BCBSMA MEDICARE HMO SalesKit Book 07/01/2021 Approved by Danielle Roy 0/21/2021 4:55 PM

Our Commitment to Confidentiality

This Notice describes how medical information about you
may be used and disclosed, and how you can get access to
this information. Please review it carefully.

Our Commitment: We respect your right to privacy. We won’t disclose personally
identifiable information about you without your permission, unless the disclosure is
necessary to provide our services to you or is otherwise in accordance with the law.

Collection of Information

We collect only personal or medical information we need to carry out our business.
• Examples of personal information are name, address, date of birth, and social security

number. Most often, you and your employer supply this information to enroll you in a plan.
• Examples of medical information are diagnoses, treatments, and names of providers who

treat you. Most often, your providers supply this information.

Use and Disclosure of Information

We’re required by law to protect the confidentiality of your personal and medical information and
to notify you in case of a breach affecting your personal or medical information. We’ll supply
your information to you upon your request or to help you understand treatment options and other
benefits available to you.
We also may use and disclose your information without your written authorization for the
following purposes, and as otherwise permitted or required by law:
• Treatment—to help providers manage or coordinate your health care and related services.

For example, to refer you to another provider or remind you of appointments.
• Payment—to obtain payment for your coverage, provide you with health benefits, and assist

another health plan or provider in its payment activities. For example, to manage enrollment
records, make coverage determinations, administer claims, or coordinate benefits with other
coverage you may have.
• Health Care Operations—to operate our business, including accreditation, credentialing, customer
service, disease management, and fraud-prevention activities. For example, to do business
planning, arrange for medical review, or conduct quality assessment and improvement activities.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.

• Legal Compliance—to comply with applicable laws. For example, to respond to regulatory
authorities responsible for oversight of government benefit programs or our operations; to
parties or courts in the course of judicial or administrative proceedings; to law enforcement
officials during an investigation; and as necessary to comply with workers’ compensation laws.

• Research and Public Health—for medical research studies in accordance with laws for the
protection of human research subjects, and to report to public health authorities and otherwise
prevent or lessen a serious and imminent threat to health or safety. For example, for the purpose
of preventing or controlling disease, injury, or disability.

• To an Account (such as an employer) or Party It Designates—for administration of its
health plan. For example, to a self-insured account for claim review and audits. We’ll disclose
your information only to designated individuals. That, along with contract obligations, helps
protect your information from unauthorized use.

To carry out these purposes, we share information with entities that perform functions for us
subject to contracts that limit use and disclosure to intended purposes. We use physical,
electronic, and procedural safeguards to protect your privacy. Even when allowed, uses and
disclosures are limited to the minimum amount reasonably necessary for the intended task.

Special Notes Regarding Disclosure

Special protections apply to information about certain medical conditions. For example, with
very few exceptions allowed by law, we won’t disclose any information regarding HIV or AIDS to
any party without your written permission. We won’t disclose mental health treatment records
to you without first receiving approval from your treating provider or another equally qualified
mental health professional. Also, we’re prohibited from using or disclosing genetic information
for underwriting purposes.

Except as provided in this notice, we won’t use or disclose your personal or medical information
without your written authorization. A form for this purpose is available on our website or by calling
Member Service. Specifically, we must have your written authorization to use or disclose your
information for:
• Marketing purposes;
• The sale of PHI;
• Most use and disclosures of psychotherapy notes.

You may revoke your authorization at any time. Your authorization must be in writing.
Your revocation won’t affect any action that we have already taken in reliance on your authorization.

Your Privacy Rights

You have the following rights with respect to your personal and medical information.
To exercise any of these rights, contact us using the information listed at the end of this notice.

• You have the right to receive information about privacy protections. Your member-education
materials include a notice of your rights, and you may request a paper copy of this notice at
any time.

• You have the right to inspect and get copies of information we collect about you.
We’ll provide access to this information within 30 days of receiving a written request. We may
charge a reasonable fee for copying and mailing records. You may also ask your providers for
access to your records.

• You have the right to receive an accounting of disclosures. Your request must be in writing.
Our response will exclude any disclosures made in support of treatment, payment, and health
care operations or that you authorized (among others). An example of a disclosure that would
be reported to you is a disclosure of your information in response to a subpoena.

• You have the right to ask us to correct or amend information you believe to be incorrect.
Your request to correct, amend, or delete information should be in writing. We’ll notify you if we
make an adjustment as a result of your request. If we don’t make an adjustment, we’ll send you
a letter explaining why within 30 days. In this case, you may ask us to make your request part of
your records, or ask the commissioner of insurance to review our decision. We may also provide
notice of your requested changes to others who received this information in the past two years.

• You have the right to designate someone to receive information and interact with us on
your behalf. Your personal representative has the same rights concerning your information as
you. Your designation and any subsequent revocation must be in writing, and a form for this
purpose is available on our website or by calling Member Service.

• You have the right to ask that we restrict or refuse to disclose personally identifiable
information, and that we direct communications to you by alternative means or to
alternative locations. While we may not always be able to agree, we’ll make reasonable efforts
to accommodate requests. Your request and any subsequent revocation must be in writing.

• If you believe your privacy rights have been violated, you have the right to complain to us,
using the standard grievance process outlined in your benefit materials, or to the secretary
of the U.S. Department of Health and Human Services, without fear of retaliation.

About This Notice

This notice is effective September 23, 2013. We’re required by law to provide this notice to you
and to abide by it while it is in effect. We reserve the right to change this notice. Any changes will
apply to all personal and medical information that we maintain, regardless of when it was created
or received. Before we make any material changes in our privacy practices, we’ll post a new notice
on our website. We’ll provide information about the changes to our privacy practices and how to
obtain a new notice in our next annual mailing to members who are then covered by one
of our health plans.

If you have any questions, contact Member Service. We’re here to help. Please call the Member
Service toll-free number on the front of your ID card or visit our website at bluecrossma.org.

® Registered Marks of the Blue Cross and Blue Shield Association.
© 2020 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

000401903 Y0014_18157_C 37-0830-21 (9/20)

04

Enrollment



Medicare HMO Blue SaverRx (HMO)
Medicare HMO Blue ValueRx (HMO)
Medicare HMO Blue FlexRx (HMO-POS)
Medicare HMO Blue PlusRx (HMO)

Who can use this form? What do I need to complete this form?

People with Medicare who want to join a • Your Medicare Number (the number on your
Medicare Advantage Plan red, white, and blue Medicare card)

To join a plan, you must: • Your permanent address and phone number
• Be a United States citizen or be lawfully Note: You must complete all items in Section 1. The items
in Section 2 are optional — you can’t be denied coverage
present in the U.S. because you don’t fill them out.
• Live in the plan’s service area
Reminders:
Important: To join a Medicare Advantage Plan,
you must also have both: • If you want to join a plan during fall open
enrollment (October 15–December 7), the
• Medicare Part A (Hospital Insurance) plan must get your completed form by
• Medicare Part B (Medical Insurance) December 7.

When do I use this form? • Your plan will send you a bill for the plan’s
premium. You can choose to sign up to
You can join a plan: have your premium payments deducted
• Between October 15–December 7 each year from your bank account or your monthly
Social Security (or Railroad Retirement
(for coverage starting January 1) Board) benefit.
• Within 3 months of first getting Medicare
• In certain situations where you’re allowed to

join or switch plans

Visit medicare.gov to learn more about when
you can sign up for a plan.

What happens next?

Send your completed and signed form to:
Blue Cross Blue Shield of Massachusetts
Enrollment Department
P.O. Box 55011
Boston, MA 02205
Once they process your request to join, they’ll contact you.

How do I get help with this form?

Call Medicare HMO Blue SaverRx/ValueRx/FlexRx/PlusRx at 1-800-200-4255. TTY users can call 711.

Or, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.

OMB No. 0938-1378 Expires: 7/31/2023 H2261_20100_C

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

Select the plan you want to join: Medicare HMO Medicare HMO Medicare HMO Medicare HMO
Blue SaverRx Blue ValueRx Blue FlexRx Blue PlusRx

Barnstable, Bristol, Essex, $0 per month $36 per month $96 per month $267 per month
Franklin, Hampden, Hampshire,
Middlesex, Norfolk, Plymouth,
Suffolk Counties

Worcester County $0 per month $56 per month $106 per month $267 per month
FIRST name: LAST name: Middle Initial:

Birth date: Sex: Phone number:
(MM/DD/YYYY) (__ __/__ __/__ __ __ __)
Optional: Email address: Male Female ( ) -
Permanent Residence street address (Don’t enter a PO Box):
City: Optional: County: State: ZIP Code:

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

Street address: City: State: ZIP Code:

Your Medicare information:

Medicare Number: ___ ___ ___ ___ — ___ ___ ___ — ___ ___ ___ ___

Answer these important questions:

Will you have other prescription drug coverage (like VA, TRICARE) in addition to
Medicare HMO Blue SaverRx/ValueRx/Flex Rx/PlusRx? Yes No

Name of other coverage: Member number for this Group number for this
coverage: coverage

IMPORTANT: Read and sign below:

• I must keep both Hospital (Part A) and Medical (Part B) to stay in Medicare HMO Blue SaverRx/ValueRx/Flex Rx/
PlusRx .

• By joining this Medicare Advantage Plan or Medicare Prescription Drug Plan, I acknowledge that Medicare
HMO Blue SaverRx/ValueRx/Flex Rx/PlusRx 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.

continued

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

• 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.

Signature: Today’s date:

If you’re the authorized representative, sign above and fill out these fields:
Name:

Address:

Phone number: Relationship to enrollee:

Section 2 – All fields in Section 2 are optional

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

Check here if you want us to send you information in a language other than English.
Language:_________________________

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

Large print: ________
If you need information in an accessible format other than what’s listed above please call us at 1-800-200-4255. Our
office hours are 8:00 a.m. to 8:00 p.m. Eastern Time, seven days a week, except April 1 through September 30 when
we are open Monday through Friday. TTY users can call 711.

Do you work? Yes No Does your spouse work? Yes No

List your Primary Care Physician (PCP), clinic, or health center:

Paying your plan premiums

You have a choice in how to pay your monthly plan premium (including any late enrollment penalty that you currently
have or may owe). Please select a premium payment option below:

Get a Bill Monthly

Electronic Funds Transfer (EFT) from your bank account each month. We will send you a brochure and form to
enroll. (Please pay your premium by mail until you receive notification that your EFT payment option is activated.)

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 Medicare HMO Blue SaverRx/ValueRx/Flex Rx/PlusRx
the Part D-IRMAA.s

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.

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 recently had a change in my Medicaid
(newly got Medicaid, had a change in level of Medicaid
I am enrolled in a Medicare Advantage plan and want assistance, or lost Medicaid) on (insert date):
to make a change during the Medicare Advantage Open ( __ __ /__ __ /__ __ __ __)
Enrollment Period (MA OEP). (M M/ D D/ Y Y Y Y)

I’m in a Medicare Advantage Plan and have had I recently had a change in my Extra Help paying for
Medicare for less than 3 months. I want to make Medicare prescription drug coverage (newly got Extra
a change. Help, had a change in the level of Extra Help, or lost
Extra Help) on (insert date):
I recently moved outside of the service area for my ( __ __ /__ __ /__ __ __ __)
current plan or I recently moved and this plan is a new (M M/ D D/ Y Y Y Y)
option for me. I moved on (insert date):
( __ __ /__ __ /__ __ __ __) I have both Medicare and Medicaid (or my state helps
(M M/ D D/ Y Y Y Y) pay for my Medicare premiums) or I get Extra Help
paying for my Medicare prescription drug coverage,
I recently was released from incarceration. I was but I haven’t had a change.
released on (insert date):
( __ __ /__ __ /__ __ __ __) I am moving into, live in, or recently moved out of a
(M M/ D D/ Y Y Y Y) Long-Term Care Facility (for example, a nursing home
or long term care facility). I moved/will move into/out of
I recently returned to the United States after living the facility on (insert date):
permanently outside of the U.S. I returned to the U.S. ( __ __ /__ __ /__ __ __ __)
on (insert date): (M M/ D D/ Y Y Y Y)
( __ __ /__ __ /__ __ __ __)
(M M/ D D/ Y Y Y Y)

I recently obtained lawful presence status in the United
States. I got this status on (insert date):
( __ __ /__ __ /__ __ __ __)
(M M/ D D/ Y Y Y Y)

continued

I recently left a PACE program on (insert date): I was enrolled in a Special Needs Plan (SNP) but
( __ __ /__ __ /__ __ __ __) I have lost the special needs qualification required to
(M M/ D D/ Y Y Y Y) be in that plan. I was disenrolled from the SNP on
(insert date):
I recently involuntarily lost my creditable prescription ( __ __ /__ __ /__ __ __ __)
drug coverage (coverage as good as Medicare’s). I lost (M M/ D D/ Y Y Y Y)
my drug coverage on (insert date):
( __ __ /__ __ /__ __ __ __) I was affected by an emergency or major disaster
(M M/ D D/ Y Y Y Y) (as declared by the Federal Emergency Management
Agency (FEMA) or by a Federal, state or local
I am leaving employer or union coverage on government entity. One of the other statements here
(insert date): applied to me, but I was unable to make my enrollment
( __ __ /__ __ /__ __ __ __) request because of the disaster
(M M/ D D/ Y Y Y Y)
I’m in a plan that was recently taken over by the
I belong to a pharmacy assistance program state because of financial issues. I want to switch to
provided by my state. another plan.

My plan is ending its contract with Medicare, or I’m in a plan that’s had a star rating of less than 3 stars
Medicare is ending its contract with my plan. for the last 3 years. I want to join a plan with a star
rating of 3 stars or higher.
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):
( __ __ /__ __ /__ __ __ __)
(M M/ D D/ Y Y Y Y)

If none of these statements applies to you or you’re not sure, please contact Medicare HMO Blue SaverRx/ValueRx/Flex
Rx/PlusRx at 1-800-200-4255 (TTY users should call 711) to see if you are eligible to enroll. We are open 8:00 a.m.
to 8:00 p.m. ET, Monday–Friday, from April 1 to September 30; and 8:00 a.m. to 8:00 p.m. ET, 7 days a week, from

October 1 to March 31.

Blue Cross Blue Shield of Massachusetts is an HMO and PPO plan with a Medicare contract.
Enrollment in Blue Cross Blue Shield of Massachusetts depends on contract renewal.

Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate
on the basis of race, color, national origin, age, disability, sex, sexual orientation or gender identity.

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 1-800-200-4255 (TTY: 711).

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis.
Ligue para 1-800-200-4255 (TTY: 711).

® Registered of the Blue Cross and Blue Shield Association.
© 2020 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

000406613 55-0169-21 (9/20)

Medicare HMO Blue SaverRx (HMO)
Medicare HMO Blue ValueRx (HMO)
Medicare HMO Blue FlexRx (HMO-POS)
Medicare HMO Blue PlusRx (HMO)

Who can use this form? What do I need to complete this form?

People with Medicare who want to join a • Your Medicare Number (the number on your
Medicare Advantage Plan red, white, and blue Medicare card)

To join a plan, you must: • Your permanent address and phone number
• Be a United States citizen or be lawfully Note: You must complete all items in Section 1. The items
in Section 2 are optional — you can’t be denied coverage
present in the U.S. because you don’t fill them out.
• Live in the plan’s service area
Reminders:
Important: To join a Medicare Advantage Plan,
you must also have both: • If you want to join a plan during fall open
enrollment (October 15–December 7), the
• Medicare Part A (Hospital Insurance) plan must get your completed form by
• Medicare Part B (Medical Insurance) December 7.

When do I use this form? • Your plan will send you a bill for the plan’s
premium. You can choose to sign up to
You can join a plan: have your premium payments deducted
• Between October 15–December 7 each year from your bank account or your monthly
Social Security (or Railroad Retirement
(for coverage starting January 1) Board) benefit.
• Within 3 months of first getting Medicare
• In certain situations where you’re allowed to

join or switch plans

Visit medicare.gov to learn more about when
you can sign up for a plan.

What happens next?

Send your completed and signed form to:
Blue Cross Blue Shield of Massachusetts
Enrollment Department
P.O. Box 55011
Boston, MA 02205
Once they process your request to join, they’ll contact you.

How do I get help with this form?

Call Medicare HMO Blue SaverRx/ValueRx/FlexRx/PlusRx at 1-800-200-4255. TTY users can call 711.

Or, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.

OMB No. 0938-1378 Expires: 7/31/2023 H2261_20100_C

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

Select the plan you want to join: Medicare HMO Medicare HMO Medicare HMO Medicare HMO
Blue SaverRx Blue ValueRx Blue FlexRx Blue PlusRx

Barnstable, Bristol, Essex, $0 per month $36 per month $96 per month $267 per month
Franklin, Hampden, Hampshire,
Middlesex, Norfolk, Plymouth,
Suffolk Counties

Worcester County $0 per month $56 per month $106 per month $267 per month
FIRST name: LAST name: Middle Initial:

Birth date: Sex: Phone number:
(MM/DD/YYYY) (__ __/__ __/__ __ __ __)
Optional: Email address: Male Female ( ) -
Permanent Residence street address (Don’t enter a PO Box):
City: Optional: County: State: ZIP Code:

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

Street address: City: State: ZIP Code:

Your Medicare information:

Medicare Number: ___ ___ ___ ___ — ___ ___ ___ — ___ ___ ___ ___

Answer these important questions:

Will you have other prescription drug coverage (like VA, TRICARE) in addition to
Medicare HMO Blue SaverRx/ValueRx/Flex Rx/PlusRx? Yes No

Name of other coverage: Member number for this Group number for this
coverage: coverage

IMPORTANT: Read and sign below:

• I must keep both Hospital (Part A) and Medical (Part B) to stay in Medicare HMO Blue SaverRx/ValueRx/Flex Rx/
PlusRx .

• By joining this Medicare Advantage Plan or Medicare Prescription Drug Plan, I acknowledge that Medicare
HMO Blue SaverRx/ValueRx/Flex Rx/PlusRx 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.

continued

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

• 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.

Signature: Today’s date:

If you’re the authorized representative, sign above and fill out these fields:
Name:

Address:

Phone number: Relationship to enrollee:

Section 2 – All fields in Section 2 are optional

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

Check here if you want us to send you information in a language other than English.
Language:_________________________

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

Large print: ________
If you need information in an accessible format other than what’s listed above please call us at 1-800-200-4255. Our
office hours are 8:00 a.m. to 8:00 p.m. Eastern Time, seven days a week, except April 1 through September 30 when
we are open Monday through Friday. TTY users can call 711.

Do you work? Yes No Does your spouse work? Yes No

List your Primary Care Physician (PCP), clinic, or health center:

Paying your plan premiums

You have a choice in how to pay your monthly plan premium (including any late enrollment penalty that you currently
have or may owe). Please select a premium payment option below:

Get a Bill Monthly

Electronic Funds Transfer (EFT) from your bank account each month. We will send you a brochure and form to
enroll. (Please pay your premium by mail until you receive notification that your EFT payment option is activated.)

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 Medicare HMO Blue SaverRx/ValueRx/Flex Rx/PlusRx
the Part D-IRMAA.s

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.

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 recently had a change in my Medicaid
(newly got Medicaid, had a change in level of Medicaid
I am enrolled in a Medicare Advantage plan and want assistance, or lost Medicaid) on (insert date):
to make a change during the Medicare Advantage Open ( __ __ /__ __ /__ __ __ __)
Enrollment Period (MA OEP). (M M/ D D/ Y Y Y Y)

I’m in a Medicare Advantage Plan and have had I recently had a change in my Extra Help paying for
Medicare for less than 3 months. I want to make Medicare prescription drug coverage (newly got Extra
a change. Help, had a change in the level of Extra Help, or lost
Extra Help) on (insert date):
I recently moved outside of the service area for my ( __ __ /__ __ /__ __ __ __)
current plan or I recently moved and this plan is a new (M M/ D D/ Y Y Y Y)
option for me. I moved on (insert date):
( __ __ /__ __ /__ __ __ __) I have both Medicare and Medicaid (or my state helps
(M M/ D D/ Y Y Y Y) pay for my Medicare premiums) or I get Extra Help
paying for my Medicare prescription drug coverage,
I recently was released from incarceration. I was but I haven’t had a change.
released on (insert date):
( __ __ /__ __ /__ __ __ __) I am moving into, live in, or recently moved out of a
(M M/ D D/ Y Y Y Y) Long-Term Care Facility (for example, a nursing home
or long term care facility). I moved/will move into/out of
I recently returned to the United States after living the facility on (insert date):
permanently outside of the U.S. I returned to the U.S. ( __ __ /__ __ /__ __ __ __)
on (insert date): (M M/ D D/ Y Y Y Y)
( __ __ /__ __ /__ __ __ __)
(M M/ D D/ Y Y Y Y)

I recently obtained lawful presence status in the United
States. I got this status on (insert date):
( __ __ /__ __ /__ __ __ __)
(M M/ D D/ Y Y Y Y)

continued

I recently left a PACE program on (insert date): I was enrolled in a Special Needs Plan (SNP) but
( __ __ /__ __ /__ __ __ __) I have lost the special needs qualification required to
(M M/ D D/ Y Y Y Y) be in that plan. I was disenrolled from the SNP on
(insert date):
I recently involuntarily lost my creditable prescription ( __ __ /__ __ /__ __ __ __)
drug coverage (coverage as good as Medicare’s). I lost (M M/ D D/ Y Y Y Y)
my drug coverage on (insert date):
( __ __ /__ __ /__ __ __ __) I was affected by an emergency or major disaster
(M M/ D D/ Y Y Y Y) (as declared by the Federal Emergency Management
Agency (FEMA) or by a Federal, state or local
I am leaving employer or union coverage on government entity. One of the other statements here
(insert date): applied to me, but I was unable to make my enrollment
( __ __ /__ __ /__ __ __ __) request because of the disaster
(M M/ D D/ Y Y Y Y)
I’m in a plan that was recently taken over by the
I belong to a pharmacy assistance program state because of financial issues. I want to switch to
provided by my state. another plan.

My plan is ending its contract with Medicare, or I’m in a plan that’s had a star rating of less than 3 stars
Medicare is ending its contract with my plan. for the last 3 years. I want to join a plan with a star
rating of 3 stars or higher.
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):
( __ __ /__ __ /__ __ __ __)
(M M/ D D/ Y Y Y Y)

If none of these statements applies to you or you’re not sure, please contact Medicare HMO Blue SaverRx/ValueRx/Flex
Rx/PlusRx at 1-800-200-4255 (TTY users should call 711) to see if you are eligible to enroll. We are open 8:00 a.m.
to 8:00 p.m. ET, Monday–Friday, from April 1 to September 30; and 8:00 a.m. to 8:00 p.m. ET, 7 days a week, from

October 1 to March 31.

Blue Cross Blue Shield of Massachusetts is an HMO and PPO plan with a Medicare contract.
Enrollment in Blue Cross Blue Shield of Massachusetts depends on contract renewal.

Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate
on the basis of race, color, national origin, age, disability, sex, sexual orientation or gender identity.

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 1-800-200-4255 (TTY: 711).

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis.
Ligue para 1-800-200-4255 (TTY: 711).

® Registered of the Blue Cross and Blue Shield Association.
© 2020 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

000406613 55-0169-21 (9/20)



FOR MORE INFORMATION, OR TO ENROLL:

Medicare Plan Sales: 1-800-678-2265 (TTY: 711)
October 1 through March 31, 8:00 a.m. - 8:00 p.m. ET, seven days a week
April 1 through September 30, 8:00 a.m. - 8:00 p.m. ET, Monday through Friday

bluecrossma.com/Medicare

Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws
and does not discriminate on the basis of race, color, national origin, age,
disability, sex, sexual orientation, or gender identity.

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 1-800-678-2265 (TTY: 711).

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis.
Ligue para 1-800-678-2265 (TTY: 711).

000391520 ® Registered Marks of the Blue Cross and Blue Shield Association.
© 2020 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross

and Blue Shield of Massachusetts HMO Blue, Inc.

55-2274-21(0(79//0210/)21)