Group Medicare plan enrollment

Small groups (2-50 eligible employees) can use these forms and follow these enrollment rules to sign up for a Priority Health Medicare plan.

Go to specific enrollment rules at the bottom of the page.

Enrollment forms and instructions

Follow all instructions exactly as written. Send a copy of each completed form to Priority Health Medicare sales via:

• Email: 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

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

Employer Group Agreement

Medicare Part D - MAPD Employer Group Agreement (95KB PDF) - Updated 03/2011
or
Medicare Part D - PDP (prescription drug only) Employer Group Agreement (91KB PDF) - Updated 03/2011
Every group that chooses a Medicare Advantage Part D (MAPD) or Prescription Drug Plan (PDP) 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, the group must:
   • Sign their name in the By field
   • Print their name
   • Enter their title
   • Date the document
2. Make a copy for your files.
3. Send the original to Priority Health via mail, fax, or email

30-day employer notification letter

30-day employer notification letter (27KB DOC) - Updated 08/2008
The 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 the 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 email

Retiree verification form

Retiree verification form (174KB PDF) - Updated 05/2010
This form confirms which of the group's employees are eligible for Medicare coverage.

Instructions

1. The employer group representative must: 
   • 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 email

Enrollment application

Enrollment application (126KB PDF) - Updated 03/2010
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 12/01/2011 must be signed on or before 11/30/2011.

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
   • Section 2C - 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 email

Enrollment rules

The Centers for Medicare and Medicaid Services (CMS) has made these requirements for group Medicare plan enrollment:

• You must use enrollment and disenrollment forms that meet CMS requirements. All Priority Health forms meet the requirements (see above). You can use your own forms as long as they follow CMS model forms.
• You can submit enrollment/disenrollment forms in any way (mail, email, fax) as long as you keep a copy of the original form on file.
• You can't make retroactive enrollment requests more than 80 days past the effective date (per Section 60.6.1, Enrollment/Disenrollment, Medicare Managed Care Manual).
• You can't make retroactive disenrollment requests more than 90 days past the effective date (per Section 60.6.2, Enrollment/Disenrollment, Medicare Managed Care Manual).