• How can I enroll in Blue Medicare PPO, a preferred provider health insurance plan?
• Who is eligible to enroll for Blue Medicare PPO?
• Enrollment Periods

How can I enroll in Blue Medicare PPO?

We offer two easy ways to enroll in Blue Medicare PPO:

1. Enroll online now
2. Mail: Download the enrollment form (PDF), complete and mail in to the address below:

   Blue Medicare PPO
   PO Box 3567
   Scranton, PA 18503

Our plan is offered by HCSC Insurance Service Company, a Medicare Advantage Preferred Provider Organization (PPO) plan. The attached Summary of Benefits highlights some important health benefits. It does not list every service that we cover or list every limitation or exclusion. To obtain a complete list of benefits, you may download the Evidence of Coverage.

Evidence of Coverage

• Value Plan (PDF, 1.3MB)
• Advantage Plan (PDF, 1.3MB)
• Premier Plan (PDF, 1.3MB)

Summary of Benefits

• Summary of Benefits (PDF, 116KB)

Make paying your premiums easy!
Download, complete and sign the Automatic Premium Payment Program Form (PDF, 181KB). You can even send it in with your application.

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Who is eligible to enroll for Blue Medicare PPO?

Blue Medicare PPO is open to all Medicare beneficiaries eligible by age or disability in the Plan's service area. You must be entitled to Medicare under Part A and enrolled in Medicare Part B and live in the following counties in Texas; Harris, Jefferson, Galveston (zip codes 77550, 77551, 77554 not included), Montgomery or El Paso. You must continue to pay your Medicare Part A and Part B premium, if applicable. Blue Medicare PPO is available to Medicare beneficiaries and is an approved Medicare advantage plan. (Individuals with end-stage renal disease are not eligible to enroll.) If you had a kidney transplant and no longer need dialysis, or if you enrolled in a Medicare Advantage Plan that has withdrawn from your coverage area, then you may enroll in Blue Medicare PPO.

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Enrollment Periods

Annual Enrollment Period (AEP)
During the AEP, Medicare Advantage eligible individuals may enroll in or disenroll from a MA plan. The last enrollment made, determined by the date the election was received by the MA organization, will be the election that takes effect.

The AEP occurs November 15 through December 31 of every year.

Initial Enrollment Period (IEP)
The Initial Enrollment Period is the period during which an individual newly eligible for Medicare (and Medicare Advantage) may make an initial election to enroll in a MA plan. This seven (7) month period consists of:

• three (3) months before the month of your 65th birthday
• the month of your 65th birthday
• three (3) months after the month of your 65th birthday

Those who are under age 65 and have a disability may also be eligible to enroll.

Special Enrollment Period (SEP)
You may also enroll in Blue Medicare PPO outside of the initial or annual enrollment periods under circumstances such as (but not limited to):

• moving into the service area
• involuntarily losing creditable coverage
• becoming dual eligible

Because documentation is required to enroll during this period, please contact our Customer Service Department, for specific details, at (866) 308-4781, 8 a.m. - 8 p.m., CST, 7 days a week. For the hearing or speech impaired, please call (800) 538-0380.

Open Enrollment Period (MA-OEP)
Each year, from January 1 through March 31, a Medicare Advantage (MA) eligible individual may make ONE MA-OEP election.

However, there are some limits for the OEP. The following chart describes the applicable scenarios and available options.

Possible MA-OEP election options:

If you choose not to enroll during these required time frames, the federal government may impose a late enrollment penalty of 1% per month for every month you delay enrollment. To learn more about the late enrollment penalty, please call our Customer Service Department, for specific details, at (866) 308-4781, Monday - Friday, 8 a.m. - 8 p.m., CST, 7 days a week. For the hearing or speech impaired, please call (800) 538-0380.

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Alternate formats of this material, including translation, may be available. Please contact Customer Service, at (866) 308-4781, Monday-Friday, 8 a.m. - 8 p.m. CST, 7 days a week, for additional information. For the hearing or speech impaired, please call (800) 538-0380.