How to complete a Paper Application 2014

Objective and Scope Objective of the project To provide the necessary steps to accurately complete a paper application. To highlight the changes to the AEF (Abbreviated Enrollment Form) and the OSB (Optional Supplemental Benefit) application. Scope Individual Medicare paper applications Electronic enrollment channels Special Needs Plans (SNP) forms

Instructions: Please print clearly and press hard. Use blue or black ink only. Completely fill the ovals. Print clear numbers and capital block letters in the boxes. Print only one letter or number in each box. If you make a mistake, fix it by crossing out the box with an X. Put in the correct letter or number above or below the box as shown.

Instructions: When filling out dates, be sure dates appear in the MMDDYYYY format. Don’t use dashes or spaces. SAMPLE CHECK (If you are choosing the auto bank withdrawal. Important things to know: Something as simple as failing to properly mark the application can cause the application to pend and delay the start of coverage

Humana Medicare Enrollment Form: Medicare Medicare Information: Take this directly from your Medicare Card Print your last name Your first name Medicare ID number Hospital Part A and Part B effective dates MMDDYYYY (07062012)

Humana Medicare Enrollment Form: Plan In this section completely fill in the circle Are you currently on Medicaid? If so, Please fill out the Medicaid number section on the right. Name of plan you are enrolling in: Fill in the circle for Plan. Group ID and Benefit number Your agent will provide this number to you Plan option number : The agent will review this number. Note: The plan number will have only 3 digits after the dash. The Agent SAN number is required at the top. This will be provided to you but your agent

Humana Medicare Enrollment Form: OSB Optional Supplemental Benefits To add any of the optional supplemental benefits fill in the circle next to the ones you want to enroll in. Note: These are added benefits with an additional cost

Humana Medicare Enrollment Form: ESRD ESRD Question – Please select accordingly Residential address – This must be a physical address – do not list a PO Box in this field. The county must also be listed Telephone number – This should be a number that Humana can use to contact you. Date of birth - This will be 2 digit month, 2 digit day and 4 digit year. Sex – Fill in the circle that matches your gender Mailing address – only complete this section if your mailing address is different then your residential address. A PO Box can be used for the mailing address.

Humana Medicare Enrollment Form: Contact Info Every page of the application will require your Medicare ID number Other contact information (optional) – enter the number that the Humana agent can best contact you and select what time of day. Email address – this is optional The email address will allow Humana to send you non-enrollment plan materials via e-mail. Ex: New Member Orientation invitation. Primary Care Physician (PCP) – this is only needed if enrolling in an HMO or Prime Choice PPO Requested (but optional) for PFFS and some PPO. The agent can look up the PCP number in the provider directory.

Humana Medicare Enrollment Form: Other Health Coverage Answer Yes or No to every question If the answer is Yes to any question additional information will be needed. Question 1–3: Other medical health coverage once enrolled. "This is referring to you having other coverage, whether under your spouse's policy or some other coverage.“ If you are covered under your spouse’s policy, that information is needed.

Humana Medicare Enrollment Form: Nursing Home Remember every page of the application will require your Medicare ID number Question 4: Resident in a nursing home. If the answer is Yes, please provide the facility information.

Humana Medicare Enrollment Form: Payment Select how you would like to pay for the plan Social Security deduction – only requires marking the circle. This is the preferred method of payment. Coupon book – only requires marking the circle. Electronic Fund Transfer (Bank deduction) – will require bank information in Depository section. Auto Credit Card Charge (Credit card payment) – will require credit card information.

Humana Medicare Enrollment Form: SEP Special Election Period Statements Enter your Medicare ID number at the top. If this is not your Initial Enrollment or the Annual Enrollment, you may be using a Special Election Period. If you are unsure of your election period, please ask the agent.

Humana Medicare Enrollment Form: Important Information Enter your Medicare ID number. Page 5 and 6 are review pages that only require your Medicare ID number. These pages can be left With the member. The do not need to be faxed with the application.

Humana Medicare Enrollment Form: Signature Enter your Medicare ID number Signature of applicant – this is the person being insured or the Power of Attorney for the insured. Please sign and date. If unable to sign your name you may just put an X (We would prefer any other indication of signature rather than an X if possible) If an P.O.A does sign the application, the bottom portion must be filled out. Don’t forget to select the language preference here at the bottom

Humana Medicare Enrollment Form: Agent Use Only Proposed effective date: only need to add the month. Scope of Appointment Type: 3 digit code that represents where the appt. was completed. Group ID and Benefit Number : These numbers are found on the customer number grid. Scope of Appointment ID Number: Paper Application – number under the bar code IVR – The ID number will be the confirmation number MAPA : is the application number Date: Date the application was signed

Thank You for your time and attention. “FIN” Thank You for your time and attention.