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
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.
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, another Hispanic, Latino/a, or Spanish origin
I choose not to answer.
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.