You are eligible for membership in our plan as long as:
- You live in our geographic service area
- You have both Medicare Part A and Medicare Part B
- You do not have End-Stage Renal Disease (ESRD), with limited exceptions, such as if you develop ESRD when you are already a member of a plan that we offer, or you were a member of a different plan that was terminated.
- You meet the eligibility requirements to enroll in a special need plan.
Important Information About the Enrollment Periods
Initial Coverage Election Period (ICEP)
During the Initial Enrollment Period, you must enroll in Medicare Parts A and B as well as in 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 will begin on October 15 and end on December 7 of each year.
Medicare Advantage Disenrollment Period
The period for Medicare Advantage Disenrollment will be 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 Period can be at any time of the year. There are several reasons why a member could be eligible for a Special Enrollment Period. Some of them are:
- The member moves outside the coverage are for a period longer than 6 consecutive months.
- Breach of contract – the member demonstrates that the plan did not comply with the stipulated contract or the sales agent did not correctly represent the plan.
- Termination of contract
- The contract was not renewed
- The beneficiary is eligible for Medicare and Medicaid (for example, Medicare Platino)
- The beneficiary is diagnosed with a chronic health disease such as: diabetes mellitus, cardiovascular disorders; or chronic heart failure.
Instructions for filling out Triple-S Advantage Enrollment Form
- Please read this information carefully, write clearly, press hard and use only blue or black ink.
- Type 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 put dashes or blank spaces.
- Select the Plan you want to enroll in
- Complete your personal information as it appears on your Medicare Card (name, Social Security number, effective date of Medicare Part A and/or B, etc.). If your home and/or postal address is different from the one on your Medicare Card, please include your current address and 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 form.
- Keep the 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
Member and Plan Rights and Responsibilities upon Disenrollment
If you are a member of Triple-S Advantage and would like 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 communication requesting the disenrollment and stating your reason for disenroll. It is important that this communication is signed by the member or his/her authorized representative.representante autorizado.
Types of Disenrollment
Voluntary Disenrollment by Member (your own choice)
A member may request disenrollment from an MA plan only during one of the election periods by:
- Enrolling in another plan (during a valid enrollment period);
- Giving or faxing a signed written notice to the MA organization, or through his/her employer or union, where applicable;
- Submitting a request via the Internet to the MA organization (if the MA organization offers such an option)
- Calling 1-800-MEDICARE.
Involuntary Disenrollment (not your own choice)
The MA organization must disenroll a member from an MA plan in the following cases:
- A change in residence (includes incarceration) makes the individual ineligible to remain enrolled in the plan
- The member loses entitlement to either Medicare Part A or Part B
- The SNP enrollee loses special needs status and does not reestablish SNP eligibility prior to the expiration of the period of deemed continued eligibility
- The member dies
- The MA organization contract is terminated, or the MA organization reduces its service area to exclude 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 will be changing to Original Medicare you might have a special temporary right to buy a Medigap policy, also known as Medicare supplement 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 protections described above. Puerto Rico may have laws that provide more Medigap protections. If you have questions about Medigap or Medigap rights in Puerto Rico, you should contact your State Health Insurance Program (SHIP) Oficina de Procurador de las Personas Pensionadas y de la Tercera Edad at 787-721-6121. You can also call 1-800-MEDICARE (1-800-633-4227) anytime, 24 hours a day, 7 days a week for more information. TTY users should call 1-877-486-2048.
All correspondence should be mailed to:
Attn: Enrollment Department
PO BOX 11320
San Juan PR 00922
You may also fax your requests to:
Last update: 10/03/2016