Typically, you may enroll in a Medicare Advantage plan only during the annual enrollment period from October 15 through December 7 of each year. There are exceptions that may allow you to enroll in a Medicare Advantage plan outside of this period.
Please read the following statements carefully and check the box if the statement applies to you. By checking any of the following boxes you are certifying that, to the best of your knowledge, you are eligible for an Enrollment Period. If we later determine that this information is incorrect, you may be disenrolled.
If none of these statements applies to you or you’re not sure, please contact Reliance Medicare at 855-959-5855
(TTY users should call 711 to see if you are eligible to enroll. We are open October 1-March31: Seven Days a week from 8:00a.m.–8:00 p.m. Eastern. April 1-September 30: Monday—Friday from 8:00 a.m.—8:00 p.m. Eastern.
Please Read This Important Information
If you currently have health coverage from an employer or union, joining Reliance Medicare Advantage could affect your employer or union health benefits. You could lose your employer or union health coverage if you join Reliance Medicare Advantage. Read the communications your employer or union sends you. If you have questions, visit their website, or contact the office listed in their communications. If there isn’t any information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.
By completing this enrollment application, I agree to the following:
Reliance Medicare Advantage is a Medicare Advantage plan and has a contract with the Federal government. I will need to keep my Medicare Parts A and B. I can be in only one Medicare Advantage plan at a time, and I understand that my enrollment in this plan will automatically end my enrollment in another Medicare health plan or prescription drug plan. It is my responsibility to inform you of any prescription drug coverage that I have or may get in the future. I understand that if I don’t have Medicare prescription drug coverage, or creditable prescription drug coverage (as good as Medicare’s), I may have to pay a late enrollment penalty if I enroll in Medicare prescription drug coverage in the future. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes only at certain times of the year when an enrollment period is available (Example: October 15 – December 7 of every year), or under certain special circumstances.
Reliance Medicare Advantage serves a specific service area. If I move out of the area that Reliance Medicare Advantage serves, I need to notify the plan so I can disenroll and find a new plan in my new area. Once I am a member of Reliance Medicare Advantage, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from Reliance Medicare Advantage when I get it to know which rules I must follow to get coverage with this Medicare Advantage plan. I understand that people with Medicare aren’t usually covered under Medicare while out of the country except for limited coverage near the U.S. border.
I understand that beginning on the date Reliance Medicare Advantage coverage begins, I must get all of my health care from Reliance Medicare Advantage, except for emergency or urgently needed services or out-of-area dialysis services. Services authorized by Reliance Medicare Advantage and other services contained in my Reliance Medicare Advantage Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR RELIANCE MEDICARE ADVANTAGE WILL PAY FOR THE SERVICES.
I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or contracted with Reliance Medicare Advantage, he/she may be paid based on my enrollment in Reliance Medicare Advantage.
Release of Information: By joining this Medicare health plan, I acknowledge that Reliance Medicare Advantage will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that Reliance Medicare Advantage will release my information including my prescription drug event data to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations. The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan.