2014 Medicare Enrollment Applications

1. 2014 Medicare Enrollment Applications Agent Guide to Changes and Notes from Enrollment

2. Full Individual Application

3. Highlighted Changes on Individual Full Application • Completely re-designed cover page • Re-worded verbiage to increase clarification

4. Highlighted Changes on Individual Full Application • No major changes

5. Highlighted Changes on Individual Full Application • Updated with 2014 plan options and split PDP bubbles • Moved the Group and Benefit Number (BN) fields from page 7 and placed in an “Agent Use Only” box • Reminder: Group/BN are required on all applications. Without this information, we may not be able to determine onto which plan to enroll the member. Missing Group/BN is one of our top incomplete errors every year and may lead to enrollment denial. Group/BN sheets can be downloaded from the Agent Portal. • “Plan Option” has been renamed to “Contract – PBP”

6. Highlighted Changes on Individual Full Application • Updated 2014 OSB options • Reminder: If a member is currently on an OSB and wishes to remain on that OSB, it must be chosen every time a new application is submitted. If the OSB is not chosen, the member will be disenrolled from that OSB. Some OSBs have been discontinued for 2014. • Mailing address has been moved to page 2 • Reminder: All members with a PO Box must also have a physical address. Per CMS regulation, we have to know a member’s actual address to ensure they’re in the correct plan.

7. Highlighted Changes on Individual Full Application • Moved Effective Date, ETC bubbles, and SEP Reason Code from page 7 and placed in an “Agent Use Only” box • Reminder: ETCs and SEPs • ICEP is valid for MA and MAPD plans. • IEP is valid for PDP and MAPD plans. • If member qualifies for both ICEP and IEP and is applying for an MAPD plan, use the IEP bubble • If the member is applying using the second or “re age-in” IEP, use the IEP bubble. • If the SEP bubble is selected, an SEP code is required on this page. SEP codes are located on page 4. • If the member qualifies for multiple SEPs, choose any one of the codes to place on this page.

8. Highlighted Changes on Individual Full Application • Mailing address has been moved to page 2 • Reminder: All members with a PO Box must also have a physical address. • Clarification on which plans require a PCP has been added • Reminder: All HMO and some PPO plans require a PCP. We request that a PCP be included on every MA or MAPD plan. The Summary of Benefits will advise which PPO plans require a PCP. Please enter the number exactly as it appears in the directory or in Physician Finder Plus. • Questions have been re-worded for clarification

9. Highlighted Changes on Individual Full Application • The Coupon Book is now the last-displayed payment option so that members have full disclosure on all payment options prior to selection.

10. Highlighted Changes on Individual Full Application • No significant changes • Reminder: Place the SEP code from this page onto page 1. If the member qualifies for multiple SEPs, choose any one of the codes to place onto page 1.

11. Highlighted Changes on Individual Full Application • No significant changes

12. Highlighted Changes on Individual Full Application • Re-worded “Scope of Appointment Type” to “Appointment Type” • Reminder: Leave the “Location” field blank unless you are with an Affinity Partner that requires this field be completed. • Added a reminder that the barcode which appears on page 7 is the barcode which should be placed on the Scope of Appointment form

13. AEF Individual Application

14. Highlighted Changes on Individual AEF Application • Completely re-designed cover page • Re-worded verbiage to increase clarification

15. Highlighted Changes on Individual AEF Application • No major changes

16. Highlighted Changes on Individual AEF Application • Updated with 2014 plan options and split PDP bubbles • Updated 2014 OSB options • Reminder: If a member is currently on an OSB and wishes to remain on that OSB, it must be chosen every time a new application is submitted. If the OSB is not chosen, the member will be disenrolled from that OSB. Some OSBs have been discontinued for 2014. • Mailing address has been moved to page 2 • Reminder: All members with a PO Box must also have a physical address.

17. Highlighted Changes on Individual AEF Application • Prefilled “H” in the Member ID Number field on all pages • Moved Effective Date, ETC bubbles, and SEP Reason Code to page 1 and placed in an “Agent Use Only” box • Reminder: ETCs and SEPs • If the member is applying using the second or “re age-in” IEP, use the IEP bubble. • If the SEP bubble is selected, an SEP code is required on this page. SEP codes are located on page 4. • If the member qualifies for multiple SEPs, choose any one of the codes to place on this page.

18. Highlighted Changes on Individual AEF Application • Mailing address has been moved to page 2 • Reminder: All members with a PO Box must also have a physical address. • Added “Contract – PBP” fields • Added clarification that in order to use the AEF, the member’s current contract number must match their new contract number. • Reminder: If the contract numbers do not match, a full application must be completed. If the wrong form is used, the enrollment will be denied.

19. Highlighted Changes on Individual AEF Application • Clarification on which plans require a PCP has been added • Reminder: All HMO and some PPO plans require a PCP. We request that a PCP be included on every MA or MAPD plan. The Summary of Benefits will advise which PPO plans require a PCP. Please enter the number exactly as it appears in the directory or in Physician Finder Plus.

20. Highlighted Changes on Individual AEF Application • The Coupon Book is now the last-displayed payment option so that members have full disclosure on all payment options prior to selection.

21. Highlighted Changes on Individual AEF Application • No significant changes • Reminder: Place the SEP code from this page onto page 1. If the member qualifies for multiple SEPs, choose any one of the codes to place onto page 1.

22. Highlighted Changes on Individual AEF Application • Re-worded “Scope of Appointment Type” to “Appointment Type” • Shortened the Agent Name field • Note: If your full name no longer fits the field, enter your name in • ‘LastNameFirstName’ • format until you run out of spaces. Ensure your SAN number is correct. • Added Affinity Partner Fields • Reminder: Leave the “Location” field blank unless you are with an Affinity Partner that requires this field be completed.

23. OSB Individual Application

24. Highlighted Changes on Individual OSB Application • Completely re-designed cover page • Re-worded verbiage to increase clarification

25. Highlighted Changes on Individual OSB Application • No major changes

26. Highlighted Changes on Individual OSB Application • Updated 2014 OSB options and added an additional disclaimer • Reminder: If a member is currently on an OSB and wishes to remain on that OSB, it must be chosen every time a new application. If the OSB is not chosen, the member will be disenrolled from that OSB. Some OSBs have been discontinued for 2014.

27. Highlighted Changes on Individual OSB Application • Added clarification that members should contact Customer Service to change their existing payment options. • Reminder: OSB plans use the same payment method as the member’s base plan. The member cannot have two payment methods. If the member has an existing payment option on their base plan and wish to change that, they will need to call Customer Service. Choosing an option on this form will not change the member’s payment option for either their base plan or OSB plan.

28. Highlighted Changes on Individual OSB Application • Added Affinity Partner Fields • Reminder: Leave the “Location” field blank unless you are with an Affinity Partner that requires this field be completed.