Application Received Date

00/00/000

Mr. Mrs Ms.______, I have a brief statement required by Medicare. You are not required to

Provide any health related information; unless used to determine enrollment eligibility. Our

Conversation during this call will be recorded and this call will complete an enrollment eligibility.

Our request. Do you understand and agree?

  • Yes/No

Am I speaking to the individual who wants to enroll?

  • Yes/No

We will now begin the enrollment. May I have your name as it appears on your Medicare card?

  • First name?

  • Middle initial?

  • Last name?

Title? Ex. (Mr. Mrs. Ms.)

May I have your home telephone number? May I have an alternate phone number if available?

( Social Security number, optional)

Is your home phone a cell phone? If “yes”,  Clover Health may, from time to time, want to send recorded and electronic healthcare messages to you. You may withdraw your permission at any time by calling the Member Services number located on the back of your ID card. Do you consent to receive recorded and electronic messages from Clover Health?

What is your birthdate?  00/00/0000

Sex? Female/Male

Do you have an email address you would like to provide? (Optional*)

  • Yes/No

May I have your permanent residence address? (P.O. BOXES are not permitted to be entered here. Must be a physical street address)

Street Address        City

Address 2            State

Zip                         County

Is this the same as your mailing address?

  • Yes/No

Who would be your Emergency Contact? What is their phone number and relationship to you?

Emergency Contact          Phone Number                Relationship to you           E-Mail address

               Section: 2. Medicare Information

In order to complete this application, I need to verify the information listed on your Medicare Card.

  • Name

  • Medicare Number

We have your Medicare Number as (applicant). Is this correct?

  • Yes/No

*Is Entitled to*

  • Hospital (Part A) – Effective Date

  • Medical (Part B) – Effective Date

  • Medicare (Part D) – Effective Date

Note to agent: Either verify information, or “Please read your Medicare insurance card information to me”.

You are enrolling in [ Plan Name] with [Premium]

Is this a plan change?

  • Yes/No

Section: 4. Select a Primary Care Physician (PCP)

Search Group Name

Please enter the Physician name without any special characters or numbers

  • PCP First Name
  • PCP Last Name
  • PCP Phone

Section 5: Paying your Plan Premium/Late Enrollment Penalty

Note to agent: Read the following if beneficiary has a premium or owes a late enrollment penalty.

If we determine that you owe a late enrollment penalty (or if you currently have a late enrollment penalty), we need to know how you would prefer to pay it. You can pay by mail (check) each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month.

Note to agent: Read the following if beneficiary does NOT have LIS

If you are assessed a Part D-Income related Monthly Adjustment Amount, you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either need to have the amount withheld from your Social Security benefit check or be billed directly by Medicare or the RRB. DO NOT pay Gateway Health the Part D-IRMAA.

People with limited incomes may qualify for extra help to pay for their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including those who qualify will not be subject to the coverage gap or late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this extra help, contact your local Social Security office, or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for extra help online at www.socialsecurity.gov/prescriptionhelp.

If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay for all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn’t cover. If you don’t select a payment option, you will bill each month.

                              Paying Plan Premium

Please select a premium payment option

  • Get a bill
  • Automatic deduction from your monthly Social Security Or RRB benefit check.
  • No premium

Section: 6 Other Health Insurance Information

Some individuals may have other drug coverage, including other private insurance, TRICARE, federal employee health benefits coverage, VA benefits, or state pharmaceutical assistance programs.

Will you have other PRESCRIPITION drug coverage in addition to Clover Health?

  • Yes/No

Are you receiving group health insurance through you or your spouse’s employer?

  • Yes/No

Are you currently enrolled in your State Medicaid program?

  • Yes/No

Section: 7 Important Questions

Do you have End Stage Renal Disease?

  • Yes/No

ESD is permanent kidney failure and requires regular kidney dialysis or a transplant to stay alive.

Note: If you have ESRD, you cannot enroll in this plan.

If you have had a successful kidney transplant and/or you don’t need regular dialysis any more, we may contact you to provide a note or records from your doctor showing you have has a successful kidney transplant or you don’t need dialysis.

Have you ever received a Medicare covered transplant?

  • Yes/No

Are you a resident in a long-term care facility, such as a nursing home?

  • Yes/No

Do you or your spouse work?

  • Yes/No

Section: 8 Information to Determine Your Enrollment Period

  • I am making my annual enrollment period election (October 15- December 7).
  • I am new to Medicare.
  • 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 recently returned to the United States after living permanently outside of the U.S.
  • I have both Medicare and Medicaid, or my state helps pay for my Medicare premiums.
  • I get extra help paying for Medicare prescription drug coverage.
  • I no longer qualify for extra help paying for my Medicare prescription drugs.
  • 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).
  • In the last 12 months, I left a Medigap to join a Medicare Advantage Plan* for the first time (*Medicare Advantage plan with prescription drug coverage)
  • I recently left a PACE program.
  • I recently involuntarily lost my creditable prescription drug coverage (coverage as good as Medicare’s)
  • My plan is ending its contract with Medicare
  • My plan is ending its contract with Medicare, or Medicare is ending its contract with my plan
  • I am enrolling with an eligible chronic condition
  • This is my first time for Part B Entitlement
  • I have been on Medicare but just turned 65 or will be turning 65 in the next 3 months
  • I am within the 4th to 7th month of my initial election period

You are enrolling for the effective date of:

00/00/000

Continue to next page

Section: 9 Alternative Format Options

Would prefer us to send you information in a language other than English?

  • Large Print

  • Braille

  • Spanish

  • Other

Do you have any questions about the information I just read to you?

  • Yes/No

By completing this enrollment application, you are agreeing to the following:

  1. Clover _  is a Medicare Advantage plan and has a contract with the Federal government. I will need to keep my Medicare Parts A and B. I can be in only one Medicare Advantage plan at a time, and I understand that my enrollment in this plan will automatically end my enrollment in another Medicare health plan or prescription drug plan.
  2. It is my responsibility to inform you of any prescription drug coverage that I have or may get in the future.
  3. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes only at certain times of the year when an enrollment period is available (Example: October 15- December 7 of every year), or under certain special circumstances.
  4. Clover             Serves a specific service area. If I move out of the area that serves, I need to notify the plan so I can disenroll and find a new plan in my new area.
  5. Once I am a member of Clover, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from Clover when I get it to know which rules I must follow to get coverage with this Medicare Advantage plan.
  6. I understand that people with Medicare aren’t usually covered under Medicare while out of the country except for limited coverage near the U.S. border.
  7. I understand that beginning on the date Clover coverage begins, I must get all of my health care from Clover, except for emergency or urgent needed services or out-of area dialysis services.
  8. Services authorized by Clover and other services contained in my Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR GATEWAY HEALTH WILL PAY FOR THE SERVICES.
  9. I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or contracted with Clover, he/she may be paid based on my enrollment.
  10. Release of Information: By joining this Medicare health plan, I acknowledge that Clover will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that Clover will release my information including my prescription drug event data to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations.
  11. 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.
  12. I understand that my signature (or the signature of the person authorized to act on my behalf under the laws of the State where I live) on this applicant means that I have read and understand the contents of this application.

Do you understand and agree to these statements?

  • Yes/No

I will sign this electronic application with your name and will sign my name as the sales agent assisting you.

Type Name of Prospective Member

Type Name of Prospective Member

Type Name of Sales Agent

Sales agent Writing Number

DSNP Only Closing

You must have both Medicare and Medicaid in order to be eligible for [plan name]. If you lose your eligibility, you will be disenrolled after 90 days. Once you are a member, you will want to show both your CLOVER card and you Medicaid card when visiting a provider or the pharmacy.

Read for all plans

Please do not use you CLOVER card for medical or prescription coverage until after your effective date. You will receive a Verification Letter, and a Welcome Call or Welcome Letter.

You will receive a confirmation letter. You may use the confirmation letter as proof of your coverage until you receive your ID card.

(If beneficiary is currently on supplement or Medicare Advantage plan): Do not disenroll from your current plan until you receive your confirmation letter from CLOVER

If you have any questions, you may call (888-657-1207).

Note to agent: From October 1st through February 14th say: “Our business hours are 8 a.m.-8 p.m., 7 days a week” From February 15th through September 30th say: “Our business hours are 8 a.m.- 8 p.m., Monday through Friday”

Submit Application Below and provide Confirmation Code to Enrollee