Vantage Medicare Advantage

Plan Selection Change Form

I want to transfer from my current plan to the plan I have selected below. I understand that if this form is received by the end of any month, my new plan will generally be effective the 1st of the following month.

Paying For Your Plan

If your plan has a monthly premium or if we determine that you owe a late enrollment penalty or if youcurrently have a late enrollment penalty, we need to know how you prefer to pay for your plan.

You can pay by mail, Electronic Funds Transfer (EFT), credit/debit card each month, or by prepayingquarterly or annually. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month.

If you have to pay a Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA), you must pay this extra amount in addition to your plan premium. The amount is usually taken out of your Social Security benefit, or you may get a bill from Medicare (or the RRB). DO NOT pay Vantage Medicare Advantage the Part D-IRMAA.

 Receive a bill
 Automatic deduction from your monthly Social Security (SSA) benefit check
 Automatic deduction from your monthly Railroad Retirement Board (RRB) benefit check
 Electronic funds transfer (EFT) from your bank account each month

The fields in this section are optional.

Answering these questions is your choice. You can’t be denied coverage because you don’t fill them out.

No, not of Hispanic, Latino/a, or Spanish origin
Yes, Mexican, Mexican American, Chicano/a
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino/a, or Spanish origin
I choose not to answer.
American Indian or Alaska Native
Asian Indian
Black or African American
Guamanian or Chamorro
Native Hawaiian
Other Asian
Other Pacific Islander
I choose not to answer.

Plan Documents

 Audio CD
 Digital Documents (only certain documents are available in a paperless format)
 Large Print

Please contact Vantage Health Plan toll-free at 866-704-0109 (TTY users should call 711) if you need information in large print or Spanish. Member Services is available seven days a week, 8:00 a.m. – 8:00 p.m. CST from October through March, and available five days a week, 8:00 a.m. – 8:00 p.m. CST from April through September.

Attestation of Eligibility for an Enrollment Period

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 Vantage Health Plan at (866) 704-0109 (TTY users should call 711) to see if you are eligible to enroll. Our phone lines are open 7 days a week from 8 a.m. to 8 p.m.

  • I must keep both Hospital (Part A) and Medical (Part B) to stay in Vantage Medicare Advantage.
  • By joining this Medicare Advantage Plan or Medicare Prescription Drug Plan, I acknowledge that Vantage Medicare Advantage will share my information with Medicare, who may use it to track my enrollment, to make payments, and for other purposes allowed by Federal law that authorize the collection of this information (see Privacy Act Statement below).
  • 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 I intentionally 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 Vantage Medicare Advantage coverage begins, I must get all of my medical and prescription drug benefits from Vantage Medicare Advantage. Benefits and services provided by Vantage Medicare Advantage and contained in my Vantage Medicare Advantage “Evidence of Coverage” document (also known as a member contract or subscriber agreement) will be covered. Neither Medicare nor Vantage Medicare Advantage 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 this application means that I have read and understand the contents of this application. If signed by an authorized representative (as described above), this signature certifies that:
    1. This person is authorized under State law to complete this enrollment, and
    2. Documentation of this authority is available upon request by Medicare.

 I am an Authorized Personal Representative

If you are the Authorized Personal Representative, you must provide the following information:

Vantage Health Plan (Vantage) is an HMO with a Medicare contract. Enrollment in Vantage depends on contract renewal.

This information is not a complete description of benefits. Call 1-888-823-1910 (TTY users call 711) for more information.