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OMB No. 0938-1378Expires: 7/31/20232022 Year Medicare Advantage Plan IndividualEnrollment Request Form Cover PageWho can use this form?Reminders:People with Medicare who want to join aMedicare Advantage Plani If you want to join a plan during fall openenrollment (October 15–December 7), theplan must get your completed form byDecember 7.i Your plan will send you a bill for the plan’spremium. You can choose to sign up tohave your premium payments deductedfrom your bank account or your monthlySocial Security (or Railroad RetirementBoard) benefit.To join a plan, you must:i Be a United States citizen or be lawfullypresent in the U.S.i Live in the plan’s service areaImportantTo join a Medicare Advantage Plan, you mustalso have both:i Medicare Part A (Hospital Insurance)i Medicare Part B (Medical Insurance)When do I use this form?You can join a plan:i Between October 15–December 7 eachyear (for coverage starting January 1)i Within 3 months of first getting Medicarei In certain situations where you’re allowedto join or switch plansVisit Medicare.gov to learn more about whenyou can sign up for a plan.What do I need to completethis form?i Your Medicare Number (the number onyour red, white, and blue Medicare card)i Your permanent address andphone numberY0036 22 98346 M Final 72Send your completed and signed form to:MAS EnrollmentCignaPO Box 29030Phoenix, AZ 85050Once they process your request to join,they’ll contact you.How do I get help with this form?Call Cigna at 1-855-721-1589 (TTY 711).Or, call Medicare at 1-800-MEDICARE(1-800-633-4227). TTY users cancall 1-877-486-2048.En español: Llame a Cigna al 1-855-721-1589(TTY 711) o a Medicare gratisal 1-800-633-4227 y oprima el 2 paraasistencia en español y un representanteestará disponible para asistirle.ENROLLMENTNote: You must complete all items inSection 1. The items in Section 2 areoptional—you can’t be denied coveragebecause you don’t fill them out.What happens next?22 EF 051 PHBK1
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2022 Medicare Advantage PlanIndividual Enrollment Request FormNew CustomerPlan ChangePage 1 of 9RFI Follow-upSECTION 1All fields in this section are required (unless marked optional)2022 MEDICARE ADVANTAGE PLAN INDIVIDUAL ENROLLMENT REQUEST FORMSELECT THE PLAN YOU WANT TO JOINMedicare Advantage plan (HMO) with a Part D drug benefit:Cigna Alliance Medicare (HMO) H0354-028 0.00 per monthCigna Preferred Medicare (HMO) H0354-001 0.00 per monthMedicare Advantage plan (HMO SNP) with a Part D drug benefit:Cigna Achieve Medicare (HMO C-SNP) H0354-027 0.00 per monthThis plan is for those who have been diagnosed with Diabetes.ABOUT YOUProvide the following information.Last NameFirst NameMiddle InitialTitleDate of BirthGenderMr.Mrs.Ms.Phone NumberHomeCell//MaleFemaleAlternate Phone NumberHomeCellPERMANENT ADDRESSPO Box is not allowed.Permanent Residence Street AddressCityStateZip CodeENROLLMENTCounty3
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Enrollee Medicare Number (Required):Page 2 of 9MAILING ADDRESSLeave blank if same as permanent address.Street AddressCityStateZip Code2022 MEDICARE ADVANTAGE PLAN INDIVIDUAL ENROLLMENT REQUEST FORMYOUR MEDICARE INFORMATIONUse your red, white and blue Medicare card to complete this section. Provide this information as it appears onyour Medicare card, or attach a copy of your Medicare card or your letter from Social Security or the RailroadRetirement Board.NameCoverage StartsEntitled ToMedicare NumberHospital (Part A)//Medical (Part B)//ANSWER THESE IMPORTANT QUESTIONSWill you have other prescription drug coverage in addition to this plan for which you are applying?Some people may have other drug coverage, including private insurance, TRICARE, federal employee healthbenefits coverage, VA benefits or State pharmaceutical assistance programs.YesNoIf Yes, Name of Other Coverage (located on your ID card)ID Number of Other CoverageGroup Number for Other CoverageRxBINRxPCNPhone NumberEffective Date//ENROLLMENT5
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Enrollee Medicare Number (Required):Page 3 of 9Do you live in a Long Term Care Facility, such as a nursing home?YesNoIf Yes, Name of FacilityAddressStateZip CodePhone NumberDate of Admission to Facility//2022 MEDICARE ADVANTAGE PLAN INDIVIDUAL ENROLLMENT REQUEST FORMCityAre you enrolled in your State Medicaid program? (Required for Cigna TotalCare and TotalCare Plus)YesNoIf Yes, Medicaid NumberMedicaid Case Number (Texas Only)To qualify for the Cigna Achieve Medicare (HMO C-SNP) plan, please answer the following question:Have you been diagnosed with Diabetes?YesNoENROLLMENT7
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Enrollee Medicare Number (Required):Page 4 of 9STOPImportant: Read and sign belowi I must keep both Hospital (Part A) and Medical (Part B) to stay in Cigna.i By joining this Medicare Advantage Plan, I acknowledge that Cigna will share my information with Medicare,iii1. This person is authorized under State law to complete this enrollment, and2. Documentation of this authority is available upon request by Medicare.By signing below and providing my phone number, I agree that Cigna, its affiliates, and representatives maycontact me regarding additional products or services by calling or texting me at the number above, by email, orby letter. I acknowledge these messages may be delivered using an automatic telephone dialing system and/oran artificial or prerecorded voice. I agree that Cigna may use the information provided or obtained in connectionwith this application, or insurance coverage provided by Cigna including my personal information, to offer meadditional products and services or to send related marketing communications regarding Cigna products. Iacknowledge that I am not required to provide consent to receive these communications as a condition ofapplying for coverage. If I choose not to receive marketing communications, I will indicate that below or canwithdraw my consent at any time by contacting Cigna.I do not consent to receive marketing communications.Signature of Customer/Enrollee or Authorized RepresentativeToday’s Date//2022 MEDICARE ADVANTAGE PLAN INDIVIDUAL ENROLLMENT REQUEST FORMiiwho may use it to track my enrollment, to make payments and for other purposes allowed by Federal law thatauthorize the collection of this information (see Privacy Act Statement included in this document).Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan.The information on this Enrollment Form is correct to the best of my knowledge. I understand that if Iintentionally provide false information on this form, I will be disenrolled from the plan.I understand that people with Medicare are generally not covered under Medicare while out of the country,except for limited coverage near the U.S. border.I understand that when my Cigna coverage begins, I must get all of my medical and prescription drug benefitsfrom Cigna. Benefits and services provided by Cigna and contained in my Cigna Evidence of Coveragedocument (also known as a member contract or subscriber agreement) will be covered. Neither Medicare norCigna will pay for benefits or services that are not covered.I understand that my signature (or the signature of the person legally authorized to act on my behalf) on thisapplication means that I have read and understand the contents of this application. If signed by an authorizedrepresentative (as described above), this signature certifies that:ENROLLMENT9
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Enrollee Medicare Number (Required):Page 5 of 9AUTHORIZED REPRESENTATIVEIf you are the Authorized Representative (who signed above), you must provide the following information.Last NameFirst NameMiddle InitialPhone NumberRelationship to EnrolleeCityStateZip CodeSECTION 2All fields in this section are optionalAnswering these questions is your choice. You can’t be denied coverage because you don’t fill them out.OTHER LANGUAGESelect if you want us to send you information in a language other than English.SpanishACCESSIBLE FORMATSSelect one if you want us to send you information in an accessible format.BrailleLarge PrintAudio CDIf you need information in a format other than what is listed, please call Cigna at1-888-284-0268 (TTY 711), 8 a.m. to 8 p.m. local time, 7 days a week October 1 to March 31,Monday to Friday April 1 to September 30. Our automated phone system may answer yourcall during weekends, holidays and after hours.WORK STATUSDo you work?YesNoDoes your spouse work?YesNo2022 MEDICARE ADVANTAGE PLAN INDIVIDUAL ENROLLMENT REQUEST FORMStreet AddressPRIMARY CARE PROVIDER (PCP), CLINIC OR HEALTH CENTER SELECTIONRefer to the online Provider Directory located at CignaMedicare.com.ENROLLMENTPCP Full NameEnter PCP ID exactly as it appears in the Provider Directory. Include zeros, but not dashes.Provider/PCP IDAre you an existing patient now seeing or have you recently seen this doctor?YesNo11
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Enrollee Medicare Number (Required):Page 6 of 9CHRONIC CONDITIONSThis question applies only to those individuals whose plan offers a chronic condition–specific benefit; however,answering this question is not required, and choosing not to respond will not affect your enrollment.You must be diagnosed with a chronic condition, such as, but not limited to diabetes, heart disease orhypertension to be eligible to receive certain plan benefits. Have you been diagnosed with a chronic condition?YesNoYes, email my important plan information.Yes, email me helpful tips and articles on healthy living, the “More From Life” newsletter, surveys andgeneral information.Email AddressPAYING YOUR PLAN PREMIUMSIf you have a monthly plan premium (or if you currently have a late enrollment penalty), we need to know howyou want to pay. You can pay by mail or Electronic Funds Transfer (EFT) each month. You can also chooseto pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB)monthly benefit check.Part D-IRMAAIf you are assessed a Part B or Part D-Income Related Monthly Adjustable Amount (IRMAA), you will be notifiedby the Social Security Administration. You will be responsible for paying this extra amount in addition to yourplan premium. You will either 1) have the amount withheld from your Social Security benefit check or 2) be billeddirectly by Medicare or RRB. DO NOT PAY the Part D-IRMAA to Cigna.Extra HelpIf you have a limited income, you may be able to get Extra Help to pay for prescription drugs. If eligible,Medicare could pay for 75% or more of your drug costs, including monthly prescription drug premiums, annualdeductibles and coinsurance.Additionally, if you qualify, you will not be subject to the Coverage Gap or a Medicare late enrollment penalty.Many people are able to get these savings and do not know it. For more information about this Extra Help:2022 MEDICARE ADVANTAGE PLAN INDIVIDUAL ENROLLMENT REQUEST FORMEMAILTo receive information via email, please choose one or both email options.i Call your local Social Security office, ori Call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.You can also apply for Extra Help online at If you are able to get Extra Help with your Medicare prescription drug coverage costs, Medicare will pay all orpart of your plan premium. If Medicare pays only a portion of your premium, you will be billed for the amountMedicare does not cover.13
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Enrollee Medicare Number (Required):Page 7 of 9PLEASE SELECT A PREMIUM PAYMENT OPTION:If you do not select a payment option, you will receive a bill each month for the amount Medicare doesnot cover.Automatic deduction from your Social Security or Railroad Retirement Board benefit check.I get monthly benefits from:Social SecurityRRBGet a monthly bill.You also have the option of paying your monthly bill online at CignaMedicare.com/paymybill.Automatic deduction from your checking account each month (EFT – Electronic Funds Transfer).Provide the following:Bank NameRouting NumberAccount NumberPrivacy Act StatementThe Centers for Medicare & Medicaid Services (CMS) collects information from Medicare plans to trackbeneficiary enrollment in Medicare Advantage (MA) Plans, improve care, and for the payment of Medicarebenefits. Sections 1851 and 1860D-1 of the Social Security Act and 42 CFR §§ 422.50 and 422.60 authorize thecollection of this information. CMS may use, disclose and exchange enrollment data from Medicare beneficiariesas specified in the System of Records Notice (SORN) “Medicare Advantage Prescription Drug (MARx)”, SystemNo. 09-70-0588. Your response to this form is voluntary. However, failure to respond may affect enrollment inthe plan.2022 MEDICARE ADVANTAGE PLAN INDIVIDUAL ENROLLMENT REQUEST FORMThe Social Security/RRB deduction may take two or more months to begin after Social Security or RRBapproves the deduction. In most cases, if Social Security or RRB accepts your request for automatic deduction,the first deduction from your Social Security or RRB benefit check will include all premiums due from yourenrollment effective date up to the point withholding begins. If Social Security or RRB does not approve yourrequest for automatic deduction, we will send you a paper bill for your monthly premiums.ENROLLMENT15
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Enrollee Medicare Number (Required):Page 8 of 9AGENT USE ONLYNote: This area must be completed in its entiretyto prevent the delay or denial of application.Proposed Coverage Start Date/ 0 1 / 2 0 2 2Select Enrollment Period(Must be after the enrollee sign date)SEP Code (Required if SEP selected)OEPSEPAEPOEPI2022 MEDICARE ADVANTAGE PLAN INDIVIDUAL ENROLLMENT REQUEST FORMICEP MA or MAPDIEP PDP or MAPDSEP Date//Licensed Sales Agent NameLicensed Sales Agent IDLicensed Sales Agent Phone NumberScope of Appointment ID NumberAppointment TypeDate//SPECIAL ENROLLMENT PERIODRead the followingUsually, you may join a Medicare Advantage plan only during the Annual Enrollment Period from October 15through December 7 of each year. There are conditions that may allow you to join a Medicare Advantage planduring a Special Enrollment Period outside of the Annual Enrollment Period.Check the box if the statement applies to you. If you check any of the following boxes, you are certifying that,to the best of your knowledge, you are eligible for a Special Enrollment Period. If we later determine that thisinformation is incorrect, you may be disenrolled.If the below statements do not apply to you or you’re not sure, contact Cigna at 1-800-627-7534 (TTY 711)to see if you are eligible to enroll. We are open 8 a.m. to 8 p.m. local time, 7 days a week October–March,Monday to Friday April–September. Our automated phone system may answer your call during weekends,holidays and after hours.I am new to Medicare.OEPI am enrolled in a Medicare Advantage plan and want to make a change during the MedicareAdvantage Open Enrollment Period (MA OEP).MOVI recently moved outside of the service area for my current plan; or, I recently moved and this is anew option for me. I moved on//.(insert date)LECI am leaving employer or union coverage on//(insert date)ENROLLMENTNEW.17
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Enrollee Medicare Number (Required):Page 9 of 9LCCI recently involuntarily lost my creditable prescription drug coverage (as good as Medicare’s) on//(insert date).PAPI belong to a pharmacy assistance program provided by my State.RUSI recently returned to the U.S. after living permanently outside of the U.S. I returned to the U.S. on//(insert date).PACI recently left a PACE program on//(insert date)EOCMy plan is ending its contract with Medicare; or, Medicare is ending its contract with my plan.INCI recently was released from incarceration. I was released on//.(insert date)LAWI recently obtained lawful presence status in the U.S. I got this status on//.(insert date)5STI am enrolling in a 5-star Medicare plan.MCDI recently had a change in my Medicaid (newly got Medicaid, had a change in the level of Medicaidassistance or lost Medicaid) on//.(insert date)NLSI recently had a change in my Extra Help paying for Medicare prescription drug coverage (newly gotExtra Help, had a change in the level of Extra Help or lost Extra Help) on//.(insert date)OTHI was enrolled in a plan by Medicare (or my State) and I want to choose a different plan. Myenrollment in that plan started on//.(insert date)DSTI was affected by a weather-related emergency or major disaster (as declared by the FederalEmergency Management Agency (FEMA)). One of the other statements here applied to me, but Iwas unable to make my enrollment because of the natural disaster.MDEI have both Medicare and Medicaid (or my State helps pay for Medicare premiums) or I get ExtraHelp paying for my Medicare prescription drug coverage, but I haven’t had a change.LTCI am moving into, live in or recently moved out of a Long Term Care Facility (example: a nursinghome). My moving date is on//.(insert date).2022 MEDICARE ADVANTAGE PLAN INDIVIDUAL ENROLLMENT REQUEST FORMSNPI was enrolled in a Special Needs Plan (SNP) but I have lost the special needs qualificationrequired to be in that plan. I was disenrolled from the SNP on//.(insert date)ENROLLMENT19
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2022 MEDICARE ADVANTAGE PLAN INDIVIDUAL ENROLLMENT REQUEST FORM21ENROLLMENTAll Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation.The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. Cigna contracts withMedicare to offer Medicare Advantage HMO and PPO plans and Part D Prescription Drug Plans (PDP) in selectstates, and with select State Medicaid programs. Enrollment in Cigna depends on contract renewal. Enrollment inthe Cigna Achieve Medicare plan is for those who have been diagnosed with Diabetes. You must live in the plan’sservice area. Call Customer Service at 1-800-627-7534 (TTY 711), 8 a.m. to 8 p.m. local time, 7 days a weekOctober 1 to March 31, Monday to Friday April 1 to September 30. Our automated phone system may answeryour call during weekends, holidays and after hours Individuals may enroll in a plan only during specific timesof the year and must have Medicare Parts A and B. Prior authorization and/or referrals are required for certainservices. This information is not a complete description of benefits, which vary by individual plan. 2021 Cigna
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ENROLLMENT. 2022 Medicare Advantage Plan Individual Enrollment Request Form . New Customer Plan Change RFI Follow-up Page 1 of 9 . SECTION 1 . All fields in this section are required (unless marked optional) SELECT THE PLAN YOU WANT TO JOIN Medicare Advantage plan (HMO) with a Part D drug benefit: Cigna Alliance Medicare (HMO) H0354-028 0.00 .
