Use this form if you live in one of the following counties
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Use this form if you live in one of the following counties:
Bannock, Bingham, Blaine, Bonneville, Cassia, Fremont, Gooding,
Jefferson, Jerome, Lincoln, Madison, Minidoka, Power, Twin Falls
2022 True Blue® (HMO) Enrollment Form
South Central Idaho, Eastern Idaho
Who can use this form? • Your plan will send you a bill for the plan’s
People with Medicare who want to join a premium–you can choose to sign up to have
Medicare Advantage Plan or Medicare Prescription your premium payments deducted from your
Drug Plan. bank account or your monthly Social Security (or
Railroad Retirement Board) benefit.
To join a plan, you must:
What happens next?
• Be a United States citizen or be lawfully present
in the U.S. Send your completed and signed form to:
• Live in the plan’s service area Blue Cross of Idaho Care Plus, Inc.
Important: To join a Medicare Advantage Plan, P.O. Box 8406
you must also have both: Boise, ID 83707-2406
• Medicare Part A (Hospital Insurance) Or enroll online at medicare.bcidaho.com.
• Medicare Part B (Medical Insurance)
Once they process your request to join, they’ll
When do I use this form? contact you.
You can join a plan: How do I get help with this form?
• Between October 15 – December 7 each year Call Blue Cross of Idaho Care Plus, Inc. at
(for coverage starting January 1) 1-888-494-2583. TTY users can call 711.
• Within three months of first getting Medicare
We are available seven days a week from 8 a.m.
• In certain situations where you’re allowed to join to 8 p.m., October 1 to March 31. Our hours of
or switch plans operation for the rest of the year are Monday
Visit Medicare.gov to learn more about when you through Friday from 8 a.m. to 8 p.m.
can sign up for a plan.
Or call Medicare at 1-800-MEDICARE
What do I need to complete this form? (1-800-633-4227). TTY users can call
1-877-486-2048.
• Your Medicare ID number (the number on your
red, white and blue Medicare card) Llame a Blue Cross of Idaho Care Plus, Inc. al
1-888-494-2583 (TTY: 711). Estamos disponibles
• Your permanent address and phone number para atenderlo de 8 a.m. a 8 p.m., los siete días a
Note: You must complete all items in Section 1. la semana, desde el 1 de octubre hasta el 31 de
The items in Section 2 are optional – you can’t be marzo. Entre el 1 de abril y el 30 de septiembre,
denied coverage because you don’t fill them out. abrimos de lunes a viernes de 8 a.m. a 8 p.m
O llame a Medicare gratis al 1-800-633-4227
Reminders:
(TTY: 1-877-486-2048) y oprima el 2 para asistencia
• If you want to join a plan during fall Annual en español y un representante estará disponible
Enrollment Period (October 15 – December para asistirle.
7), the plan must get your completed form by
December 7 1
Powered by Blue Cross of Idaho Care Plus, Inc. | Form No. 16-591 (09-21)PLEASE CHECK WHICH PLAN YOU WANT TO ENROLL IN:
Available in Bannock, Bingham, Bonneville, Cassia, Fremont, Gooding, Jefferson, Jerome, Madison, Minidoka,
Power and Twin Falls counties:
o True Blue Rx (HMO) $89 o True Blue Rx Option I (HMO) $169
o True Blue Rx Essentials (HMO) $0 o True Blue Rx Option II (HMO) $110
($30 Part B buy-down reduction) o True Blue Valor (HMO) $30
o True Blue Rx Gem (HMO) $19
Available in Bannock, Bingham, Bonneville and Jefferson counties:
o True Blue Rx Preferred (HMO) $0
Available in Blaine, Gooding, Jerome, Lincoln and Twin Falls counties:
o True Blue Rx | St. Luke’s Health Partners (HMO) $0
OPTIONAL SUPPLEMENTAL COVERAGE:
¨ True Dental: (available for True Blue Rx Option I or ¨ True Dental Enhanced: (available for
True Blue Rx Option II) Preventive and basic dental True Blue Rx) Additional comprehensive dental
coverage for $23.70 per month. Preventive dental including basic and major coverage for $27.60 per
services have no waiting period; basic dental month. Comprehensive dental services have a six-
services have a six-month waiting period without month waiting period without evidence of existing
evidence of existing continuous coverage*. continuous coverage*.
¨ True Trio (available for True Blue Rx Essentials): add a supplemental bundle for $30.90 per month
• TRUE DENTAL ENHANCED: • VSP® VISION SERVICES: • TRUHEARING®:
Comprehensive dental coverage– Comprehensive eye exam Routine hearing exam and
diagnostic dental services have no and coverage for lenses low copay hearing aids
waiting period, comprehensive dental and frames or contacts
services have a six-month waiting
period without evidence of existing
continuous coverage*
o Please add my additional (optional) supplemental benefit plan to my Medicare Advantage coverage.
Are you currently enrolled in a Blue Cross of Idaho dental plan? o Yes o No
If yes, do you want to keep your current dental plan? o Yes o No
If yes, Name of Dental Plan:__________________________________ ID Number:________________________
*Dental waiting period can be waived when you submit your application if you had 12 consecutive months of
dental insurance prior to enrolling in this plan, with a lapse in coverage of 60 days or less.
o Yes, I have had 12 consecutive months of dental insurance and would like my waiting period waived.
Prior Carrier: __________________________ ID/Policy Number: __________________________
Effective Date: ____________________ Termination/End Date: ____________________
o No, I do not have 12 consecutive months of dental insurance.
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Powered by Blue Cross of Idaho Care Plus, Inc. | Form No. 16-591 (09-21)Section 1 – All fields on this page are required (unless marked optional)
PLEASE PROVIDE YOUR INFORMATION:
First Name Middle Initial (optional) Last Name
Birth Date (mm/dd/yyyy) Gender: Phone Alt. Phone
o Male o Female ( ) ( )
Email Address* County
Permanent Residence Street Address (P.O. Box not allowed) City State Zip Code
Mailing Address (only if different from above) City State Zip Code
*OPTIONAL: By providing your email address, you agree to receive communication via email regarding your
plan benefits, and health and well-being updates.
YOUR MEDICARE INFORMATION:
Medicare ID Number: ________________________
Medicare Beneficiary Identifier (MBI).
MEDICARE HEALTH INSURANCE
Name/Nombre
JAMIE SAMPLE
Medicare Number/Número de Medicare
1EG4-TE5-MK72
Entitled to/Con derecho a Coverage starts/Cobertura empieza
HOSPITAL (PART A) 01-01-2020
MEDICAL (PART B) 01-01-2020
ANSWER THIS IMPORTANT QUESTION:
Will you have other prescription drug coverage (like VA, TRICARE) in addition to
Blue Cross of Idaho? o Yes o No
Name of other Coverage: Member Number for this Coverage: Group Number for this Coverage:
___________________________ ____________________________ ________________________
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Powered by Blue Cross of Idaho Care Plus, Inc. | Form No. 16-591 (09-21)PLEASE CONFIRM YOUR ELIGIBILITY FOR ENROLLMENT:
Typically, you may enroll in a Medicare Advantage plan only during the Annual Enrollment Period (AEP)
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. If
none of these statements applies to you or you’re not sure, please contact Blue Cross of Idaho Care Plus, Inc.
at 1-888-492-2583 (TTY 711) to see if you are eligible to enroll.
¨ I am enrolling during the Annual Enrollment Period (AEP) October 15 – December 7.
¨ 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’m moving into, live in or recently moved out of a long-term care facility (such as a nursing home).
I moved/will move into/out of the facility 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)_________________.
¨ I belong to a pharmacy assistance program provided by my state.
¨ 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 a weather-related emergency or major disaster, as declared by the Federal Emergency
Management Agency (FEMA). One of the other statements here applied to me, but I was unable to make my
enrollment because of the natural disaster.
¨ I have had Medicare prior to now, but am now turning 65 years of age.
¨ In the last 12 months, I joined a Medicare Advantage plan when I turned 65 years of age.
¨ My plan is ending its contract with Medicare, or Medicare is ending its contract with my plan.
¨ None of these statements applies to me. I feel a recent change in my situation allows me an exception to
enroll. My reason and date it occurred is: ____________________________________________________
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Powered by Blue Cross of Idaho Care Plus, Inc. | Form No. 16-591 (09-21)Section 2 – All fields on this page are optional
ANSWERING THESE QUESTIONS IS OPTIONAL.
You can’t be denied coverage because you don’t fill them out.
Do you currently have other health insurance coverage with Blue Cross of Idaho?
o Yes o No
Will this policy continue? o Yes o No
______________________________ ____________________________ _______________________________
Blue Cross of Idaho Plan Name Blue Cross of Idaho Blue Cross of Idaho Group Number
Member ID Number
Please contact customer service if you wish to end your other Blue Cross of Idaho health coverage.
Do you or your spouse work? o Yes o No
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.
¨ Spanish
¨ Another accessible format (audio, Braille or large print):
Please contact a customer advocate at 1-888-494-2583 (TTY 711) if you need information in an accessible
format or language other than what is listed above.
Please choose a primary care provider (PCP) from the True Blue (HMO) Provider Network. 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 one of the following for a list of participating network providers.
bcidaho.com/FindTrueBlueDoctors
True Blue Rx Essentials, True Blue Rx Gem, True Blue Rx Option I, True Blue Rx Option II, True Blue Rx,
True Blue Valor
bcidaho.com/SLHP-doctors
True Blue Rx | St. Luke’s Health Partners
bcidaho.com/preferred-doctors
True Blue Rx Preferred
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.
Requested Service Effective Date:____________________________________
5
Powered by Blue Cross of Idaho Care Plus, Inc. | Form No. 16-591 (09-21)PLEASE SELECT A PREMIUM PAYMENT OPTION:
You can pay your monthly plan premium (including any late enrollment penalty that you currently have or may
owe) by choosing one of the following options.
If you don’t select an option below, we will keep your current billing option in place, or send you a monthly bill.
¨ Monthly bill
¨ Automatic deduction from your bank account – automated clearing house (ACH)
Please attach a voided check (not a deposit slip). Your signature is required. We automatically deduct your
payment on the 5th of each month, unless you choose a different date.
Account Holder Name: ________________________________________________________________________
Bank Name and Address (city and state): ________________________________________________________
Routing Number:________________________________ Account Number:_____________________________
Account Holder Signature(s): ___________________________________________________________________
Day of the month you would like your payment to draft (1st-10th): _________________________________
¨ Automatic deduction from monthly Social Security or Railroad Retirement Board (RRB) benefit check.
The Social Security/RRB deduction may take two or more months to begin after Social Security or RRB
approves the deduction. You are responsible for paying your premium until we notify you of your start
date. In most cases, if Social Security or RRB accepts your request for automatic deduction, the first deduction
from your Social Security or RRB benefit check will include all premiums due from your enrollment effective
date up to the point that withholding begins. If Social Security or RRB does not approve your request for
automatic deduction, we will send you a paper bill for your monthly premiums.
I get monthly benefits from: o Social Security o RRB
¨ PERSI: We will contact PERSI for permission to access your funds. You are responsible for paying your
premium until we notify you of your start date.
I am a State of Idaho/Statewide Schools:
o Retiree o Requesting payment from my spouse who is a PERSI retiree
Retiree Name: ________________________________________________________________________________
Retiree Social Security Number:_________________________________________________________________
Member Social Security Number (if different from retiree): _________________________________________
Statewide School District Number:_______________________________________________________________
True Blue Rx Essentials (HMO) offers a Part B buy-down. We will reduce your Part B monthly premium by $30
per month. This reduction is set up by Medicare and administered through the Social Security Administration
(SSA). Depending on how you pay your Medicare Part B premium, your reduction may be credited to your
Social Security check or credited on your Medicare Part B premium statement. Reductions may take several
months to be issued; however, you will receive a full credit.
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 Blue Cross of Idaho Care Plus, Inc. the
Part D IRMAA.
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Powered by Blue Cross of Idaho Care Plus, Inc. | Form No. 16-591 (09-21)IMPORTANT – 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 payment, 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 Blue Cross of Idaho Care Plus, Inc. coverage begins, I must get all of my medical
and prescription drug benefits from Blue Cross of Idaho Care Plus, Inc. Benefits and services provided by
Blue Cross of Idaho Care Plus, Inc. and contained in my Blue Cross of Idaho Care Plus, Inc. Evidence of
Coverage document (also known as a member contract or subscriber agreement) will be covered. Neither
Medicare nor Blue Cross of Idaho Care Plus, Inc. 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.
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: _____________________________
ICEP/IEP: ______________ AEP: ______________ SEP (type): _____________ Not Eligible: __________
Broker Email: ____________________________________________________
7
Powered by Blue Cross of Idaho Care Plus, Inc. | Form No. 16-591 (09-21)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.
H1350_OP22180_C
©2021 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.
Blue Cross of Idaho and Blue Cross of Idaho Care Plus, Inc. (collectively referred to as Blue Cross of Idaho) complies
with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age,
disability or sex. ATTENTION: If you speak Arabic, Bantu, Chinese, Farsi, French, German, Japanese, Korean, Nepali,
Persian (Farsi), Romanian, Russian, Serbo-Croatian, Spanish, Tagalog, or Vietnamese, language assistance services,
free of charge, are available to you. Call 1-888-494-2583 (TTY: 711). Chinese 注意：如果您使用繁體中文，您可以免費
獲得語言援助服務。請致電 1-888-494-2583 (TTY：711)。Spanish ATENCIÓN: si habla español, tiene a su disposición
servicios gratuitos de asistencia lingüística. Llame al 1-888-494-2583 (TTY: 711).
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Powered by Blue Cross of Idaho Care Plus, Inc. | Form No. 16-591 (09-21)You can also read
