Enrolling small groups in Medicare plans

Use these forms and instructions to sign a small group up for a Priority Health Medicare plan. Follow all instructions exactly as written. Send a copy of each completed form to Priority Health Medicare sales via:

• E-mail: PH-Medicare-agent@priorityhealth.com (preferred)
• Fax: 616 975-0281
• Mail: Priority Health, 1231 East Beltline Ave. NE, MS1125 - Medicare Sales, Grand Rapids, MI 49525

Jump down to:

• Employer Group Agreement
• 30-day employer notification letter
• Retiree verification form
• Enrollment application

Employer Group Agreement

Medicare Part D Employer Group Agreement (25KB PDF) - Updated 07/2008 (Log-in required)
Every group that chooses a Medicare Advantage Part D (MAPD) plan MUST sign a group agreement with Priority Health. NOTE: The group agreement is updated regularly. Check to verify the form here matches your most recent copy.

Instructions

1. Under the Employer heading on page 4, have the employer group representative:
   
   • Sign their name in the By field
   • Print their name
   • Enter their title
   • Date the document
2. Make a copy for both your file and the group's file.
3. Send the original to Priority Health via mail, fax, or e-mail

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30-day employer notification letter

30-day employer notification letter (27KB DOC) - Updated 08/2008 (Log-in required)
Your employer group should send this letter to all retirees eligible for Medicare benefits 30 days before the plan's effective date. Each employee needs their own letter (spouses do not need a separate copy).

Instructions

1. Copy the letter text onto a template that fits your employer group's letterhead
2. Complete the blank fields
3. Sign the letter
4. Print a copy of the signed letter
5. Send a copy of that letter to each employee no later than 30 days prior to the plan's effective date
6. Send a copy to Priority Health via mail, fax, or e-mail
   

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Retiree verification form

Retiree verification form (60KB PDF) - Updated 06/2009 (Log-in required)
This form confirms which of the group's employees are eligible for Medicare coverage.

Instructions

1. Have the employer group representative
   
   • Fill in their own contact information
   • Enter the retiree's information:
     
     • Name (spouse does not need to be listed)
     • Date of retirement or effective date of MAPD group plan
     • Whether employee is presently covered by an existing group retiree plan
   • Sign and date the form
2. Make a copy for the employer group file
3. Send the original to Priority Health via mail, fax, or e-mail
   

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Enrollment application

Enrollment application (86KB PDF) - Updated 06/2006 (Log-in required)
Each retiree must fill this form out. NOTE: Retiree/spouse signature must be documented prior to the first of the month the plan starts. For example, a plan effective 12/01/2009 must be signed on or before 11/30/2009.

Instructions

1. Have the retiree fill out:
   
   • Section 1A - Subscriber's Enrollment Information
     
   • Section 2A - Under Subscriber Medicare Claim Number
   • Section 2B - for Subscriber
     
   • Section 2C  - if applicable for Subscriber
   • Section 3 - Signature
   • Section 4 - Subscriber's Signature
2. Have the retiree's spouse fill out:
   
   • Section 1B - Spouse's Enrollment Information
     
   • Section 2A - Under Spouse/Dependent's Medicare Claim Number
   • Section 2B - for Spouse
   • Section2C - if applicable for Spouse
   • Section 4 - Spouse's Signature
3. Have the group fill out:
   
   • Section 5 - Sign and date
4. Make a copy for the retiree and group.
5. Send the original to Priority Health via mail, fax, or e-mail