Enroll in a 2012 Plan
Usually you may enroll in a Medicare Advantage Plan only during the annual enrollment period, the annual disenrollment period, or during a special enrollment period.
If you have both Medicare and full Medicaid benefits, you are entitled to a continuous special election period. This means that you can enroll at any time during the year.
Annual Election Period
October 15, 2011 through December 7, 2011 is the Annual Election Period for 2012. During this time you can switch from one way of getting Medicare to another. You have the opportunity to choose the plan that’s best for you. The change will take effect on January 1, 2012.
Annual Disenrollment Period
The MADP begins on January 1, 2012 and ends on February 14, 2012. During the MADP, an individual enrolled in a Medicare Advantage (MA) plan may prospectively disenroll from that plan and return to Original Medicare. The effective date of the disenrollment from the MA plan is the first day of the month following the date the disenrollment request is received thus, disenrollment requests received by MA organization in January are effective February 1; those received from February 1 through February 15 are effective March 1.
During the same 45-day period, an individual using the MADP to disenroll from a MA plan is eligible for a special enrollment period (SEP) to enroll in a stand-alone Part D plan (PDP). The individual gets this opportunity regardless of whether the MA plan from which the individual disenrolled included a Part D beneft. Like for disenrollments, the effective dates of the enrollment in the PDP is the first day of the month following the date the enrollment request is received.
Special Election Period
The Special Election Period is a special period of time during which you may enroll. For instance if you:
- are turning 65 and are newly eligible for Medicare in 2012
- have just moved into the plan’s service area
- are enrolled in another prescription drug plan or a Medicare Advantage plan whose 2012 contract is terminated
- have full Medicaid benefits or prescription drug assistance through PACE
This is not a complete list. To obtain more information about these election periods, please call 1-877-393-6733 (TTY/TDD: 1-877-219-5457), 8 a.m. to 8 p.m., seven days a week. However, please be aware that on weekends and holidays from February 15 through September 30, your call may be sent to an answering machine.
You may enroll online, by phone or by mail:
Completing your application
If you prefer to enroll by phone, need help completing the form, or if you have any questions concerning our plans, just call our toll-free number at 1-877-393-6733 (TTY/TDD: 1-877-219-5457), 8 a.m. to 8 p.m., seven days a week. However, please be aware that on weekends and holidays from February 15 through September 30, your call may be sent to an answering machine.
If anyone helps you fill out your application, that individual must sign the form and indicate his or her relationship to you.
No premium payment is required at time of enrollment.
Once your application has been processed, we will notify you of your effective date and we’ll send you a member packet that includes your identification card, your Evidence of Coverage, and other important information.
Enroll in a Medicare Advantage plan online
Click on the plan you would like to join, and complete the online enrollment form.
Enroll me in |
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| Keystone 65 Select/Preferred HMO |  |
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| Personal Choice 65 PPO | |
More information |
Enroll in a Medicare Advantage plan by phone
Call toll-free 1-877-393-6733 (TTY/TDD: 1-877-219-5457), 8 a.m. to 8 p.m., seven days a week. However, please be aware that on weekends and holidays from February 15 through September 30, your call may be sent to an answering machine.
Enroll in a Medicare Advantage plan by mail
Click on your selected plan to download the application form.
Enroll me in |
Mail completed applications to |
 Keystone 65 Select/Preferred HMO (Philadelphia/Bucks) |
Keystone 65 HMO Medicare Department P.O. Box 13713 Philadelphia, PA 19101-3713 |
| Keystone 65 Select/Preferred HMO (Chester/Delaware/Montgomery) |
Keystone 65 HMO Medicare Department P.O. Box 13713 Philadelphia, PA 19101-3713 |
| Personal Choice 65 PPO |
Personal Choice 65 PPO Medicare Department P.O. Box 13713 Philadelphia, PA 19101-3713 |
Disenrollment from a Medicare Advantage Plan
Please note this important information about disenrollment:
- If you move out of the area that your plan serves, you must notify the plan so you can disenroll and find a new plan in your new area.
- If you intentionally provide false information on your enrollment form, you will be disenrolled from the plan.
- You may disenroll from our plan only at certain times of the year, or under certain special circumstances, by sending a written request.
Send a written request for disenrollment to:
Independence Blue Cross
Medicare Department
P.O. Box 13713
Philadelphia, PA 19101-9606
Or you can call 1-800-MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048), 24 hours a day/seven days a week.
MedigapSecurity Enrollment
If you need help completing the form, or if you have any questions concerning MedigapSecurity, just call our toll-free number 1-877-393-6733 (TTY/TDD: 1-877-219-5457), 8 a.m. to 8 p.m., seven days a week. However, please be aware that on weekends and holidays from February 15 through September 30, your call may be sent to an answering machine.
No premium payment is required at the time you apply.
Once your application has been processed, we will notify you of your effective date and we’ll send your MedigapSecurity identification card, subscription agreement, and other important information.
Enroll in a MedigapSecurity plan online
Click on the Enroll button below to complete the online enrollment form.
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Enroll in a MedigapSecurity plan by mail
Download the MedigapSecurity application form.
An application (in PDF format) will open in a new window for you to download.
To view the application, you will need a “plug-in” for your browser or the Acrobat Reader software. For more information about PDFs and to download the free software, visit the Adobe Acrobat Reader website.
When you have completed the form, print it, sign it, and mail it to:
MedigapSecurity
Medicare Department
Independence Blue Cross
P.O. Box 7330
Philadelphia, PA 19101-8957
Disenrollment from a MedigapSecurity Plan
You may disenroll from MedigapSecurity by sending a written request to:
MedigapSecurity
Medicare Department
Independence Blue Cross
P.O. Box 7330
Philadelphia, PA 19101-7330
Important information about links to other sites
You must continue to pay your Medicare Part B premium.
The Medicare Contract is renewed annually, and the availability of coverage beyond the end of the current year is not guaranteed.
The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change January 1, 2013. Members may enroll in the plan during specific times of the year. Contact the plan for more information. Please reference the Evidence of Coverage for information on premiums, cost-sharing, out-of-network coverage, rights and responsibilities upon disenrollment and any applicable conditions associated with using the plan benefits, as well as limitations, copayments, and restrictions. Members must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity limitations and restrictions may apply.
You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call:
- 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week;
- The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or
- Your State Medicaid Office.
People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay for up to seventy-five (75) percent or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users should call 1-877-486-2048.”
You must use plan providers except in emergency or urgent care situations or for out-of-are renal dialysis or other services. You must use plan providers except in emergency or urgent care situations or for out-of-are renal dialysis or other services. If you obtain routine care from out-of-network providers neither Medicare nor Keystone 65 HMO or Personal Choice 65 PPO will be responsible for the costs.
Please contact Keystone 65 HMO or Personal Choice 65 PPO Customer Service for more information.
Y0041_HM_12_300a Pending CMS Approval
