Fill in a Valid Kaiser Senior Enrollment Template

The Kaiser Senior Enrollment Form is a critical document for individuals looking to enroll in the Kaiser Permanente Senior Advantage Plans, specifically designed for Medicare recipients. This form ensures that applicants meet eligibility requirements and can express their choice of plan within Kaiser Permanente’s offerings. For those interested in accessing all the available options, completing the form accurately is essential—click the button below to begin your enrollment process.

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The Kaiser Senior Enrollment form is a crucial document for individuals seeking to join a Kaiser Permanente Medicare Advantage Plan, specifically the Senior Advantage (HMO) or the Senior Advantage Medicare Medi-Cal Plan (HMO D-SNP). Designed with the needs of Medicare beneficiaries in mind, this form outlines critical information required for enrollment, including eligibility criteria and essential personal details. Eligible applicants must be U.S. citizens or lawfully reside in the United States and live within the service area of the chosen plan. The enrollment period predominantly occurs between October 15 and December 7 each year for coverage beginning January 1. Other enrollment opportunities exist in specific situations, allowing flexibility for those who qualify. Completing the form requires key information such as Medicare numbers and addresses, with certain sections optional to facilitate a smoother application process. Once submitted, the form must be sent promptly to ensure timely enrollment, prompting a review by Kaiser Permanente to confirm its completeness. Understanding the implications of coverage, including potential changes to existing employer or union health benefits, is also vital for prospective members. As Medicare recipients consider this transition, it is essential to recognize the importance of the form and seek assistance if needed to ensure all necessary fields are accurately completed before submission.

Kaiser Senior Enrollment Example

OMB No. 0938-1378

Expires: 7/31/2023

Individual Plan

Kaiser Permanente Senior Advantage (HMO) or

Kaiser Permanente Senior Advantage Medicare Medi-Cal Plan (HMO D-SNP)

Enrollment form

Northern California or Southern California Region Individual Plan

Who can use this form?

People with Medicare who want to join a Medicare		Have you thought about enrolling on
Advantage Plan		kp.org/enrollonline instead? It’s a
Advantage Plan		kp.org/enrollonline instead? It’s a
To join a plan, you must:		fast, secure, and easy way to apply.
To join a plan, you must:

•Be a United States citizen or be lawfully present

	in the U.S.	What happens next?
•	Live in the plan’s service area
Important: To join a Medicare Advantage Plan, you		Send your completed and signed form to:
must also have both:		Kaiser Permanente – Medicare Unit
•	Medicare Part A (Hospital Insurance)	P.O. Box 232400
• Medicare Part B (Medical Insurance)		San Diego, CA 92193-2400
When do I use this form?		•	We’ll review your form to make sure it’s complete.
You can join a plan:		•	We’ll let Medicare know that you’ve applied for
• Between October 15–December 7 each year (for			Senior Advantage.
	coverage starting January 1)	•	Within 10 calendar days after Medicare confirms
•	Within 3 months of first getting Medicare
			you’re eligible, we’ll let you know when your
•	In certain situations where you’re allowed to join
			coverage starts. Then we’ll send you a
	or switch plans
			Kaiser Permanente ID card and information

Visit Medicare.gov to learn more about when you			for new members.
can sign up for a plan.		•	You can check the progress of your application
What do I need to complete this form?			online at kp.org/medicare/applicationstatus
			(does not apply to HMO D-SNP).
• Your Medicare Number (the number on your red,

	white, and blue Medicare card)	How do I get help with this form?
• Your permanent address and phone number		Call Kaiser Permanente at 1-800-443-0815.
Note: You must complete all items in Section 1.
		TTY users can call 711.
The items in Section 2 are optional — you can’t be		Or, call Medicare at 1-800-MEDICARE
denied coverage because you don’t fill them out.
		(1-800-633-4227). TTY users can call 1-877-486-2048.
Reminders:
		En español: Llame a Kaiser Permanente al
•	If you want to join a plan during fall open
		1-800-443-0815/TTY 711 o a Medicare gratis
	enrollment (October 15–December 7), the plan
		al 1-800-633-4227 y oprima el 2 para asistencia
	must get your completed form by December 7.
		en español y un representante estará disponible
•	We will send you a bill for the plan’s premium.
		para asistirle.
	You can choose to sign up to have your premium

payments deducted from your bank account or your monthly Social Security (or Railroad

Retirement Board) benefit.

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According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-NEW. The time required to complete this information is estimated to average 20 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

IMPORTANT

Do not send this form or any items with your personal information (such as claims, payments, medical records, etc.) to the PRA Reports Clearance Office. Any items we get that aren’t about how to improve this form or its collection burden (outlined in OMB 0938-1378) will be destroyed. It will not be kept, reviewed, or forwarded to the plan. See “What happens next?” on this page to send your completed form to the plan.

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Name

Kaiser Permanente Medical/Health Record Number (for current or past members)

Please contact Kaiser Permanente if you need information in another language or accessible format (Braille).

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

Select the plan you want to join:

Service areas for some plans do not include the full county. Please refer to the Summary of Benefits for detailed information on plan service areas.

SOUTHERN CALIFORNIA:

Senior Advantage Medicare Medi-Cal Plan South (HMO D-SNP) - $30.50 per month

Special Needs Plan (SNP) - For people who are entitled to both Medicare and state Medicaid benefits

Senior Advantage Inland Empire (HMO) - $0 per month Senior Advantage Kern County - Basic (HMO) - $0 per month Senior Advantage Kern County - Enhanced (HMO) - $29 per month

Senior Advantage Los Angeles and Orange Counties (HMO) - $0 per month Senior Advantage San Diego County (HMO) - $0 per month

Senior Advantage Ventura County (HMO) - $0 per month

NORTHERN CALIFORNIA:

Senior Advantage Medicare Medi-Cal Plan North (HMO D-SNP) - $30.50 per month

Special Needs Plan (SNP) - For people who are entitled to both Medicare and state Medicaid benefits

Senior Advantage Alameda County - Basic (HMO) - $24 per month

Senior Advantage Alameda, Napa, and SF Counties (HMO) - $84 per month Senior Advantage Contra Costa County - Basic (HMO) - $24 per month Senior Advantage Contra Costa County - Enhanced (HMO) - $84 per month Senior Advantage Greater Fresno Area - Basic (HMO) - $15 per month Senior Advantage Greater Fresno Area - Enhanced (HMO) - $75 per month Senior Advantage Greater Sac & Sonoma County - Basic (HMO) - $15 per month Senior Advantage Greater Sac & Sonoma County - Enhanced (HMO) - $75 per month Senior Advantage Marin and San Mateo Counties (HMO) - $89 per month

Senior Advantage San Francisco County - Basic (HMO) - $24 per month Senior Advantage San Joaquin County - Basic(HMO) - $15 per month Senior Advantage San Joaquin County - Enhanced (HMO) - $75 per month Senior Advantage Santa Clara County - Basic (HMO) - $15 per month Senior Advantage Santa Clara County - Enhanced (HMO) - $75 per month Senior Advantage Santa Cruz County (HMO) - $79 per month

Senior Advantage Solano County (HMO) - $89 per month

Senior Advantage Stanislaus County - Basic (HMO) - $15 per month Senior Advantage Stanislaus County - Enhanced (HMO) - $75 per month

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Name

Advantage Plus (optional supplemental benefits package):

Would you also like to add Advantage Plus to your Kaiser Permanente Senior Advantage plan? The Advantage Plus

package is optional. For an additional $16 per month, you can add more benefits (dental, hearing, and extra vision coverage). The monthly premium for Advantage Plus will be added to your Kaiser Permanente Senior Advantage monthly premium. Note: This option is not available under the Senior Advantage Medicare Medi-Cal (HMO D-SNP) plans.

Yes No

LAST Name:

FIRST Name:

Birth Date: (mm/dd/yyyy)

Home Phone Number:

Permanent Residence Street Address (P.O. Box is not allowed):

Gender:

Male Female

Middle Initial:

Mobile Phone Number:

- -

City:

County:

State:

ZIP Code:

Mailing Address, if different from your permanent address (PO Box allowed)

Street Address:

City:

State:

ZIP Code:

E-mail Address:

Your Medicare information:

Medicare Number:

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Name

Answer these important questions:

1.Will you have other prescription drug coverage (like VA, TRICARE) in addition to Kaiser Permanente? Yes No

If “yes,” please list your other coverage and your identification (ID) number(s) for this coverage:

Name of other coverage:
ID # for this coverage:	Group # for this coverage:

2. Are you enrolled in your State Medicaid program? Yes No If “yes,” please provide your Medicaid number:

STOP Please Read This Important Information

If you currently have health coverage from an employer or union, joining Kaiser Permanente could affect your employer or union health benefits. You could lose your employer or union health coverage if you join Kaiser Permanente Senior Advantage. 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.

IMPORTANT: Read and sign below:

•I must keep both Hospital (Part A) and Medical (Part B) to stay in Kaiser Permanente Senior Advantage.

•By joining this Medicare Advantage Prescription Drug Plan, I acknowledge that Kaiser Permanente 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.

•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 people with Medicare are generally not covered under Medicare while out of the country, except for limited coverage near the U.S. border.

•I understand that when my Kaiser Permanente Senior Advantage coverage begins, I must get all of my medical and prescription drug benefits from Kaiser Permanente. Benefits and services provided by Kaiser Permanente and contained in my Kaiser Permanente Senior Advantage “Evidence of Coverage” document (also known as a member contract or subscriber agreement) will be covered. Neither Medicare nor Kaiser Permanente will pay for benefits or services that are not covered.

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Name

•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 and

2.Documentation of this authority is available upon request by Medicare.

Advantage Plus optional supplemental benefits conditions of enrollment

If you checked “Yes” to add the Advantage Plus optional supplemental benefits package on page 2, please read the information below.

By completing this enrollment application:

•I agree to adding the Advantage Plus optional supplemental benefits package that gives me (dental, hearing, and extra vision coverage) for $16 per month. This amount is in addition to my Medicare and Kaiser Permanente Senior Advantage premiums.

•I understand that the optional supplemental benefits package adds more benefits to my Kaiser Permanente Senior Advantage coverage, and the terms and conditions can be found in the Kaiser Permanente Senior Advantage Evidence of Coverage.

•I understand that the Advantage Plus optional supplemental benefits package is only available to members enrolled in a Kaiser Permanente Senior Advantage Individual Plan.

•I understand that I must get covered care from network providers, except for emergency or urgently needed services.

•I understand that I can stop my Advantage Plus optional supplemental benefits package coverage anytime. If I disenroll, I won’t be eligible to enroll again until the next Advantage Plus optional supplemental benefits package annual election period for coverage that has a start date of January 1 or I have another Special Enrollment Period.

Signature:

Today’s Date:

If you are the authorized representative, you must sign above and provide the following information:

Name:

Address:

Phone Number: -

Relationship to Enrollee:

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Name

Section 2 – All fields in this section are optional

Answering these questions is your choice. You can’t be denied coverage because you don’t fill them out.

Select one if you want us to send you information in a language other than English.

Spanish

Chinese

Select one if you want us to send you information in an accessible format.

Large Print

Braille

Audio CD

Please contact Kaiser Permanente at 1-800-443-0815 if you need information in an accessible format other than what’s listed above. Our office hours are seven days a week, 8 a.m. to 8 p.m. TTY users should call 711.

Do you work?

Yes

Does your spouse work?

Yes

Paying Your Plan Premium

You can pay your monthly plan premium (including any late enrollment penalty that you currently have or may owe) by mail, phone, or online each month. You can also choose to pay your premium by having it automatically taken out of your Social Security or Railroad Retirement Board (RRB) benefit each month.

If you have to pay a Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA), you must pay this extra amount in addition to your plan premium. The amount is usually taken out of your Social Security benefit or you may get a bill from Medicare (or the RRB). DON’T pay Kaiser Permanente the Part D-IRMAA.

Please select a premium payment option: If you don’t select a payment option, you will get a bill each month. Get a bill

After you receive your first bill, you can choose a different payment option.

•You can have your monthly payment automatically deducted from your bank account. Please call us at

1-888-236-4490 (TTY 711) to request a Medicare Autopay Selection Form or if you have any questions.

•To pay by credit or debit card, visit kp.org/payonline or call us at 1-888-236-4490 (TTY 711). You will need your account information from your bill to make a payment.

Automatic deduction from your monthly Social Security or Railroad Retirement Board (RRB) benefit check.

I get monthly benefits from:

Social Security

RRB

PRIVACY ACT STATEMENT

The Centers for Medicare & Medicaid Services (CMS) collects information from Medicare plans to track beneficiary enrollment in Medicare Advantage (MA) or Prescription Drug Plans (PDP), improve care, and for the payment of Medicare benefits. Sections 1851 and 1860D-1 of the Social Security Act and 42 CFR

§§422.50, 422.60, 423.30 and 423.32 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.

Office Use Only:

Name of staff member/agent/broker (if assisted in enrollment):

Plan ID #:

Effective Date of Coverage:

ICEP/IEP:

AEP:

SEP (type):

Not Eligible:

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Name

Attestation of Eligibility for an Enrollment Period

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.

I am new to Medicare.

I am enrolled in a Medicare Advantage plan and want to make a change during the Medicare Advantage Open Enrollment Period (MA OEP).

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 on (insert date)

I recently was released from incarceration. I was released on (insert date)

I recently returned to the United States after living permanently outside of the U.S. I returned to the U.S. on

(insert date)

I recently obtained lawful presence status in the United States. I got this status on (insert date)

I recently had a change in my Medicaid (newly got Medicaid, had a change in level of Medicaid assistance, or lost Medicaid)

on (insert date)

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) on (insert date)

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.

I am moving into, live in, or recently moved out of a Long-Term Care Facility (for example, a nursing home or long-term care

facility). I moved/will move into/out of the facility on (insert date)

I recently left a PACE program on (insert date)			/			/
I recently left a PACE program on (insert date)			/			/

I recently involuntarily lost my creditable prescription drug coverage (coverage as good as Medicare’s). I lost my drug

coverage on (insert date)

I am leaving employer or union coverage on (insert date) /

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Name

I belong to a pharmacy assistance program provided by my state.

My plan is ending its contract with Medicare, or Medicare is ending its contract with my plan.

I was enrolled in a plan by Medicare (or my state) and I want to choose a different plan. My enrollment in that plan started on

(insert date)

I was enrolled in a Special Needs Plan (SNP) but I have lost the special needs qualification required to be in that plan. I was

disenrolled from the SNP on (insert date) /

I was affected by an emergency or a major disaster as declared by a Federal, state, or local government entity. One of the other statements here applied to me, but I was unable to make my enrollment because of the natural disaster.

I am in a plan that was recently taken over by the state because of financial issues. I want to switch to another plan.

I am in a plan that’s 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.

If none of these statements applies to you or you’re not sure, please contact Kaiser Permanente at 1-800-443-0815 (TTY users should call 711) to see if you are eligible to enroll. We are open seven days a week, from 8 a.m. to 8 p.m.

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Click for Kaiser Senior Enrollment File

File Breakdown

Fact Name	Description
OMB Control Number	The form is assigned OMB No. 0938-1378, which is valid until July 31, 2023.
Eligible Users	This form is for people with Medicare wishing to enroll in a Medicare Advantage Plan.
Basic Requirements	Applicants must be U.S. citizens or legally present, and reside in the plan’s service area.
Enrollment Period	Applications are accepted from October 15 to December 7 for coverage starting January 1.
Document Return Address	Completed forms should be sent to Kaiser Permanente, Medicare Unit, P.O. Box 232400, San Diego, CA 92193-2400.
Medicare Numbers	Applicants must provide their Medicare number, found on their Medicare card.
Section 1 Completion	All fields in Section 1 must be filled out. Some items in Section 2 are optional.
Help with the Form	Assistance is available by calling Kaiser Permanente at 1-800-443-0815 or Medicare at 1-800-MEDICARE.
Optional Benefits	The Advantage Plus package can be added for an additional monthly fee, excluding HMO D-SNP plans.
State-Specific Laws	California state laws govern the Kaiser Senior Enrollment form for residents within the state.

Guide to Using Kaiser Senior Enrollment

Once you have your Kaiser Senior Enrollment form in hand, you will begin a straightforward process. Ensuring all necessary information is filled out accurately will help facilitate your application for enrollment in the plan of your choice. Please follow the steps outlined below to complete the form effectively.

Start by selecting the plan you wish to join from the options listed. Make sure it corresponds to your county and specific needs.
Fill in your last name, first name, and middle initial where indicated.
Provide your birth date in the format mm/dd/yyyy.
Enter your home phone number and, if applicable, your mobile phone number.
Write your permanent residence street address. Avoid using a P.O. Box.
Specify your city, county, state, and ZIP code.
If you have a different mailing address, provide it, including P.O. Box if needed.
Include your email address for further communication.
Locate your Medicare number from your red, white, and blue Medicare card and enter it correctly.
Answer the questions regarding any additional prescription drug coverage and state Medicaid enrollment.
Read the important information provided at the bottom of the section carefully.
Sign and date the form to confirm your understanding and agreement to the terms outlined.
Finally, review the entire form for accuracy before sending it. Make sure it is complete to avoid processing delays.

Once you've completed the form, it should be sent to the designated address for processing. Remember, providing accurate and thorough information is essential, as it ensures a smooth transition into the plan. Soon after submitting, you will receive confirmation regarding your enrollment status.

Get Answers on Kaiser Senior Enrollment

What is the Kaiser Senior Enrollment form used for?

The Kaiser Senior Enrollment form is designed for individuals who wish to enroll in the Kaiser Permanente Senior Advantage plans, which include options for both standard Medicare and Medicare Medi-Cal (HMO D-SNP) coverage. This form must be filled out to officially join a Medicare Advantage Plan. It ensures that you meet the necessary requirements and allows Kaiser to process your application effectively. Completing this form is step one in accessing healthcare benefits offered through these plans.

Who is eligible to use this form?

To be eligible to use the Kaiser Senior Enrollment form, you must meet several criteria: you need to be a citizen of the United States or be lawfully present within the nation. Additionally, you must reside within the specific service area of the plan you intend to join. Importantly, you should also possess Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) to qualify for enrollment in a Medicare Advantage Plan. Ensuring that you meet these requirements before submitting your form will help streamline the enrollment process.

What information is required to complete the enrollment form?

When filling out the Kaiser Senior Enrollment form, there are a few key pieces of information needed. In Section 1, it is essential to provide:

Your full name
Your Medicare Number (found on your Medicare card)
Your permanent address and contact information
Your birth date

Completing all items in Section 1 is mandatory. While Section 2 includes optional items, remember that providing more detailed information can be beneficial. Be sure to check that all necessary fields are filled out accurately to avoid delays in the processing of your enrollment.

How can I get help if I need assistance with the form?

If you encounter any challenges while completing the Kaiser Senior Enrollment form, there are resources available to help you navigate the process. You can contact Kaiser Permanente directly at 1-800-443-0815 for assistance. For those who prefer TTY services, simply dial 711. Alternatively, Medicare also offers support at 1-800-MEDICARE (1-800-633-4227), with TTY users able to reach out at 1-877-486-2048. Both organizations have personnel trained to assist you with any questions or concerns regarding the enrollment process and will ensure you receive the necessary guidance.

Common mistakes

Completing the Kaiser Senior Enrollment form can be straightforward, but there are common mistakes that can lead to delays or complications. One frequent error is the omission of necessary identifying information. Applicants must ensure their name, Medicare number, and contact details are filled out completely. Missing or incorrect details can stall the enrollment process.

Another common oversight is neglecting to check eligibility for the selected plan. Each plan has specific residency requirements. If an applicant resides outside the plan's service area but selects that plan anyway, their application may be rejected. It's crucial to double-check that the chosen option is available for your location.

People often skip the "Have you thought about enrolling online?" section. Although optional, the online enrollment process is quicker and more efficient. By dismissing this option, applicants might miss out on potential benefits or streamlined service.

Another frequent mistake occurs in Section 1, where all fields are required unless otherwise indicated. Incomplete sections can result in automatic rejection of the application. It’s essential that every required field, including your address and phone number, is filled out completely and accurately.

A common issue arises with mailing addresses. If your mailing address differs from your permanent address, it is crucial to indicate this clearly. Failure to do so may lead to important information getting lost in transit. Always verify that both addresses are correctly entered to ensure smooth communication.

Some applicants also underestimate the importance of the optional questions regarding additional coverage, like having other prescription drug insurance or Medicaid. Though optional, answering these questions can provide more tailored service and benefits. Not fully disclosing all forms of insurance could limit coverage options.

Moreover, failing to sign the form correctly cannot be overlooked. An unsigned form will halt the enrollment process. It's a good practice to carefully read and sign the acknowledgment section to verify understanding and agreement with the terms outlined.

Lastly, applicants sometimes mix up plan types, especially choosing between standard Medicare Advantage and Medicare Medi-Cal plans. Each plan has distinct qualifications and benefits. Hence, recognizing and comprehending the differences helps in selecting the right plan for your healthcare needs.

Documents used along the form

The Kaiser Senior Enrollment form is just one part of the process for those looking to enroll in the Kaiser Permanente Senior Advantage plans. Several other documents may accompany this form to streamline the enrollment process. Here’s a brief overview of some commonly used documents:

Evidence of Coverage (EOC): This document provides detailed information about the benefits, services, and coverage that the plan offers. It outlines what is included and any limitations that may apply.
Summary of Benefits: This is a concise outline of the key benefits of the plan, including costs for premiums, deductibles, and copayments. It helps individuals quickly understand their coverage.
Medicare Card: The Medicare card contains crucial information, such as an individual's Medicare number, which is necessary for enrollment and verification of eligibility for Medicare services.
Medicare Advantage Plan Comparison Chart: This chart helps potential enrollees compare different Medicare Advantage plans available in their area, emphasizing benefits, costs, and provider networks.
Authorization for Release of Information: This form allows Kaiser Permanente to access necessary medical records and personal information to facilitate enrollment and provide care.
Income Verification Forms: For those who may qualify for additional assistance, these forms help establish eligibility for special programs based on income.
Extra Help Application for Prescription Drug Costs: This application assists individuals in applying for programs that reduce prescription drug costs for those with limited income.
Plan Selection Form: Depending on the plan, this form is often used to specify preferences for additional coverage options, such as dental or vision care.
Durable Medical Equipment (DME) Order Form: If an enrollee needs specific medical equipment, this form submits requests for authorization and coverage through the plan.
Provider Directory: This directory lists the healthcare providers and facilities that accept the Kaiser Permanente plan, aiding enrollees in choosing where to receive care.

These documents, among others, help ensure a smooth enrollment process for individuals seeking Kaiser Permanente’s Senior Advantage plans. It's important to review each form carefully and ensure all necessary information is provided to avoid delays in coverage.

Similar forms

The Kaiser Senior Enrollment form shares similarities with various other documents that serve the purpose of enrolling individuals in health insurance or Medicare plans. Here’s a list of 10 documents that resemble the Kaiser Senior Enrollment form and how they are alike:

Medicare Advantage Enrollment Form: This document allows individuals to enroll in a Medicare Advantage plan. Like the Kaiser form, it requires personal information and Medicare numbers to process the application.
Medicaid Application Form: Similar to the Kaiser form, the Medicaid application collects personal details and residency information from individuals applying for state medical assistance.
Prescription Drug Plan Enrollment Form: This document is used to enroll in a stand-alone Medicare Part D plan. Both forms seek similar eligibility information and require applicants to provide their Medicare numbers.
Health Insurance Marketplace Application: Like the Kaiser Senior Enrollment form, this application gathers personal details and household information to determine eligibility for health coverage options.
Medicare Savings Program Application: This application helps determine qualification for programs that help cover Medicare costs. Like the Kaiser form, it requests income information and other financial details.
Special Needs Plan (SNP) Enrollment Form: SNPs serve individuals who have specific needs, much like the Senior Advantage plans. This form also requires Medicare details and residency verification.
Long-Term Care Insurance Application: Similar in nature, this application collects health and personal information to determine eligibility for long-term care coverage.
Veterans Affairs (VA) Health Care Application: This form captures personal data and eligibility information akin to the Kaiser Enrollment form, ensuring that those seeking VA benefits can enroll accurately.
Critical Illness Insurance Application: This document requires extensive medical details and personal information, paralleling the Kaiser form's requirements for health-related enrollment.
Disability Insurance Application: Like the Kaiser Senior Enrollment form, this document gathers personal and medical information to assess eligibility for disability benefits.

Dos and Don'ts

When filling out the Kaiser Senior Enrollment form, it’s essential to keep a few important do’s and don’ts in mind. Here’s a helpful guide:

Do have your Medicare Number ready. This is crucial for proper identification.
Do ensure you fill out all required fields in Section 1 completely.
Do carefully read all instructions provided with the form.
Do double-check your personal information for accuracy, including your name and address.
Do send your completed form to the correct address: Kaiser Permanente – Medicare Unit, P.O. Box 232400, San Diego, CA 92193-2400.

Don't use a P.O. Box as your permanent address; it’s not acceptable on the form.
Don't leave any required section blank; this could delay your enrollment.
Don't forget to sign the form at the end before submitting.
Don't include any personal belongings or documents with your form; only send the completed form itself.

Misconceptions

When it comes to the Kaiser Senior Enrollment form, a number of misconceptions often arise. Understanding the truth behind these misconceptions can help individuals navigate the enrollment process more effectively. Here’s a breakdown of five common misunderstandings:

Everyone is eligible to enroll at any time. Many believe they can join the Medicare Advantage Plan whenever they want. In reality, enrollment is restricted to specific periods, typically from October 15 to December 7 annually, unless you qualify for special circumstances.
Completing the form is optional. Some perceive that filling out the enrollment form is a mere suggestion. However, it is essential to complete and submit this form if you wish to enroll in the plan.
You need to provide all information in the form. There is a misunderstanding that all sections of the enrollment form are mandatory. In fact, Section 2 items are optional. Not filling out these items will not impact your coverage eligibility.
Your Medicare coverage will begin as soon as you apply. Many think that submitting their enrollment form means they will instantly gain coverage. After review, the coverage starts on a specific date depending on when the application is processed and if it falls within an open enrollment period.
All Medicare plans are the same. Some assume that every Medicare Advantage Plan offers identical benefits. This is misleading. Each Kaiser membership plan can vary significantly in terms of coverage and premiums, so it’s crucial to review the specifics of the plan you are considering.

Clearing up these common misunderstandings can simplify the enrollment process and ensure that individuals make informed decisions regarding their healthcare coverage.

Key takeaways

Eligibility is key. You must be a U.S. citizen or lawfully present in the U.S. and reside in the plan’s service area.
Enrollment windows are important. You can join a Kaiser Medicare Advantage plan during specified periods, such as October 15 to December 7 for coverage starting January 1.
Your Medicare information is required. Be prepared to provide your Medicare number, which is found on your red, white, and blue Medicare card.
Section 1 must be fully completed. All items in this section are required for your application to be considered.
Help is available. For assistance with the form, consider calling Kaiser Permanente or Medicare directly, using the numbers provided.
Optional information in Section 2. Filling out optional items will not affect your eligibility, so you can choose to leave those blank if desired.
Premium payment options exist. You have the choice to set up deductions for your premium from your Social Security payments or bank account.