Value Terms and Conditions

By completing this enrollment application, I agree to the following: 
Martin’s Point Generations Advantage is a Medicare Advantage plan and has a contract with the federal government. I will need to keep my Medicare Parts A and B. I can be in only one Medicare Advantage plan at a time, and I understand that my enrollment in this plan will automatically end my enrollment in any other Medicare health plan or Medicare prescription drug plan. It is my responsibility to inform you of any prescription drug plan that I have or may get in the future. 

Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes only at certain times of the year when an enrollment period is available (example: October 15–December 7 of every year), or under certain special circumstances. 

Martin’s Point Generations Advantage serves a specific service area. If I move out of the area that Generations Advantage serves, I need to notify the plan so I can disenroll and find a new plan in my new area. Once I am a member of Generations Advantage, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage to know which rules I must follow to be covered under this Medicare Advantage plan. I understand that people with Medicare aren’t usually covered under Medicare while out of the country except for limited coverage near the US border. 
I understand that if I do not have Medicare prescription drug coverage, or creditable prescription drug coverage (as good as Medicare’s), I may have to pay a Part D late enrollment penalty if I enroll in Medicare prescription drug coverage in the future.  I understand that, beginning on the date Generations Advantage coverage begins, only Medicare-covered services received from Generations Advantage network providers will be covered (except for emergency or urgently needed services, or out-of-the-area dialysis, which are covered in-and out-of-network).  
I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or contracted with Generations Advantage, they may be paid based on my enrollment in Generations Advantage. 

Release of Information: By joining this Medicare health plan, I acknowledge that Generations Advantage will release my information to Medicare and other plans as is necessary for treatment, payment, and health care operations. I also acknowledge that Generations Advantage will release my information including my prescription-drug-event data to Medicare, who may release it for research and other purposes which follow all applicable federal statutes and regulations. 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 my signature (or the signature of the person authorized to act on my behalf under the laws of the state where I live) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (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 from Medicare.