Pre-Enrollment Qualification Assessment Form

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Health Net Jade (HMO SNP)
Pre-enrollment Qualification
Assessment Tool
Health Net Jade is a Medicare Advantage Special Needs Plan (SNP) designed for people with chronic conditions
such as diabetes, chronic heart failure and certain cardiovascular disorders.
Enrollee information
Last name:
First name:
MI:
Medicare ID number (HICN):
Date of birth:
Phone number:
Please complete and submit this form with your enrollment application. If you can answer “Yes” or “Not
sure” to any of the following questions, you may be eligible to join our chronic care SNP. When this form is
completed and submitted along with an enrollment application, you will be enrolled into Health Net Jade. We
will attempt to verify your chronic condition(s) with your provider during the first month of enrollment. If we
are unable to verify your chronic condition(s), we are required to disenroll you from the Special Needs Plan.
Chronic condition questions
Yes
No
Not sure
Have you been diagnosed with diabetes?
Have you had problems with high blood sugar?
Yes
No
Not sure
Do you take medication and/or have you been put on a special diet to control your
Yes
No
Not sure
blood sugar?
Yes
No
Not sure
Have you been diagnosed with chronic (or congestive) heart failure (CHF)?
Have you had problems with fluid retention in your lungs or swelling in your legs
Yes
No
Not sure
due to a heart problem?
Do you take medication to prevent fluid retention?
Yes
No
Not sure
Yes
No
Not sure
Have you been diagnosed with any of the following cardiovascular disorders?
• Cardiac arrhythmia
• Chronic venous thromboembolic disorder
• Coronary artery disease
• Peripheral vascular disease
Have you had problems with rapid, erratic heart beats?
Yes
No
Not sure
Have you had problems with chest pain or tightness, shortness of breath,
Yes
No
Not sure
heart attack, or stroke?
Has a physician ever told you that you have a blood clot?
Yes
No
Not sure
(continued)
White – Health Net
Yellow – Member
6030704 CA111292 (7/14) 1 of 2
Material ID # Y0035_2015_0030 (H0351, H0562, H6815) CMS Accepted 08142014

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