UPMC Health Plan Application Agreement

If you currently have health coverage from an employer or union, joining UPMC for Life could affect your employer or union health benefits. You could lose your employer or union health coverage if you join UPMC for Life.

Read the communications your employer or union sends you. If you have questions, visit their website or contact the office listed in their communications. If there isn’t any information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.

By completing this enrollment application, I agree to the following:

UPMC for Life is a Medicare Advantage plan and has a contract with the federal government. I will need to keep my Medicare Parts A and B coverage. 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. It is my responsibility to inform you of any prescription drug coverage that I have or may get in the future. I understand that if I don’t have Medicare prescription drug coverage or creditable prescription drug coverage (as good as Medicare’s), I may have to pay a late enrollment penalty if I enroll in Medicare prescription drug coverage in the future. I understand that when I am enrolled in a UPMC for Life Medicare Advantage Prescription Drug Plan, I will receive my Medicare prescription drug coverage through this plan. I do not need to enroll in a separate Prescription Drug Plan (PDP). 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.

UPMC for Life serves a specific service area. If I move out of the area that UPMC for Life serves, I need to notify the plan so I can disenroll and find a new plan in my new area. Once I am a member of UPMC for Life, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from UPMC for Life when I get it to know which rules I must follow to get coverage with this Medicare Advantage plan. 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.

For HMO plans: I understand that beginning on the date UPMC for Life coverage begins, I must get all my health care from UPMC for Life, except for emergency or urgently needed services or out-of-area dialysis services.

Services authorized by UPMC for Life and other services contained in my UPMC for Life Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR UPMC FOR LIFE WILL PAY FOR THE SERVICES.

I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or contracted with UPMC for Life, he/she may be paid based on my enrollment in UPMC for Life.

Release of Information: By joining this Medicare Advantage health plan, I acknowledge that UPMC for Life will release my information to Medicare and other plans as is necessary for treatment, payment, and health care operations. I also acknowledge that UPMC for Life will release my information, including my prescription drug event data (if applicable), to Medicare, who may release it for research and other purposes which follow all applicable federal statutes and regulations. 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 authorized to act on my behalf under the laws of the state where I live) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (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 from Medicare.