H1350-025 2023 True Blue Special Needs Plan (HMO D-SNP) Enrollment Form

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                                                                  2023 True Blue Special Needs Plan
                                                                  (HMO D-SNP) Enrollment Form
✂ Fold and tear along dotted line to detach pages for mailing ✂

                                                                  Who can use this form?                                  Reminders:
                                                                  People with Medicare and Enhanced Medicaid who          • This is a dual-eligible special needs plan (D-SNP).
                                                                  want to join a Medicare-Medicaid Special Needs            Your ability to enroll will be based on verification
                                                                  Plan that includes prescription drug coverage.            that you are entitled to both Medicare and
                                                                                                                            Enhanced Medicaid.
                                                                  To join a D-SNP plan, you must:
                                                                  • Be at least 21 years of age                           What happens next?
                                                                  • Live in our service area                              Send your completed and signed form to:
                                                                  • Be entitled to Medicare Part A                        Blue Cross of Idaho Care Plus, Inc.
                                                                  • Be enrolled in Medicare Part B                        P.O. Box 8406
                                                                  • Be on Enhanced Medicaid                               Boise, ID 83707-2406
                                                                  • Be a United States citizen or be lawfully present     Or enroll online at
                                                                    in the U.S.
                                                                  When do I use this form?                                Once we process your request to join,
                                                                  You can join a D-SNP plan any time of the year.         we’ll contact you.
                                                                  Effective dates for coverage begin the 1st day of       How do I get help with this form?
                                                                  the following month.
                                                                                                                          Call Blue Cross of Idaho Care Plus, Inc. at
                                                                  What do I need to complete this form?                   1-888-495-2583. TTY users can call 711.
                                                                  • Your Medicare ID number (the number on your           Or call Medicare at 1-800-MEDICARE
                                                                    red, white and blue Medicare card)                    (1-800-633-4227). TTY users can call
                                                                                                                          1-877-486-2048, 24 hours a day, seven days a week.
                                                                  • Your Idaho Medicaid ID number (the number on
                                                                    your Idaho Medicaid card)                             En español: Llame a Blue Cross of Idaho Care Plus,
                                                                                                                          Inc. al 1-888-495-2583 (TTY: 711) o a Medicare
                                                                  • Your permanent residence address and
                                                                                                                          gratis al 1-800-633-4227 y oprima el 2 para
                                                                    phone number
                                                                                                                          asistencia en español y un representante estará
                                                                  Note: You must complete all items in Section 1.         disponible para asistirle.
                                                                  The items in Section 2 are optional – you can’t be
                                                                  denied coverage because you don’t fill them out.        Individuals experiencing homelessness
                                                                                                                          If you want to join a plan but have no permanent
                                                                                                                          residence, a Post Office Box, an address of
                                                                                                                          a shelter or clinic, or the address where you
                                                                                                                          receive mail (e.g., social security checks) may be
                                                                                                                          considered your permanent residence address.

                                                                  We are available seven days a week from 8 a.m. to 8 p.m., October 1 to March 31.
                                                                  Our hours of operation for the rest of the year are Monday through Friday from 8 a.m. to 8 p.m.
                                                                                                                                                                Form No. 22-1024 (09-22)   1

o True Blue Special Needs Plan (HMO D-SNP)

Section 1 – All fields in this section are required
(unless marked optional)

First Name                                                                      Last Name                                                                     Middle Initial

                                                                                                                                                                               ✂ Fold and tear along dotted line to detach pages for mailing ✂
Birth Date (mm/dd/yyyy)                                    Gender:                                      Phone                                Alternate Phone
                                                           o Male                      o Female         (      )                             (      )
Email Address*                                                                                          County

Permanent Residence Street Address (P.O. Box not                                                        City                                 State             Zip Code

Mailing Address (only if different from above)                                                          City                                 State             Zip Code

*OPTIONAL: By providing us with your email address you are agreeing to receive communications
regarding your plan benefits and well-being. You can opt out at any time.


Medicare ID Number: _________________________ MID Number: _____________________________
You must use Medicare Beneficiary Identifier, or MBI.
                                                      Name (as it appears on your Medicaid ID card):
Name (as it appears on your Medicare ID card):        _____________________________________________

                                           MEDICARE HEALTH INSURANCE                                                             I D A H O   D E P A R T M E N T    O F

                               JAMIE SAMPLE

                               Medicare Number/Número de Medicare
                                                                                                                              Idaho Health Plan
                               Entitled to/Con derecho a            Coverage starts/Cobertura empieza
                               HOSPITAL (PART A)                    01-01-2020                                     Member First/Last Name
                               MEDICAL (PART B)                     01-01-2020                                     MID 0001234567                                  0001

Will you have other prescription drug coverage (like VA, TRICARE) in addition to
Blue Cross of Idaho Care Plus, Inc.? o Yes o No
           Name of other coverage:                                        Member number for this coverage: Group number for this coverage:
       ___________________________                                              ____________________________                ____________________________

2   Form No. 22-1024 (09-22)

                                                                  Typically, you may enroll in a Medicare Advantage plan only during the annual enrollment period from
                                                                  October 15 through December 7 of each year. 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 that this information is incorrect, you may be disenrolled.
                                                                  o I am enrolling during the Annual Enrollment Period (AEP) October 15-December 7
                                                                  o I am new to Medicare.
                                                                  o I am enrolled in a Medicare Advantage plan and want to make a change during the Medicare Advantage
                                                                    Open Enrollment Period (MA OEP).
                                                                  o I am in a Medicare Advantage Plan and have had Medicare for less than 3 months. I want to make a change.
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                                                                  o 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 or will move on _________________.
                                                                  o I recently was released from incarceration. I was or will be released on _________________.
                                                                  o I recently returned to the United States after living permanently outside of the U.S. I moved or will move
                                                                    back to the U.S. on _________________.
                                                                  o I recently obtained lawful presence status in the United States. I got or will get this status on __________.
                                                                  o I recently had a change in my Medicaid (newly got Medicaid, had a change in level of Medicaid
                                                                    assistance, or lost Medicaid). This change happened on _________________.
                                                                  o 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). This change happened on
                                                                  o 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.
                                                                  o I’m in a State Pharmaceutical Assistance Program, or I’m losing help from a State Pharmaceutical
                                                                    Assistance Program.
                                                                  o I recently moved out of a long-term care facility (for example, a nursing home or a rehabilitation
                                                                    hospital). I moved on _________________.
                                                                  o I live in a long term care facility (for example, a nursing home or rehabilitation hospital).
                                                                  o I am new to Medicare, and I was notified about getting Medicare after my Part A and/or Part B coverage
                                                                    started. I was notified of getting Medicare on ________________.
                                                                  o I have had Medicare prior to now, but I am now turning 65.
                                                                  o I left coverage from my employer or union (including COBRA coverage). I left or will leave on _________.
                                                                  o I lost other, non-Medicare prescription drug coverage that’s as good as Medicare prescription drug
                                                                    coverage (creditable coverage), or my other, non-Medicare prescription drug coverage changed and is
                                                                    no longer considered creditable. This happened on _______________.
                                                                  o I already have Hospital (Part A) and recently signed up for Medical (Part B). I want to join a Medicare
                                                                    Advantage Plan.
                                                                  o I lost my Special Needs Plan because I no longer have a condition required for that plan. This change
                                                                    happened on _______________.

                                                                                                                                                        Continued on next page

                                                                                                                                                                    Form No. 22-1024 (09-22)   3

Continued from previous page

o I want to join a Special Needs Plan that tailors its benefits to my chronic condition.
o I lost my coverage because Medicare ended its contract with my plan. I received a letter from Medicare
  saying I can join another plan. My plan ended on or will end on ________________.
o I lost my coverage because my plan no longer covers the area that I live or it ended its contract with
o I recently left a PACE (Programs of All-Inclusive Care for the Elderly) program. I dropped my coverage on
o I was enrolled in a plan by Medicare (or my state) and I want to choose a different plan. That plan started

                                                                                                                      ✂ Fold and tear along dotted line to detach pages for mailing ✂
  on ________________.
o I am in a plan that has had a star rating of less than 3 stars for the last 3 years. I want to join a plan with a
  star rating of 3 stars or higher.
o I am in a plan that was recently taken over by the state because of financial issues. I want to switch to
  another plan.
o I was affected by an emergency or a major disaster (as declared by the Federal Emergency Management
  Agency, or by Federal, my state, or my local government). One of the other statements on this page
  applied to me, but I was unable to make my request because of the disaster.
o I requested plan materials in an accessible format and was not given equal time to make an
  enrollment decision.
o Other ____________________________________________________________________________________.

4   Form No. 22-1024 (09-22)
Section 2 – All fields on this page are optional

                                                                  Are you Hispanic, Latino/a, or Spanish origin? Select all that apply.

                                                                  ¨ No, not of Hispanic, Latino/a or Spanish origin       ¨ Yes, Cuban
                                                                  ¨ Yes, Mexican, Mexican American, Chicano/a             ¨ Yes, another Hispanic, Latino/a or Spanish origin
                                                                  ¨ Yes, Puerto Rican                                     ¨ I choose not to answer

                                                                  What’s your race? Select all that apply.
                                                                  ¨ American Indian or Alaska Native   ¨ Guamanian or Chamorro              ¨ Other Pacific Islander
                                                                  ¨ Asian Indian                       ¨ Japanese                           ¨ Samoan
                                                                  ¨ Black or African American          ¨ Korean                             ¨ Vietnamese
                                                                  ¨ Chinese                            ¨ Native Hawaiian                    ¨ White
                                                                  ¨ Filipino                           ¨ Other Asian                        ¨ I choose not to answer
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                                                                  Please check one of the boxes below if you would prefer us to send you information in a language other
                                                                  than English or in an accessible format
                                                                  o Spanish    o Accessible formats (audio, Braille or large print):
                                                                  Please contact customer service at 1-888-495-2583 (TTY 711). If you need information in an accessible
                                                                  format or language other than what is listed above.

                                                                  Do you or your spouse work? o Yes          o No

                                                                  PLEASE CHOOSE A PRIMARY CARE PROVIDER:

                                                                  Please choose a primary care provider (PCP) from the True Blue Special Needs Plan (HMO D-SNP)
                                                                  Provider Network. Please enter the PCP ID number exactly as it appears on the website or in the Provider
                                                                  Directory. It will be five to eight digits (examples: BB123, 12345678).
                                                                  Please visit bcidaho.com/FindSNPDoctors for a list of participating network providers.
                                                                  Name of primary care provider (PCP):__________________________________________
                                                                  PCP ID Number:____________________         Are you an existing patient? o Yes o No
                                                                  If you do not specify a PCP one will be assigned for you.

                                                                                                                                                               Form No. 22-1024 (09-22)   5

• I must keep both Hospital (Part A) and Medical (Part B) to stay in Blue Cross of Idaho Care Plus, Inc.
• By joining this Medicare Advantage Plan, I acknowledge that Blue Cross of Idaho Care Plus, Inc. will
  share my information with Medicare, who may use it to track my enrollment, to make payments, and
  for other purposes allowed by Federal law that authorize the collection of this information (see Privacy
  Act Statement below). Your response to this form is voluntary. However, failure to respond may affect
  enrollment in the plan.
• I understand that I can be enrolled in only one MA plan at a time - and that enrollment in this plan will
  automatically end my enrollment in another MA plan (exceptions apply for MA PFFS, MA MSA plans).
• I understand that beginning on the date True Blue Special Needs Plan coverage begins, I must get all of
   my healthcare from True Blue Special Needs Plan, except for emergency or urgently needed services, out-
   of-area dialysis services and during the first 90 days I am enrolled in the plan. During the first 90 days on
   the plan, I can continue receiving services from my current providers for services I already have in place,

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   even if they are not in the True Blue Special Needs Plan provider network. My provider will need to join the
   plan’s provider network if I wish to continue receiving covered services from them after 90 days. Services
   authorized by True Blue Special Needs Plan and other services contained in my True Blue Special Needs
   Plan Evidence of Coverage document (also known as a member contract or subscriber agreement) will be
   covered. Without authorization, NEITHER MEDICARE, MEDICAID nor True Blue Special Needs Plan WILL
• The information on this enrollment form is correct to the best of my knowledge. I understand that if I
  intentionally provide false information on this form, I will be disenrolled from the plan.
• I understand that my signature (or the signature of the person legally authorized to act on my behalf) on
  this application means that I have read and understand the contents of this application. If signed by an
  authorized representative (as described above), this signature certifies that:
    1. This person is authorized under state law to complete this enrollment.
    2. Documentation of this authority is available upon request by Medicare.

        Signature:________________________________________ Today’s Date: ____________
        Relationship to beneficiary: o Self   o Authorized Representative        o Other

If you’re the authorized representative, sign above and fill out these fields.
If applicable, please attach a power of attorney form.
Name:________________________________ Relationship to Enrollee: ___________________________
Address:______________________________ City, State, Zip Code:______________________________
Phone Number: (_____)_________________


Name of agent/broker (if assisted in enrollment):___________________ Broker ID: _______________
Date Enrollment Form taken by agent: _________
Plan ID Number:______________________________
Broker email:_____________________________________________________

6   Form No. 22-1024 (09-22)
                                                                  The Centers for Medicare & Medicaid Services (CMS) collects information from Medicare plans to track beneficiary
                                                                  enrollment in Medicare Advantage (MA) Plans, improve care, and for the payment of Medicare benefits. Sections
                                                                  1851 and 1860D-1 of the Social Security Act and 42 CFR §§ 422.50 and 422.60 authorize the collection of this
                                                                  information. CMS may use, disclose and exchange enrollment data from Medicare beneficiaries as specified in the
                                                                  System of Records Notice (SORN) “Medicare Advantage Prescription Drug (MARx)”, System No. 09-70-0588. Your
                                                                  response to this form is voluntary. However, failure to respond may affect enrollment in the plan.
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                                                                  ©2022 Blue Cross of Idaho Care Plus, Inc. (“Blue Cross of Idaho Care Plus”), an Independent Licensee of the
                                                                  Blue Cross Blue Shield Association, with services provided by Blue Cross of Idaho Health Service, Inc.

                                                                                                                                                                 Form No. 22-1024 (09-22)   7
English: We have free interpreter services to answer any questions you may have about our health or drug plan.
To get an interpreter, just call us at 1-800-627-1188 (TTY: 711). Someone who speaks English can help you. This is a
free service.
Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener
sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al 1-800-627-1188
(TTY: 711). Alguien que hable español le podrá ayudar. Este es un servicio gratuito.

Chinese Mandarin: 我们提供免费的翻译服务,帮助                              Italian: È disponibile un servizio di interpretariato
您解答关于健康或药物保险的任何疑 问。如果您需要                                      gratuito per rispondere a eventuali domande
此翻译服务,请致电 1-800-627-1188 (TTY: 711)。我                         sul nostro piano sanitario e farmaceutico. Per un
们的中文工作人员很乐意帮助您。这是一项免费服务。                                      interprete, contattare il numero 1-800-627-1188
                                                              (TTY: 711). Un nostro incaricato che parla Italianovi
Chinese Cantonese: 您對我們的健康或藥物保險可能                             fornirà l’assistenza necessaria. È un servizio gratuito.
存有疑問,請此我們提供免費的翻譯 服務。如需翻譯                                      Portuguese: Dispomos de serviços de interpretação
服務,請致電 1-800-627-1188 (TTY: 711)。我們講中                         gratuitos para responder a qualquer questão que
文的人員將樂意為您提供幫助。這 是一項免費服務。                                      tenha acerca do nosso plano de saúde ou de
Tagalog: Mayroon kaming libreng serbisyo sa                   medicação. Para obter um intérprete, contacte-nos
pagsasaling-wika upang masagot ang anumang                    através do número 1-800-627-1188 (TTY: 711). Irá
mga katanungan ninyo hinggil sa aming planong                 encontrar alguém que fale o idioma Português para o

                                                                                                                         ✂ Fold and tear along dotted line to detach pages for mailing ✂
pangkalusugan o panggamot. Upang makakuha ng                  ajudar. Este serviço é gratuito.
tagasaling-wika, tawagan lamang kami sa 1-800-627-            French Creole: Nou genyen sèvis entèprèt gratis
1188 (TTY: 711). Maaari kayong tulungan ng isang              pou reponn tout kesyon ou ta genyen konsènan plan
nakakapagsalita ng Tagalog. Ito ay libreng serbisyo.
                                                              medikal oswa dwòg nou an. Pou jwenn yon entèprèt,
French: Nous proposons des services gratuits                  jis rele nou nan 1-800-627-1188 (TTY: 711). Yon moun
d’interprétation pour répondre à toutes vos                   ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis.
questions relatives à notre régime de santé ou
d’assurance-médicaments. Pour accéder au service              Polish: Umożliwiamy bezpłatne skorzystanie z
d’interprétation, il vous suffit de nous appeler au           usług tłumacza ustnego, który pomoże w uzyskaniu
1-800-627-1188 (TTY: 711). Un interlocuteur parlant           odpowiedzi na temat planu zdrowotnego lub
Français pourra vous aider. Ce service est gratuit.           dawkowania leków. Aby skorzystać z pomocy tłumacza
Vietnamese: Chúng tôi có dịch vụ thông dịch miễn              znającego język polski, należy zadzwonić pod numer
phí để trả lời các câu hỏi về chương sức khỏe và              1-800-627-1188 (TTY: 711). Ta usługa jest bezpłatna.
chương trình thuốc men. Nếu quí vị cần thông dịch             Japanese: 当社の健康 健康保険と薬品 処方薬
viên xin gọi 1-800-627-1188 (TTY: 711) sẽ có nhân viên
nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí .      ランに関するご質問にお答えするため に、無料
German: Unser kostenloser Dolmetscherservice                  ご用命になるには、
beantwortet Ihren Fragen zu unserem Gesundheits-              1-800-627-1188 (TTY: 711)
und Arzneimittelplan. Unsere Dolmetscher erreichen            にお電話ください。日本語を話す人 者 が支援
Sie unter 1-800-627-1188 (TTY: 711). Man wird Ihnen
dort auf Deutsch weiterhelfen. Dieser Service ist             たします。これは無料のサー ビスです。
kostenlos.                                                    Bantu: ICITONDERWA: Nimba uvuga Ikirundi,
Korean: 당사는 의료 보험 또는 약품 보험에 관한                                uzohabwa serivisi zo gufasha mu ndimi, ku
질문에 답해 드리고자 무료 통역 서비스를 제공하고                                   buntu. Woterefona 1-800-627-1188
있습니다. 통역 서비스를 이용하려면 전화 1-800-627-                             (TTY: 711).
1188 (TTY: 711) 번으로 문의해 주십시오. 한국어를
하는 담당자가 도와 드릴 것입니다. 이 서비스는                                    Farsi: ‫هجوت‬: ‫دینک یم وگتفگ یسراف نابز هب رگا‬،
무료로 운영됩니다.                                                    ‫یم مهارف امش یارب ناگیار تروصب ینابز تالیهست‬
Russian: Если у вас возникнут вопросы                         ‫دشاب‬. ‫اب‬1-800-627-1188 (TTY: 711) ‫دیریگب سامت‬.
относительно страхового или медикаментного
плана, вы можете воспользоваться нашими                       Nepali: ध्यान दिनुहोस्: तपार्इंले नेपाली बोल्नुहुन्छ
бесплатными услугами переводчиков. Чтобы                      भने तपार्इंको निम्ति भाषा सहायता सेवाहरू निःशुल्क
воспользоваться услугами переводчика,
позвоните нам по телефону 1-800-627-1188 (TTY:                रूपमा उपलब्ध छ । फोन गर्नुहोस् 1-800-627-1188
711). Вам окажет помощь сотрудник, который                    (टिटिवाइ: 711) ।
говорит по-pусски. Данная услуга бесплатная.
                                                              Romanian: ATENȚIE: Dacă vorbiți limba română,
                                                              vă stau la dispoziție servicii de asistență lingvistică,
                                                              gratuit. Sunați la 1-800-627-1188 (TTY: 711).
                                                              Serbo-Croatian: OBAVJEŠTENJE: Ako govorite
                                                              srpsko-hrvatski, usluge jezičke pomoći dostupne
Hindi: हमारे स्वास्थ्य या दवा की योजना के बारे में आपके       su vam besplatno. Nazovite 1-800-627-1188
किसी भी प्रश्न के जवाब देने के लिए हमारे पास मुफ्त दुभाषिया   (TTY: Telefon za osobe sa oštećenim govorom ili
सेवाएँ उपलब्ध हैं. एक दुभाषिया प्राप्त करने के लिए, बस हमें   sluhom: 711).
1-800-627-1188 (TTY: 711). पर फोन करें. कोई व्यक्ति जो
हिन्दी बोलता है आपकी मदद कर सकता है. यह एक मुफ्त सेवा है.                          Form No. 16-1080 (08-22)

8   Form No. 22-1024 (09-22)                                                                     H1350_025_MK23215_C
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