Page 46 - Demo

Important Information
Regarding Your Medicare Advantage Plan
I understand that I need to keep my Medicare Parts A & B. I must maintain my Medicare Part B insurance by continuing to pay the Part B premium, if applicable.
I understand that by enrolling in this Medicare Advantage plan, I will automatically be disenrolled by the Centers for Medicare
& Medicaid Services (CMS) from any other Medicare Advantage plan of which I am currently a member. I can only be in one Medicare Advantage plan at a time. It is
my responsibility to inform you of any prescription drug coverage that I have
or may get in the future.
I will read the Evidence of Coverage document from this Medicare Advantage plan when
I receive it to know which rules I must
follow in order to receive coverage with this Medicare Advantage plan. I understand that beneficiaries of Medicare generally are not covered under Medicare while out of the country except for limited coverage near
the U.S. border.
Release of Information: By joining this Medicare health plan, I acknowledge that the Medicare health plan will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations.
Once I am a member of this Medicare Advantage plan, I have the right to appeal plan decisions about payment or services
if I disagree. I will read the Evidence of Coverage from the plan when I receive it to know which rules I must follow to receive coverage with this Medicare Advantage plan.
46 | Insurance Trust For Delta Retirees | 2021 Benefits & Resources Guide