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Medicare : Statements Of Understanding

When completing your enrollment in a WellCare Medicare Advantage Plan, you understand and acknowledge the following:

 

  1. If enrolling in a health plan with a $0 monthly 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 by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month, if eligible.
  2. If your plan has a monthly plan premium, you can pay your monthly plan premium (including any late enrollment penalty that you currently have or may owe) by mail or by having it automatically deducted from your bank (checking/savings) account each month. You can also choose to pay your premium by automatic deduction from your Social Security/Railroad Retirement Board (RRB) benefit check each month. If you don’t select a payment option, you will receive a coupon book to pay your monthly premiums.
  3. If you are enrolling in a plan that has prescription drug coverage: 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 the RRB. DO NOT pay WellCare the Part D-IRMAA.
  4. If you are enrolling in a plan that has prescription drug coverage: 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 does not cover.
  5. 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 75% 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. 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 1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for Extra Help online at www.socialsecurity.gov/prescriptionhelp
  6. 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 benefits administrator or the office that answers questions about your coverage can help.
  7.  If you are enrolling in a plan that does not offer prescription drug coverage: You understand that if you don’t have 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 if you enroll in 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.
  8. 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 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.
  9. WellCare (HMO) is a Medicare Advantage organization with a Medicare contract. Enrollment in WellCare (HMO) depends on contract renewal. You will need to keep your Medicare Parts A and B.
  10. 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.
  11. 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.
  12. 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.
  13. WellCare serves a specific service area. 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.
  14. 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.
  15. When your coverage with WellCare begins, you must get all of your health care from WellCare, except for emergency or urgently needed services or out-of-area dialysis services.
  16. 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 THE SERVICES.
  17. 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.
  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 which 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 information on this form, you will be disenrolled from the plan.
  19. By completing this enrollment request, you acknowledge that 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 from Medicare.

Y0070_NA023899_WCM_WEB_ENG CMS Approved


Last modified: 12/02/2013

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