Health Plan Choice Form (Page 2 of 2) in pdf

Health Plan Choice Form

California Department of

Health Care Services

P.O. Box 989009

W. Sacramento, CA 95798-9850

Read this important information before you sign the form.

If I Join KP Cal, LLC (Kaiser Permanente): I understand

I need to notify the plan so I can disenroll and find a

that Kaiser requires binding arbitration. This means

new plan in my new area.

that I give up my right to a jury or court trial for medical

I understand that beginning on the date my Cal

malpractice and other disagreements about benefits

MediConnect coverage begins, I must get all of my

and services. Instead, I would help choose independent

health care from my new plan, except for emergency

professionals who would make a decision about the

or urgently needed services or out-of-area dialysis

problem. I can still ask for a Medi-Cal State Hearing.

services. Services authorized by my Cal MediConnect

If I chose PACE, I will be contacted to see if I meet the

plan and other services contained in my plan's

eligibility requirements for enrollment into the PACE

Evidence of Coverage document will be covered.

health plan. I must meet the nursing home level of care

Without authorization, NEITHER Medicare, Medi-Cal

and still be able to live safely in a community setting.

NOR my Cal MediConnect plan WILL PAY FOR THE

SERVICES.

By completing this enrollment application for a

Cal MediConnect plan or by allowing the State to

Release of Information: By joining this Medicare

enroll me in a Cal MediConnect plan, I agree to the

and Medicaid plan, I acknowledge that the plan I

following:

selected will release my information to Medicare and

other plans as is necessary for treatment, payment

Cal MediConnect plans are Medicare-Medicaid plans

and health care operations. I also acknowledge that

that have a contract with the State of California and

my Cal MediConnect plan will release my information,

the Federal government. I will need to keep my

including my prescription drug event data, to Medicare,

Medicare Parts A and B and Medi-Cal. I can be in only

who may release it for research and other purposes

one Medicare plan at a time, and I understand that my

which follow all applicable Federal statutes and

enrollment in the plan selected will automatically end

regulations. The information on this enrollment form is

my enrollment in any other Medicare health plan or

correct to the best of my knowledge. I understand that

Medicare prescription drug plan.

if I intentionally provide false information on this form,

I understand that prescription drugs are covered,

I will be disenrolled from the plan.

but not always the same ones I’m already taking. I

I understand that my signature (or the signature of

understand that I’ll have access to my current drugs for

the person authorized to act on my behalf under the

at least 30 days, until I can switch to a different drug,

laws of California on this application) means that I've

and that I may have access to my current doctors for

read and understand the contents of this application.

180 days once I join a Cal MediConnect Plan. I further

If signed by an authorized individual, this signature

understand that a Cal MediConnect Plan has providers

certifies: 1) this person is authorized under State law to

and pharmacies I must use to get health care services,

complete this enrollment and 2) documentation of this

except for non-routine, emergency situations.

authority is available upon request from Medicare.

Cal MediConnect plans serve a specific service area.

If I move out of the area covered by the plan chosen,

Privacy Statement

The Department of Health Care Services will keep the information you provide. It is used only to enroll and/

or disenroll people that are eligible for Medi-Cal managed care. The laws that allow this are in the Welfare and

Institutions Code, Section 10416.5, 14016.6, 14087.305, 14087.31, 14087.35, 14087.36, 14087.38, 14087.96,

14088, 14089, 14089.5, and 14631, and California Code of Regulations, Section 51085.5.

Only other government agencies that relate to the Medi-Cal program can see the information you provide.

However, any information that is being used in an investigation or lawsuit cannot be seen. If you want to see

your Medi-Cal file, contact the Department of Health Care Services at the address on the other side of this form.

MU_0004000_ENG2_0114

Health Plan Choice Form Page 2

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