Enrollment You are eligible for membership in our plan as long as: 1 You live in our geographic service area 2 You have both Medicare Part A and Part B 3 You meet the eligibility requirements to enroll in a special needs plan / if applicable. Important Information About the Enrollment Periods Medicare Advantage Open Enrollment PeriodThis happens every year from January 1 to March 31. During this time, you can: Switch to another Medicare Advantage Plan. (You can choose a plan that covers prescription drugs or one that does not cover prescription drugs.) Disenroll from our plan and obtain coverage through Original Medicare. If you choose to switch to Original Medicare during this period, you have until March 31 to join a separate Medicare prescription drug plan to add drug coverage. If you make a change during this period, your membership will end on the first day of the month after you enroll in a different Medicare Advantage plan or we get your request to switch to Original Medicare. If you also choose to enroll in a Medicare prescription drug plan, your membership in the drug plan will begin the first day of the month after the drug plan gets your enrollment request. Initial Coverage Election Period (ICEP)During the Initial Enrollment Period, you must enroll in Medicare Parts A and B as well as in the Medicare Prescription Drug Plan. This period lasts seven (7) months: three (3) months prior to the beneficiary’s birthday, the beneficiary’s birthday month, and three (3) months after. Annual Enrollment Period (AEP)The Annual Enrollment Period begins on October 15 and ends on December 7 of every year. Medicare Advantage Disenrollment PeriodThe period for Medicare Advantage Disenrollment is from January 1st to February 14. During this period, you can only change to Original Medicare and enroll in a Medicare Prescription Drug Plan. You cannot change from one Medicare Advantage Plan to another. Special Enrollment Period (SEP)The Special Enrollment Periods can be at any time of the year. There are several reasons why you could be eligible for a Special Enrollment Period. You move outside the coverage are for a period longer than six (6) consecutive months. Breach of contract – you demonstrate that the plan did not comply with the contract or the sales agent did not correctly represent the plan. Termination of contract The contract was not renewed You are eligible for Medicare and Medicaid (for example, Medicare Platino) You were diagnosed with a chronic health disease, such as: diabetes mellitus, cardiovascular conditions, or chronic heart failure. Instructions to fill out the Triple-S Advantage Enrollment Form Please read this information carefully, write clearly, press hard, and use only blue or black ink Write the numbers and uppercase letters legibly in the boxes Write only one letter per box If you make a mistake, write in the space above or below When writing dates, use the month/day/year format. No need to include dashes or blank spaces Select the Plan you want to enroll in Complete your personal information as it appears on your Medicare Card (name, Medicare number, effective date of Medicare Part A and/or B, etc.). If your home and/or mailing address is different from the one on your Medicare Card, make sure to include your current address not the one on your Medicare Card Select your preferred payment method (if applicable) Provide the information of any other health plan you may have (if any) Read the terms and conditions Verify that you have completed all the information in the application Sign and date the enrollment form Keep a copy for your reference Mail or fax the form to the provided address/fax number If you have any questions regarding the Enrollment Form or the enrollment process, please contact our Customer Service Department. ENROLLMENT REQUEST FORMThe 2024 ENROLLMENT REQUEST FORM is a document to apply and join one of Triple-S Advantage 2024 plans. This document includes instructions on how to complete and return it in order to process your application. Real (HMO) AhorroMax (HMO) Magno (HMO-POS) Brillante (HMO-POS) Enlace Plus (HMO) Contigo Plus (HMO-SNP) Basic (HMO) Platino Plus (HMO-SNP) Platino Blindao (HMO-SNP) Platino Enlace (HMO-SNP) Platino Advance (HMO-SNP) Platino Selecto (HMO-SNP) Platino Titán (HMO-SNP) Óptimo (PPO) Óptimo Plus (PPO) Óptimo Xtra (PPO) Disenrollment Member and Plan Rights and Responsibilities upon Disenrollment If you are a member of Triple-S Advantage and wish to disenroll from the Plan, you should contact our Customer Service Department to receive a complete orientation of the disenrollment process. To disenroll, you must send a written request for disenrollment, including your reason to disenroll. It is important that this request is signed by the member or his/her authorized representative. Types of Disenrollment Voluntary Disenrollment by Member (your own choice)A member may request disenrollment from a Medicare Advantage plan only during one of the election periods by: Enrolling in another plan during a valid enrollment period Sending or faxing a signed written notice to your Medicare Advantage organization, or through your employer or union, if applicable Submitting an online request to the Medicare Advantage organization (if the organization offers this option) Calling 1-800-MEDICARE Involuntary Disenrollment (not your own choice)The Medicare Advantage organization must disenroll you from the plan in the following cases: Change of residence – a change in residence (including incarceration) makes the individual ineligible to remain enrolled in the plan The member loses entitlement to either Medicare Part A or Part B The Special Needs Plan member loses his/her special needs status and does not reestablish SNP eligibility before the eligibility period expires The member dies The Medicare Advantage organization contract is terminated, or the Medicare Advantage organization reduces its service area, this excluding the member The member fails to pay his/her Part D-IRMAA to the government and CMS notifies the plan to effectuate the disenrollment If you decide to change over to Original Medicare, you might be temporarily entitled obtain a Medigap policy (Medicare supplemental insurance), even if you have health problems. For example, if you are age 65 or older and you enrolled in Medicare Part B within the past 6 months, or if you move out of the service area, you may have this special right. Federal law requires the aforementioned protections to be available. Puerto Rico may have other laws that provide more Medigap protections. If you have questions about Medigap or Medigap Rights in Puerto Rico, you may contact your State Health Insurance Program (SHIP), the Oficina del Procurador de Personas de Edad Avanzada, at 787-721-6121. You may also call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week for more information. TTY/TDD users should call 1-877-486-2048. All correspondence should be mailed to: Triple-S Advantage Attn: Enrollment Department PO BOX 11320 San Juan PR 00922 You may also fax your requests to: 787-620-0931
