Enrollment Request Form - 2017 Page 5

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Please read the statement below.
·
My bank may pay my plan premium to UnitedHealthcare Insurance Company
(UnitedHealthcare Insurance Company of New York for New York residents) (UHIC). My bank
will pay the funds from my checking or savings account on or about the fifth of each month. If I
choose to stop paying directly from my account, I will tell both UHIC and my bank. I will give
them a reasonable amount of time to change my method of payment.
Account Type □ Checking □ Savings
Account Holder Name ____________________________________________________________
Bank Routing Number
Bank Account Number
Sign Here ______________________________________ Date Signed ___________________
I want to pay from my Social Security or Railroad Retirement Board (RRB) check.
¨
We’ll set it up. It may take a few months before payment starts, so the first payment may include
more than one premium. In most cases, if Social Security or RRB accepts your request for
automatic deduction, the first deduction from your Social Security or RRB benefit check will
include all premiums due from your enrollment effective date up to the point withholding begins.
If Social Security or RRB does not approve your request for automatic deduction, we will send
you a paper bill for your monthly premiums.
¨ I want to pay by mail.
We’ll send a bill to your mailing address each month.
A few notes about your costs.
If you must pay a Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA)
Social Security (SS) will send you a letter and ask you how you want to pay it:
· You can pay it from your SS check
Medicare can bill you
·
· The Railroad Retirement Board (RRB) can bill you
Please DO NOT pay the plan the Part D-IRMAA at this time.
Need help with your prescription drug costs?
If you have a limited income, you may be able to get Extra Help with your prescription drug costs. If
you qualify, Medicare could pay for 75% or more of your costs, including monthly prescription drug
premiums, annual deductibles, and co-insurance. Additionally, you won’t have a coverage gap or
late enrollment penalty. Many people are eligible for these savings and don’t even know it. If you
qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or
part of your plan premium. If Medicare pays only part of your premium, we will bill you for the
amount that Medicare doesn’t cover.
Enrollee Name
PDEX17PD3877053_000
Y0066_160609_110859 Approved

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