Fillable Form 1: Blue Shield of California Medicare Supplement (Blue Shield of California)

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Form 1: Blue Shield of California Medicare Supplement (Blue Shield of California)

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The Form 1: Blue Shield of California Medicare Supplement (Blue Shield of California) form is 8 pages long and contains:

  • 5 signatures
  • 54 check-boxes
  • 79 other fields

Country of origin: US
File type: PDF

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Blue Shield of California
Medicare Supplement Plan Transfer Application
Current BlueShield of California Medicare Supplement plan members may use this application to:
1. Transfer to a Medicare Supplement plan of equal or lesser value during an open enrollment period – Guaranteed Acceptance.
2. Enroll into the Household Savings Program
1
. (Both participants must be current BlueShield of California Medicare Supplement
plan members).
3. Enroll in a dental plan.
If you are interested in transferring to a Medicare Supplement plan of equal or lesser value outside your enrollment period or to
a richer benefit plan at any time, you must complete the Medicare Supplement Plan Enrollment Application (Form C12687).
Transferring is easy!
1
Provide ALL requested information and print clearly in all capital letters in black ink. Sign and date at the end.
2
Submit your application within 30 days of your signature date by:
• Fax to (844) 266-1850
• Email: msinstall@blueshieldca.com
• Mail: Medicare Supplement Installation, P.O. Box 3008 Lodi, CA 95241-1912
Please note: It is required that a signed copy of this contract is made for your records. Be sure to print and
save the member copy pages of this application with all other important BlueShield of California documents.
If you have questions about how to enroll, please contact your broker or call us at (888) 713-0000 or TTY: 711.
You may also contact the California Health Insurance Counseling & Advocacy Program (HICAP) for guidance. HICAP
provides health insurance counseling for California senior citizens. Call HICAP toll-free at (800) 434-0222 for a
referral to your local HICAP office. HICAP services are provided free of charge by the state of California.
Plan F Extra is only available to applicants who attained age 65 before January 1, 2020, or first become
eligible for Medicare benefits due to disability before January 1, 2020.
Personal information
First name Middle initial Last name
Home address
Home city Home state Home ZIP
Phone number (optional)
c
Landline
c
Cell
Alternate phone number (optional) (optional)
c
Landline
c
Cell
Gender:
c
Male
c
Female
c
Non-binary
Email address (Required for electronic communications) Communication preference
c
Electronic
c
Paper
Go paperless! Please watch for an email with a link which will allow you to register your account, customize your
communication preferences, and access your digital ID card and benefit information.
I agree that Blue Shield and its affiliated entities and agents may communicate with me about my account and various
health and wellness programs available to me, and other promotional information that may benefit me and my dependents,
including by phone or text to the numbers I have listed on this form, using an auto-dialer or artificial or prerecorded voice;
standard data rates apply.
c
Yes
c
No
Participation is voluntary and you can opt-out at any time, for more information visit blueshieldca.com/terms.
Mailing address (if different from above)
Mailing city Mailing state Mailing ZIP
1
Alternate phone number (optional)Phone number (optional)
c
Landline
c
Cell
Gender:
c
Male
c
Female
c
Non-binary
(optional)
c
Landline
c
Cell
Blue Shield of California copy – Mail, email, or fax this to the contact information noted above.
Billing address (if different from above)
Billing city Billing state Billing ZIP
Date of birth
– –
Month Day Year
Language preference:
c
English
c
Spanish
c
Chinese
c
Other ______________________
Please check the plan type you are applying for:
c
A
c
F Extra
c
G
c
G Extra
c
N
c
G Inspire*
Or are you choosing to stay in your current plan?
c
Yes
c
No
Requested effective date: The 1
st
day of
–
Month Year
* Plan G Inspire is available in select counties. Please see your Summary of Benefits for eligible counties.
Medicare Beneficiary Identification (MBI) number
BlueShield subscriber number
Medicare hospital (Part A) effective date
– –
Month Day Year
Medicare (Part B) effective date
– –
Month Day Year
Household Savings Program
1
If you and the other household member are age 65 and older and both members have, or are applying for, the same plan
(including any dental plans), you may be eligible for a 7% monthly savings on your combined medical plan dues when
both members are enrolled in the same eligible plan. Both members must share the same home and mailing
addresses. Tobacco users are not eligible for the Household Savings Program.
Is the other member of your household enrolled in, or applying for, the same BlueShield Medicare Supplement plan that you
are applying for and share both address types?
c
Yes
c
No
If "Yes," please provide the following information for the other household member:
Name
Beneficiary Identification (MBI) number
BlueShield Medicare Supplement plan member ID (if available)
Please provide other household member's authorization to cancel their separate BlueShield contract and enroll under the
primary subscriber's agreement for the Household Savings Program by having the other household member sign at the end
of the application.
Each individual must complete their own new member application if not already a current member. If both
members are existing enrollees, the subscriber is determined based on which application is enrolled first. Otherwise, the
existing member already enrolled on the requested plan type will be designated as the subscriber.
The subscriber is responsible for payment of dues/premiums to Blue Shield and only the subscriber can make changes to
the contract/policy. When enrolled under the Household Savings Program, Blue Shield will also accept payment of dues/
premiums from the other household member enrolled on the plan. Billing information and amounts due can/will be shared
with both parties enrolled on the plan when calling Customer Care.
Dental PPO plans
Dental plans for Medicare Supplement plan members.
Please see the page on blueshieldca.com/MedSuppDental2022 for more information.
To sign up for BlueShield dental coverage, select a plan below:
Dental plan options (check one):
c
Dental PPO 1000
c
Dental PPO 1500
c
No dental plan
Conditions of coverage
• Dental benefits aren’t subject to health plan deductible requirements.
• If your dental coverage is cancelled for any reason (by you or by BlueShield), you may apply for reenrollment, but you
will have to wait six months to reapply.
2
Blue Shield of California copy – Mail, email, or fax this to the contact information noted above.
Payment information
To determine the monthly dues amount, refer to BlueShield’s rate table included in the enrollment kit or visit
blueshieldca.com/MedSupp2022. Unless you currently participate in AutoPay, you will receive a monthly bill indicating the
amount and the date your next payment is due.
Save $3 a month by paying dues through automatic monthly debit from your checking or savings account using our AutoPay
program
1
. To enroll, after receiving and paying for your first bill, register for and log into your BlueShield account at
blueshieldca.com and access the Billing and Payment tab. You may also call Customer Care at (800) 248-2341 TTY: 711
8 a.m. - 8 p.m., seven days a week, year-round. Requests to enroll in the AutoPay program may take up to two billing cycles for
completion. Members should pay all paper bills received until an email confirming registration in the AutoPay program is received.
Conditions of membership
1
This transfer application will become part of the Evidence of Coverage for which I am applying, and together with any
endorsements, appendices, and attachments thereto, will collectively constitute the entire agreement for coverage.
2
If I choose to enroll in a plan that goes up in value, I will not be covered by a Blue Shield Medicare Supplement plan
unless BlueShield’s Underwriting Department approves this application. BlueShield is not liable for bills incurred
before the effective date of coverage.
3
Only BlueShield can approve this application. I understand that any insurance agent, broker, or sales representative
cannot grant approval, change terms, or waive requirements.
4
I acknowledge receipt of the:
• Summary of Benefits
• Rate table
• The Guide to Health Insurance for People with Medicare
• A copy of this transfer application.
With my signature below, I represent that the information provided in this transfer application is complete and
accurate to the best of my knowledge, and I understand and agree to the terms and conditions of coverage, the
Household Savings Program, and the authorizations I have provided.
I have read the Summary of Benefits and the terms, conditions, and authorizations set forth above. I certify that
I meet the eligibility requirements set forth in the Summary of Benefits. I alone am responsible for the accuracy
and completeness of this application and have answered all questions to the best of my knowledge and belief.
I understand that I will not be eligible for coverage if any information is false or incomplete, and that coverage
may be revoked based on such finding.
5
I understand I may receive materials and communications electronically versus print: I may receive required benefit plan
and coverage-related materials and communications via email and/or the Blue Shield website blueshieldca.com, as
applicable. Obtaining a document electronically will confirm my consent to electronic delivery. I also have the right to
obtain printed, mailed materials at any time and at no expense to me. To receive printed materials in the mail, to opt
out of email communications, I can call (800) 248-2341 TTY: 711 8 a.m. - 8 p.m., seven days a week, year-round.
Applicant’s signature Date
Household member's signature (if applicable) Date
3
Blue Shield of California copy – Mail, email, or fax this to the contact information noted above.
click to sign
signature
click to edit
click to sign
signature
click to edit
Blue Shield of California is an independent member of the Blue Shield Association MSP15571 (10/21)
4
1
Savings due to increased efficiencies from administering Medicare Supplement plans under this program/service are passed along to
the subscriber.
Producer information (For producer use only, if applicable)
Agency name
_______________________________________________________________________
(please print appointed agency name)
Agency ID No.
______________________________________________________________________
(please print agency ID)
Producer (writing agent) name (required)
______________________________________________________
(please print writing agent name)
Producer (writing agent) NPN or TIN (one required) ___________________________________________
Producer email address
________________________________________________________________
Producer fax number
__________________________________________________________________
Producer phone number
________________________________________________________________
Today’s date (required)
Producer’s signature (required)
Print name
Blue Shield of California copy – Mail, email, or fax this to the contact information noted above.
click to sign
signature
click to edit
5
Blue Shield of California
Medicare Supplement Plan Transfer Application
Current BlueShield of California Medicare Supplement plan members may use this application to:
1. Transfer to a Medicare Supplement plan of equal or lesser value during an open enrollment period – Guaranteed Acceptance.
2. Enroll into the Household Savings Program
1
. (Both participants must be current BlueShield of California Medicare Supplement
plan members).
3. Enroll in a dental plan.
If you are interested in transferring to a Medicare Supplement plan of equal or lesser value outside your enrollment period or to
a richer benefit plan at any time, you must complete the Medicare Supplement Plan Enrollment Application (Form C12687).
Transferring is easy!
1
Provide ALL requested information and print clearly in all capital letters in black ink. Sign and date at the end.
2
Submit your application within 30 days of your signature date by:
• Fax to (844) 266-1850
• Email: msinstall@blueshieldca.com
• Mail: Medicare Supplement Installation, P.O. Box 3008 Lodi, CA 95241-1912
Please note: It is required that a signed copy of this contract is made for your records. Be sure to print and
save the member copy pages of this application with all other important BlueShield of California documents.
If you have questions about how to enroll, please contact your broker or call us at (888) 713-0000 or TTY: 711.
You may also contact the California Health Insurance Counseling & Advocacy Program (HICAP) for guidance. HICAP
provides health insurance counseling for California senior citizens. Call HICAP toll-free at (800) 434-0222 for a
referral to your local HICAP office. HICAP services are provided free of charge by the state of California.
Plan F Extra is only available to applicants who attained age 65 before January 1, 2020, or first become
eligible for Medicare benefits due to disability before January 1, 2020.
Personal information
First name Middle initial Last name
Home address
Home city Home state Home ZIP
Email
Go paperless! Please watch for an email with a link which will allow you to register your account, customize your
communication preferences, and access your digital ID card and benefit information.
I agree that Blue Shield and its affiliated entities and agents may communicate with me about my account and various
health and wellness programs available to me, and other promotional information that may benefit me and my dependents,
including by phone or text to the numbers I have listed on this form, using an auto-dialer or artificial or prerecorded voice;
standard data rates apply.
c
Yes
c
No
Participation is voluntary and you can opt-out at any time, for more information visit blueshieldca.com/terms.
Mailing address (if different from above)
Mailing city Mailing state Mailing ZIP
Phone number (optional)
c
Landline
c
Cell
Alternate phone number (optional) (optional)
c
Landline
c
Cell
Gender:
c
Male
c
Female
c
Non-binary
Member copy – Keep with your important Blue Shield documents and information.
6
Please check the plan type you are applying for:
c
A
c
F Extra
c
G
c
G Extra
c
N
c
G Inspire*
Or are you choosing to stay in your current plan?
c
Yes
c
No
Requested effective date: The 1
st
day of
–
Month Year
* Plan G Inspire is available in select counties. Please see your Summary of Benefits for eligible counties.
Medicare Beneficiary Identification (MBI) number
BlueShield subscriber number
Medicare hospital (Part A) effective date
– –
Month Day Year
Medicare (Part B) effective date
– –
Month Day Year
Household Savings Program
1
If you and the other household member are age 65 and older and both members have, or are applying for, the same plan
(including any dental plans), you may be eligible for a 7% monthly savings on your combined medical plan dues when
both members are enrolled in the same eligible plan. Both members must share the same home and mailing
addresses. Tobacco users are not eligible for the Household Savings Program.
Is the other member of your household enrolled in, or applying for, the same BlueShield Medicare Supplement plan that you
are applying for and share both address types?
c
Yes
c
No
If "Yes," please provide the following information for the other household member:
Name
Beneficiary Identification (MBI) number
BlueShield Medicare Supplement plan member ID (if available)
Please provide other household member's authorization to cancel their separate BlueShield contract and enroll under the
primary subscriber's agreement for the Household Savings Program by having the other household member sign at the end
of the application.
Each individual must complete their own new member application if not already a current member. If both
members are existing enrollees, the subscriber is determined based on which application is enrolled first. Otherwise, the
existing member already enrolled on the requested plan type will be designated as the subscriber.
The subscriber is responsible for payment of dues/premiums to Blue Shield and only the subscriber can make changes to
the contract/policy. When enrolled under the Household Savings Program, Blue Shield will also accept payment of dues/
premiums from the other household member enrolled on the plan. Billing information and amounts due can/will be shared
with both parties enrolled on the plan when calling Customer Care.
Dental PPO plans
Dental plans for Medicare Supplement plan members.
Please see the page on blueshieldca.com/MedSuppDental2022 for more information.
To sign up for BlueShield dental coverage, select a plan below:
Dental plan options (check one):
c
Dental PPO 1000
c
Dental PPO 1500
c
No dental plan
Billing address (if different from above)
Billing city Billing state Billing ZIP
Date of birth
– –
Month Day Year
Language preference:
c
English
c
Spanish
c
Chinese
c
Other _____________________
Member copy – Keep with your important Blue Shield documents and information.
7
Payment information
To determine the monthly dues amount, refer to BlueShield’s rate table included in the enrollment kit or visit
blueshieldca.com/MedSupp2022. Unless you currently participate in AutoPay, you will receive a monthly bill indicating the
amount and the date your next payment is due.
Save $3 a month by paying dues through automatic monthly debit from your checking or savings account using our AutoPay
program
1
. To enroll, after receiving and paying for your first bill, register for and log into your BlueShield account at
blueshieldca.com and access the Billing and Payment tab. You may also call Customer Care at (800) 248-2341 TTY: 711
8 a.m. - 8 p.m., seven days a week, year-round. Requests to enroll in the AutoPay program may take up to two billing cycles for
completion. Members should pay all paper bills received until an email confirming registration in the AutoPay program is received.
Conditions of membership
1
This transfer application will become part of the Evidence of Coverage for which I am applying, and together with any
endorsements, appendices, and attachments thereto, will collectively constitute the entire agreement for coverage.
2
If I choose to enroll in a plan that goes up in value, I will not be covered by a Blue Shield Medicare Supplement plan
unless BlueShield’s Underwriting Department approves this application. BlueShield is not liable for bills incurred
before the effective date of coverage.
3
Only BlueShield can approve this application. I understand that any insurance agent, broker, or sales representative
cannot grant approval, change terms, or waive requirements.
4
I acknowledge receipt of the:
• Summary of Benefits
• Rate table
• The Guide to Health Insurance for People with Medicare
• A copy of this transfer application.
With my signature below, I represent that the information provided in this transfer application is complete and
accurate to the best of my knowledge, and I understand and agree to the terms and conditions of coverage, the
Household Savings Program, and the authorizations I have provided.
I have read the Summary of Benefits and the terms, conditions, and authorizations set forth above. I certify that
I meet the eligibility requirements set forth in the Summary of Benefits. I alone am responsible for the accuracy
and completeness of this application and have answered all questions to the best of my knowledge and belief.
I understand that I will not be eligible for coverage if any information is false or incomplete, and that coverage
may be revoked based on such finding.
5
I understand I may receive materials and communications electronically versus print: I may receive required benefit plan
and coverage-related materials and communications via email and/or the Blue Shield website blueshieldca.com, as
applicable. Obtaining a document electronically will confirm my consent to electronic delivery. I also have the right to
obtain printed, mailed materials at any time and at no expense to me. To receive printed materials in the mail, to opt
out of email communications, I can call (800) 248-2341 TTY: 711 8 a.m. - 8 p.m., seven days a week, year-round.
Applicant’s signature Date
Household member's signature (if applicable) Date
Conditions of coverage
• Dental benefits aren’t subject to health plan deductible requirements.
• If your dental coverage is cancelled for any reason (by you or by BlueShield), you may apply for reenrollment, but you
will have to wait six months to reapply.
Member copy – Keep with your important Blue Shield documents and information.
click to sign
signature
click to edit
click to sign
signature
click to edit
Blue Shield of California is an independent member of the Blue Shield Association MSP15571 (10/21)
8
1
Savings due to increased efficiencies from administering Medicare Supplement plans under this program/service are passed along to
the subscriber.
Producer information (For producer use only, if applicable)
Agency name
_______________________________________________________________________
(please print appointed agency name)
Agency ID No.
______________________________________________________________________
(please print agency ID)
Producer (writing agent) name (required)
______________________________________________________
(please print writing agent name)
Producer (writing agent) NPN or TIN (one required) ___________________________________________
Producer email address
________________________________________________________________
Producer fax number
__________________________________________________________________
Producer phone number
________________________________________________________________
Today’s date (required)
Producer’s signature (required)
Print name
Member copy – Keep with your important Blue Shield documents and information.
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Form 1: Blue Shield of California Medicare Supplement (Blue Shield of California)

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Completed 7 October 2021

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