H1350-025 2023 True Blue Special Needs Plan (HMO D-SNP) Enrollment Form
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H1350-025
2023 True Blue Special Needs Plan
(HMO D-SNP) Enrollment Form
✂ Fold and tear along dotted line to detach pages for mailing ✂
Who can use this form? Reminders:
People with Medicare and Enhanced Medicaid who • This is a dual-eligible special needs plan (D-SNP).
want to join a Medicare-Medicaid Special Needs Your ability to enroll will be based on verification
Plan that includes prescription drug coverage. that you are entitled to both Medicare and
Enhanced Medicaid.
To join a D-SNP plan, you must:
• Be at least 21 years of age What happens next?
• Live in our service area Send your completed and signed form to:
• Be entitled to Medicare Part A Blue Cross of Idaho Care Plus, Inc.
• Be enrolled in Medicare Part B P.O. Box 8406
• Be on Enhanced Medicaid Boise, ID 83707-2406
• Be a United States citizen or be lawfully present Or enroll online at
in the U.S.
bcidaho.com/idahotruebluesnp.
When do I use this form? Once we process your request to join,
You can join a D-SNP plan any time of the year. we’ll contact you.
Effective dates for coverage begin the 1st day of How do I get help with this form?
the following month.
Call Blue Cross of Idaho Care Plus, Inc. at
What do I need to complete this form? 1-888-495-2583. TTY users can call 711.
• Your Medicare ID number (the number on your Or call Medicare at 1-800-MEDICARE
red, white and blue Medicare card) (1-800-633-4227). TTY users can call
1-877-486-2048, 24 hours a day, seven days a week.
• Your Idaho Medicaid ID number (the number on
your Idaho Medicaid card) En español: Llame a Blue Cross of Idaho Care Plus,
Inc. al 1-888-495-2583 (TTY: 711) o a Medicare
• Your permanent residence address and
gratis al 1-800-633-4227 y oprima el 2 para
phone number
asistencia en español y un representante estará
Note: You must complete all items in Section 1. disponible para asistirle.
The items in Section 2 are optional – you can’t be
denied coverage because you don’t fill them out. Individuals experiencing homelessness
If you want to join a plan but have no permanent
residence, a Post Office Box, an address of
a shelter or clinic, or the address where you
receive mail (e.g., social security checks) may be
considered your permanent residence address.
We are available seven days a week from 8 a.m. to 8 p.m., October 1 to March 31.
Our hours of operation for the rest of the year are Monday through Friday from 8 a.m. to 8 p.m.
Form No. 22-1024 (09-22) 1CONFIRM THE PLAN YOU ARE APPLYING FOR BY CHECKING THE BOX BELOW
o True Blue Special Needs Plan (HMO D-SNP)
H1350-025
Section 1 – All fields in this section are required
(unless marked optional)
PLEASE PROVIDE YOUR INFORMATION:
First Name Last Name Middle Initial
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Birth Date (mm/dd/yyyy) Gender: Phone Alternate Phone
o Male o Female ( ) ( )
Email Address* County
Permanent Residence Street Address (P.O. Box not City State Zip Code
allowed)
Mailing Address (only if different from above) City State Zip Code
*OPTIONAL: By providing us with your email address you are agreeing to receive communications
regarding your plan benefits and well-being. You can opt out at any time.
PLEASE PROVIDE YOUR MEDICARE AND MEDICAID INSURANCE INFORMATION:
Medicare ID Number: _________________________ MID Number: _____________________________
You must use Medicare Beneficiary Identifier, or MBI.
Name (as it appears on your Medicaid ID card):
Name (as it appears on your Medicare ID card): _____________________________________________
_____________________________________________
MEDICARE HEALTH INSURANCE I D A H O D E P A R T M E N T O F
Name/Nombre
JAMIE SAMPLE
Medicare Number/Número de Medicare
Idaho Health Plan
1EG4-TE5-MK72
Entitled to/Con derecho a Coverage starts/Cobertura empieza
HOSPITAL (PART A) 01-01-2020 Member First/Last Name
MEDICAL (PART B) 01-01-2020 MID 0001234567 0001
Will you have other prescription drug coverage (like VA, TRICARE) in addition to
Blue Cross of Idaho Care Plus, Inc.? o Yes o No
Name of other coverage: Member number for this coverage: Group number for this coverage:
___________________________ ____________________________ ____________________________
2 Form No. 22-1024 (09-22)PLEASE READ AND ANSWER THESE IMPORTANT QUESTIONS:
Typically, you may enroll in a Medicare Advantage plan only during the annual enrollment period from
October 15 through December 7 of each year. There are exceptions that may allow you to enroll in a
Medicare Advantage plan outside of this period.
Please read the following statements carefully and check the box if the statement applies to you. By
checking any of the following boxes you are certifying that, to the best of your knowledge, you are eligible
for an Enrollment Period. If we later determine that this information is incorrect, you may be disenrolled.
o I am enrolling during the Annual Enrollment Period (AEP) October 15-December 7
o I am new to Medicare.
o I am enrolled in a Medicare Advantage plan and want to make a change during the Medicare Advantage
Open Enrollment Period (MA OEP).
o I am in a Medicare Advantage Plan and have had Medicare for less than 3 months. I want to make a change.
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o I recently moved outside of the service area for my current plan or I recently moved and this plan is a
new option for me. I moved or will move on _________________.
o I recently was released from incarceration. I was or will be released on _________________.
o I recently returned to the United States after living permanently outside of the U.S. I moved or will move
back to the U.S. on _________________.
o I recently obtained lawful presence status in the United States. I got or will get this status on __________.
o I recently had a change in my Medicaid (newly got Medicaid, had a change in level of Medicaid
assistance, or lost Medicaid). This change happened on _________________.
o I recently had a change in my Extra Help paying for Medicare prescription drug coverage (newly got
Extra Help, had a change in the level of Extra Help, or lost Extra Help). This change happened on
_________________.
o I have both Medicare and Medicaid (or my state helps pay for my Medicare premiums) or I get Extra
Help paying for my Medicare prescription drug coverage, but I haven’t had a change.
o I’m in a State Pharmaceutical Assistance Program, or I’m losing help from a State Pharmaceutical
Assistance Program.
o I recently moved out of a long-term care facility (for example, a nursing home or a rehabilitation
hospital). I moved on _________________.
o I live in a long term care facility (for example, a nursing home or rehabilitation hospital).
o I am new to Medicare, and I was notified about getting Medicare after my Part A and/or Part B coverage
started. I was notified of getting Medicare on ________________.
o I have had Medicare prior to now, but I am now turning 65.
o I left coverage from my employer or union (including COBRA coverage). I left or will leave on _________.
o I lost other, non-Medicare prescription drug coverage that’s as good as Medicare prescription drug
coverage (creditable coverage), or my other, non-Medicare prescription drug coverage changed and is
no longer considered creditable. This happened on _______________.
o I already have Hospital (Part A) and recently signed up for Medical (Part B). I want to join a Medicare
Advantage Plan.
o I lost my Special Needs Plan because I no longer have a condition required for that plan. This change
happened on _______________.
Continued on next page
Form No. 22-1024 (09-22) 3PLEASE READ AND ANSWER THESE IMPORTANT QUESTIONS:
Continued from previous page
o I want to join a Special Needs Plan that tailors its benefits to my chronic condition.
o I lost my coverage because Medicare ended its contract with my plan. I received a letter from Medicare
saying I can join another plan. My plan ended on or will end on ________________.
o I lost my coverage because my plan no longer covers the area that I live or it ended its contract with
Medicare.
o I recently left a PACE (Programs of All-Inclusive Care for the Elderly) program. I dropped my coverage on
________________.
o I was enrolled in a plan by Medicare (or my state) and I want to choose a different plan. That plan started
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on ________________.
o I am in a plan that has had a star rating of less than 3 stars for the last 3 years. I want to join a plan with a
star rating of 3 stars or higher.
o I am in a plan that was recently taken over by the state because of financial issues. I want to switch to
another plan.
o I was affected by an emergency or a major disaster (as declared by the Federal Emergency Management
Agency, or by Federal, my state, or my local government). One of the other statements on this page
applied to me, but I was unable to make my request because of the disaster.
o I requested plan materials in an accessible format and was not given equal time to make an
enrollment decision.
o Other ____________________________________________________________________________________.
4 Form No. 22-1024 (09-22)Section 2 – All fields on this page are optional
Are you Hispanic, Latino/a, or Spanish origin? Select all that apply.
¨ No, not of Hispanic, Latino/a or Spanish origin ¨ Yes, Cuban
¨ Yes, Mexican, Mexican American, Chicano/a ¨ Yes, another Hispanic, Latino/a or Spanish origin
¨ Yes, Puerto Rican ¨ I choose not to answer
What’s your race? Select all that apply.
¨ American Indian or Alaska Native ¨ Guamanian or Chamorro ¨ Other Pacific Islander
¨ Asian Indian ¨ Japanese ¨ Samoan
¨ Black or African American ¨ Korean ¨ Vietnamese
¨ Chinese ¨ Native Hawaiian ¨ White
¨ Filipino ¨ Other Asian ¨ I choose not to answer
✂ Fold and tear along dotted line to detach pages for mailing ✂
Please check one of the boxes below if you would prefer us to send you information in a language other
than English or in an accessible format
o Spanish o Accessible formats (audio, Braille or large print):
Please contact customer service at 1-888-495-2583 (TTY 711). If you need information in an accessible
format or language other than what is listed above.
Do you or your spouse work? o Yes o No
PLEASE CHOOSE A PRIMARY CARE PROVIDER:
Please choose a primary care provider (PCP) from the True Blue Special Needs Plan (HMO D-SNP)
Provider Network. Please enter the PCP ID number exactly as it appears on the website or in the Provider
Directory. It will be five to eight digits (examples: BB123, 12345678).
Please visit bcidaho.com/FindSNPDoctors for a list of participating network providers.
Name of primary care provider (PCP):__________________________________________
PCP ID Number:____________________ Are you an existing patient? o Yes o No
If you do not specify a PCP one will be assigned for you.
Form No. 22-1024 (09-22) 5IMPORTANT – READ AND SIGN BELOW:
• I must keep both Hospital (Part A) and Medical (Part B) to stay in Blue Cross of Idaho Care Plus, Inc.
• By joining this Medicare Advantage Plan, I acknowledge that Blue Cross of Idaho Care Plus, Inc. will
share my information with Medicare, who may use it to track my enrollment, to make payments, and
for other purposes allowed by Federal law that authorize the collection of this information (see Privacy
Act Statement below). Your response to this form is voluntary. However, failure to respond may affect
enrollment in the plan.
• I understand that I can be enrolled in only one MA plan at a time - and that enrollment in this plan will
automatically end my enrollment in another MA plan (exceptions apply for MA PFFS, MA MSA plans).
• I understand that beginning on the date True Blue Special Needs Plan coverage begins, I must get all of
my healthcare from True Blue Special Needs Plan, except for emergency or urgently needed services, out-
of-area dialysis services and during the first 90 days I am enrolled in the plan. During the first 90 days on
the plan, I can continue receiving services from my current providers for services I already have in place,
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even if they are not in the True Blue Special Needs Plan provider network. My provider will need to join the
plan’s provider network if I wish to continue receiving covered services from them after 90 days. Services
authorized by True Blue Special Needs Plan and other services contained in my True Blue Special Needs
Plan Evidence of Coverage document (also known as a member contract or subscriber agreement) will be
covered. Without authorization, NEITHER MEDICARE, MEDICAID nor True Blue Special Needs Plan WILL
PAY FOR THE SERVICES.
• The information on this enrollment form is correct to the best of my knowledge. I understand that if I
intentionally provide false information on this form, I will be disenrolled from the plan.
• I understand that my signature (or the signature of the person legally authorized to act on my behalf) on
this application means that I have read and understand the contents of this application. If signed by an
authorized representative (as described above), this signature certifies that:
1. This person is authorized under state law to complete this enrollment.
2. Documentation of this authority is available upon request by Medicare.
Signature:________________________________________ Today’s Date: ____________
Relationship to beneficiary: o Self o Authorized Representative o Other
If you’re the authorized representative, sign above and fill out these fields.
If applicable, please attach a power of attorney form.
Name:________________________________ Relationship to Enrollee: ___________________________
Address:______________________________ City, State, Zip Code:______________________________
Phone Number: (_____)_________________
FOR OFFICE OR AGENT USE ONLY:
Name of agent/broker (if assisted in enrollment):___________________ Broker ID: _______________
Date Enrollment Form taken by agent: _________
Plan ID Number:______________________________
Broker email:_____________________________________________________
6 Form No. 22-1024 (09-22)PRIVACY ACT STATEMENT
The Centers for Medicare & Medicaid Services (CMS) collects information from Medicare plans to track beneficiary
enrollment in Medicare Advantage (MA) Plans, improve care, and for the payment of Medicare benefits. Sections
1851 and 1860D-1 of the Social Security Act and 42 CFR §§ 422.50 and 422.60 authorize the collection of this
information. CMS may use, disclose and exchange enrollment data from Medicare beneficiaries as specified in the
System of Records Notice (SORN) “Medicare Advantage Prescription Drug (MARx)”, System No. 09-70-0588. Your
response to this form is voluntary. However, failure to respond may affect enrollment in the plan.
✂ Fold and tear along dotted line to detach pages for mailing ✂
©2022 Blue Cross of Idaho Care Plus, Inc. (“Blue Cross of Idaho Care Plus”), an Independent Licensee of the
Blue Cross Blue Shield Association, with services provided by Blue Cross of Idaho Health Service, Inc.
Form No. 22-1024 (09-22) 7English: We have free interpreter services to answer any questions you may have about our health or drug plan.
To get an interpreter, just call us at 1-800-627-1188 (TTY: 711). Someone who speaks English can help you. This is a
free service.
Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener
sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al 1-800-627-1188
(TTY: 711). Alguien que hable español le podrá ayudar. Este es un servicio gratuito.
Chinese Mandarin: 我们提供免费的翻译服务，帮助 Italian: È disponibile un servizio di interpretariato
您解答关于健康或药物保险的任何疑 问。如果您需要 gratuito per rispondere a eventuali domande
此翻译服务，请致电 1-800-627-1188 (TTY: 711)。我 sul nostro piano sanitario e farmaceutico. Per un
们的中文工作人员很乐意帮助您。这是一项免费服务。 interprete, contattare il numero 1-800-627-1188
(TTY: 711). Un nostro incaricato che parla Italianovi
Chinese Cantonese: 您對我們的健康或藥物保險可能 fornirà l’assistenza necessaria. È un servizio gratuito.
存有疑問，請此我們提供免費的翻譯 服務。如需翻譯 Portuguese: Dispomos de serviços de interpretação
服務，請致電 1-800-627-1188 (TTY: 711)。我們講中 gratuitos para responder a qualquer questão que
文的人員將樂意為您提供幫助。這 是一項免費服務。 tenha acerca do nosso plano de saúde ou de
Tagalog: Mayroon kaming libreng serbisyo sa medicação. Para obter um intérprete, contacte-nos
pagsasaling-wika upang masagot ang anumang através do número 1-800-627-1188 (TTY: 711). Irá
mga katanungan ninyo hinggil sa aming planong encontrar alguém que fale o idioma Português para o
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pangkalusugan o panggamot. Upang makakuha ng ajudar. Este serviço é gratuito.
tagasaling-wika, tawagan lamang kami sa 1-800-627- French Creole: Nou genyen sèvis entèprèt gratis
1188 (TTY: 711). Maaari kayong tulungan ng isang pou reponn tout kesyon ou ta genyen konsènan plan
nakakapagsalita ng Tagalog. Ito ay libreng serbisyo.
medikal oswa dwòg nou an. Pou jwenn yon entèprèt,
French: Nous proposons des services gratuits jis rele nou nan 1-800-627-1188 (TTY: 711). Yon moun
d’interprétation pour répondre à toutes vos ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis.
questions relatives à notre régime de santé ou
d’assurance-médicaments. Pour accéder au service Polish: Umożliwiamy bezpłatne skorzystanie z
d’interprétation, il vous suffit de nous appeler au usług tłumacza ustnego, który pomoże w uzyskaniu
1-800-627-1188 (TTY: 711). Un interlocuteur parlant odpowiedzi na temat planu zdrowotnego lub
Français pourra vous aider. Ce service est gratuit. dawkowania leków. Aby skorzystać z pomocy tłumacza
Vietnamese: Chúng tôi có dịch vụ thông dịch miễn znającego język polski, należy zadzwonić pod numer
phí để trả lời các câu hỏi về chương sức khỏe và 1-800-627-1188 (TTY: 711). Ta usługa jest bezpłatna.
chương trình thuốc men. Nếu quí vị cần thông dịch Japanese: 当社の健康 健康保険と薬品 処方薬
viên xin gọi 1-800-627-1188 (TTY: 711) sẽ có nhân viên
nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí . ランに関するご質問にお答えするため に、無料
の通訳サービスがありますございます。通訳
German: Unser kostenloser Dolmetscherservice ご用命になるには、
beantwortet Ihren Fragen zu unserem Gesundheits- 1-800-627-1188 (TTY: 711)
und Arzneimittelplan. Unsere Dolmetscher erreichen にお電話ください。日本語を話す人 者 が支援
Sie unter 1-800-627-1188 (TTY: 711). Man wird Ihnen
dort auf Deutsch weiterhelfen. Dieser Service ist たします。これは無料のサー ビスです。
kostenlos. Bantu: ICITONDERWA: Nimba uvuga Ikirundi,
Korean: 당사는 의료 보험 또는 약품 보험에 관한 uzohabwa serivisi zo gufasha mu ndimi, ku
질문에 답해 드리고자 무료 통역 서비스를 제공하고 buntu. Woterefona 1-800-627-1188
있습니다. 통역 서비스를 이용하려면 전화 1-800-627- (TTY: 711).
1188 (TTY: 711) 번으로 문의해 주십시오. 한국어를
하는 담당자가 도와 드릴 것입니다. 이 서비스는 Farsi: هجوت: دینک یم وگتفگ یسراف نابز هب رگا،
무료로 운영됩니다. یم مهارف امش یارب ناگیار تروصب ینابز تالیهست
Russian: Если у вас возникнут вопросы دشاب. اب1-800-627-1188 (TTY: 711) دیریگب سامت.
относительно страхового или медикаментного
плана, вы можете воспользоваться нашими Nepali: ध्यान दिनुहोस्: तपार्इंले नेपाली बोल्नुहुन्छ
бесплатными услугами переводчиков. Чтобы भने तपार्इंको निम्ति भाषा सहायता सेवाहरू निःशुल्क
воспользоваться услугами переводчика,
позвоните нам по телефону 1-800-627-1188 (TTY: रूपमा उपलब्ध छ । फोन गर्नुहोस् 1-800-627-1188
711). Вам окажет помощь сотрудник, который (टिटिवाइ: 711) ।
говорит по-pусски. Данная услуга бесплатная.
Romanian: ATENȚIE: Dacă vorbiți limba română,
vă stau la dispoziție servicii de asistență lingvistică,
gratuit. Sunați la 1-800-627-1188 (TTY: 711).
Serbo-Croatian: OBAVJEŠTENJE: Ako govorite
srpsko-hrvatski, usluge jezičke pomoći dostupne
Hindi: हमारे स्वास्थ्य या दवा की योजना के बारे में आपके su vam besplatno. Nazovite 1-800-627-1188
किसी भी प्रश्न के जवाब देने के लिए हमारे पास मुफ्त दुभाषिया (TTY: Telefon za osobe sa oštećenim govorom ili
सेवाएँ उपलब्ध हैं. एक दुभाषिया प्राप्त करने के लिए, बस हमें sluhom: 711).
1-800-627-1188 (TTY: 711). पर फोन करें. कोई व्यक्ति जो
हिन्दी बोलता है आपकी मदद कर सकता है. यह एक मुफ्त सेवा है. Form No. 16-1080 (08-22)
8 Form No. 22-1024 (09-22) H1350_025_MK23215_CYou can also read
