicare Supplement
Eligibility Attachment
Washington State Health Care Authority
Public Employees Benefits Board (PEBB) Program
Who Is Eligible For Coverage?
Public Employees Benefit Board (PEBB) Program Retirees, Survivors, or PEBB Continuation Coverage
(COBRA) Subscribers
To be eligible, you must be an eligible retiree, survivor, or PEBB continuation coverage (COBRA) subscriber
and enroll during one of the periods listed below:
• Upon initial enrollment in PEBB insurance coverage.
• Within six months of initial enrollment in Medicare Part B.
• If you deferred PEBB retiree health plan coverage, you may enroll during any PEBB Program annual
open enrollment or no later than 60 days after the date other qualified coverage ends.
• Existing PEBB subscribers may change their coverage by applying for another plan during a PEBB
Program annual open enrollment or a special open enrollment period, established by the PEBB
Program.
• During other enrollment periods, if any, established by the PEBB Program.
Dependents of PEBB Program Retirees or PEBB Continuation Coverage (COBRA) Subscribers
To be eligible, you must be an eligible spouse or state-registered domestic partner and enroll during one of the
periods listed below:
• At the same time as the PEBB retiree or PEBB Continuation Coverage (COBRA) subscriber.
• Within six months of initial enrollment in Medicare Part B.
• During a PEBB Program annual open enrollment or a special open enrollment period established by the
PEBB Program.
9
State Residents
To be eligible, you must be a current Washington State resident and enroll during one of the periods listed
below:
• No earlier than 30 days before you become eligible for Part A and Part B of Medicare.
• Within six months of initial enrollment in Medicare Part B provided that you are replacing a health plan
with no lapse in coverage of more than 63 days.
• Within six months of attaining age 65 or older and is enrolled in Medicare Part B.
• Within 63 days of establishing Washington State residency. Residency date: ________________
• Within 63 days of losing coverage under a retiree group health plan, a Medicare Advantage plan, a
health care prepayment plan, a Program of All-Inclusive Care for the Elderly, a Medicare supplement or
Medicare SELECT plan, or a Medicare risk or cost plan for reasons that qualify under federal law. Your
answers in section C of the application will determine if you qualify.
• When replacing coverage or enrolling during a guaranteed issue period, as allowed by law. Your
answers in section C of the application will determine if you qualify.
037397 (07-01-2021) An independent licensee of the Blue Cross Blue Shield Association
Discrimination is Against the Law
Premera Blue Cross (Premera) complies with applicable Federal and Washington state civil rights laws and does not discriminate on the
basis of race, color, national origin, age, disability, sex, gender identity, or sexual orientation. Premera does not exclude people or treat
them differently because of race, color, national origin, age, disability, sex, gender identity, or sexual orientation. Premera provides free
aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written
information in other formats (large print, audio, accessible electronic formats, other formats). Premera provides free language services to
people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these
services, contact the Civil Rights Coordinator. If you believe that Premera has failed to provide these services or discriminated in another
way on the basis of race, color, national origin, age, disability, sex, gender identity, or sexual orientation, you can file a grievance with:
Civil Rights Coordinator ─ Complaints and Appeals, PO Box 91102, Seattle, WA 98111, Toll free: 855-332-4535, Fax: 425-918-5592,
TTY: 711, Email AppealsDepartmentInquiries@Premera.com. You can file a grievance in person or by mail, fax, or email. If you need help
filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department
of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence
Ave SW, Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html. You can also file a civil rights complaint with the Washington State Office of the Insurance
Commissioner, electronically through the Office of the Insurance Commissioner Complaint Portal available at
https://www.insurance.wa.gov/file-complaint-or-check-your-complaint-status, or by phone at 800-562-6900, 360-586-0241 (TDD).
Complaint forms are available at https://fortress.wa.gov/oic/onlineservices/cc/pub/complaintinformation.aspx.
Language Assistance
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 800-722-1471 (TTY: 711).
注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電
800-722-1471
（
TTY
：
711
）。
CHÚ Ý: N
ế
u b
ạ
n nói Ti
ế
ng Vi
ệ
t, có các d
ị
ch v
ụ
h
ỗ
tr
ợ
ngôn ng
ữ
mi
ễ
n phí dành cho b
ạ
n. G
ọ
i s
ố
800-722-1471 (TTY: 711).
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.
800-722-1471 (TTY: 711)
번으로 전화해 주십시오.
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 800-722-1471 (телетайп: 711).
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 800-722-1471 (TTY: 711).
УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки.
Телефонуйте за номером 800-722-1471 (телетайп: 711).
,
800-722-1471 (TTY: 711)
注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。
800-722-1471
（
TTY:711
）まで、お電話にてご連絡ください。
ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ
800-722-1471
(መስማት ለተሳናቸው:
711
).
XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 800-722-1471 (TTY: 711).
1471
722
800
711
800-722-1471
(TTY:
711
)
ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 800-722-1471 (TTY: 711).
:
, ,
, .
800-722-1471 (TTY: 711)
.
ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 800-722-1471 (TTY: 711).
ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 800-722-1471 (ATS : 711).
UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 800-722-1471 (TTY: 711).
ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 800-722-1471 (TTY: 711).
ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 800-722-1471 (TTY: 711).
هجوت
1471 (TTY: 711)-722-800
