Medicare : Statements Of Understanding

1. If your plan has a monthly plan premium, you can pay your monthly plan premium and/or late enrollment penalty (if we determine you owe a late enrollment penalty that you currently have or may owe) by mail or electronic funds transfer (EFT) each month. You can also choose to pay your premium and/or late enrollment penalty by automatic deduction from your Social Security/Railroad Retirement Board benefit check each month. If you don't select a payment option, you will receive a coupon book/payment book.
2. If you are enrolling in a plan that has prescription drug coverage: If you qualify for Extra Help with your Medicare prescription drug costs, Medicare will pay all or part of your plan premiums. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare does not cover.
3. If you are enrolling in a plan that has prescription drug coverage: People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay for up to seventy-five (75) percent or more of your drug costs, including monthly prescription drug premiums, annual deductibles and coinsurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. For more information about this Extra Help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users should call 1-877-486-2048. You can also apply for Extra Help online at www.socialsecurity.gov/prescriptionhelp.
4. If you are enrolling in a plan that has prescription drug coverage: If you currently have health coverage from an employer or union, joining WellCare could affect your employer or union health benefits. You could lose your employer or union health coverage if you join WellCare. 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 benefit administrator or the office that answers questions about your coverage can help.
5. The agent reviewed the plan information including the Summary of Benefits. If you are enrolling in a plan that has prescription drug coverage: The agent also reviewed our formulary, which is a list of the drugs covered by WellCare and any other summary of your out-of-pocket expenses that are listed in the information kit. If you need additional information, please review your Evidence of Coverage.
6. If you are enrolling in a plan that does not offer prescription drug coverage: You understand that if you leave this plan and don't have or get other Medicare prescription drug coverage or creditable prescription drug coverage (as good as Medicare's) for a continuous period of 63 days or more, you may have to pay a late enrollment penalty in addition to your premium for Medicare prescription drug coverage in the future. If you qualify for certain exceptions such as receiving Extra Help, you may not be required to pay this penalty.
7. If you are enrolling in a plan that has a reimbursement for your Part B coverage: It is important for you to know the reimbursement is set up by Medicare and administered by the Social Security Administration (SSA). If you pay your Part B premium through your Social Security benefit check, you will see an increase in your benefit check. If your premium is paid by Medicare, you will get a credit on your Medicare Part B statement. Reimbursements typically take up to three months to be issued. However, if this is the case, you will receive a full credit once it is set up. If you have Medicaid, your Part B premium is paid for you by the state. Therefore, you will not receive a reimbursement for the premium.
8. WellCare is a Medicare Advantage plan and has a contract with the federal government. You will need to keep your Medicare Parts A and B.
9. When you enroll into one of our plans, WellCare pays for services covered by Medicare. However, you still need to pay for your Part B premium, unless it's paid on your behalf by someone else. You will be responsible for the amounts that WellCare does not cover such as co-pays or coinsurances, if applicable.
10. You can be in only one Medicare Advantage plan at a time. Once your enrollment in WellCare is approved by Medicare, you will be automatically disenrolled from your current plan. You don't need to take any action to be disenrolled from your current plan. It is your responsibility to inform WellCare of any prescription drug coverage that you have or may get in the future.
11. Enrollment in this plan is generally for the entire year. Once you enroll, you may leave this plan or make changes only at certain times of the year when an enrollment period is available (example: you may make changes October 15 - December 7 of every year), or under certain special circumstances.
12. WellCare serves specific service areas. If you move out of the area that WellCare serves, you need to notify the plan so you can disenroll and find a new plan in your new area.
13. Once you are a member of WellCare, you have the right to appeal plan decisions about payment or services if you disagree. You will read the Evidence of Coverage document from WellCare when you get it to know which rules you must follow to get coverage with this Medicare Advantage plan. You 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.
14. When your coverage with WellCare begins, you must get all your health care from WellCare, except for emergency or urgently needed services or out-of-area dialysis services.
15. Services authorized by WellCare and other services contained in your WellCare Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR WELLCARE WILL PAY FOR THESE SERVICES.
16. Counseling services may be available in your state to provide advice concerning Medicare Supplement Insurance or other Medicare Advantage or Prescription Drug plan options as well as medical assistance through the state Medicaid program and the Medicare Savings Program.
17. The person who is discussing plan options with you is either employed by or contracted with 'Ohana. This person may be paid based on your enrollment in a WellCare plan.
18. By joining this Medicare health plan, you acknowledge that WellCare will release your information to Medicare and other plans as is necessary for treatment, payment and health care operations. You also acknowledge that WellCare will release your information, including your prescription drug event data, to Medicare, who may release it for research and other purposes that follow all applicable federal statutes and regulations. The information you have provided is correct to the best of your knowledge. You understand that if you intentionally provide false data information, you will be disenrolled from the plan.
19. You understand that by completing this enrollment request, you understand the enrollment application process. If you are not the enrollee, only authorized individuals can enroll on behalf of an enrollee. Your agreement means you certify that: 1) you are authorized under state law to complete this enrollment, and 2) documentation of this authority is available upon request by WellCare or by Medicare.

Y0070_NA016404_WCM_WEB_ENG CMS Approved 10272011