Disclaimer

If you are entitled to Medicare Part A, enrolled in Medicare Part B and a resident of [county(ies)/ parishes/ plan region] [the Dual Plus plan is not available in [county name(s)] County (ies)], you are eligible to join [Plan Name].

You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting extra help, call: 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day/7 days a week; The Social Security Administration at 1-800-772-1213,TTY/TDD users should call 1-800-325-0778 [days and hours of operation], or your State Medicaid Office. You may not enroll in this plan if your current or former employer helps pay for your drugs.

The plan is authorized by law to refuse to renew its contract with CMS, that CMS also may refuse to renew the contract, and that termination or non-renewal may result in termination of the beneficiary’s enrollment in the plan. In addition, the plan may reduce its service area and no longer offer services in the area where the beneficiary resides.

[Health Plan Name] is provided by [Medicare Organization Name] is, a Coordinated Care Plan with a Medicare Advantage contract. Anyone with Medicare Parts A and B may apply. You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party. You must use contracted providers and pharmacies for care. Limitations, monthly premiums, copayments and coinsurance will apply.

Members may enroll only during certain times of the year.

For full information on [Plan Name], please call our Customer Service Department at [Phone number / TTY]. Office hours are [hours of operation].