Submit Form - EHB 27 EN

2027 Optional Supplemental Enhanced Benefits
Option A, B, or C enrollment form
This enrollment form is for current members that want to add Optional Supplemental Enhanced Benefits
Option A, B, or C to their Medicare Advantage plan. The additional premium for the Enhanced Benefits will
be added to your Medicare Advantage plan monthly premium. If you would like to make changes to your
You are not obligated to enroll in this optional benefit.
YOUR PERSONAL INFORMATION

First name *

Please provide a valid First name.

MI

Please provide a valid MI.

Last Name *

Please provide a valid Last Name.

Medicare ID *

Please provide a valid Medicare ID.

Current member *

No

Yes

Please choose one option for Current member.

Phone *

Please provide a valid Phone (e.g., 123-456-7890).

Date of birth *

Please provide a valid Date of birth.

Permanent residence street address (For individuals experiencing homelessness, a PO Box may be considered

your permanent residence address *

Please provide a valid your permanent residence address.

State *

Please provide a valid State.

Zip code *

Please provide a valid Zip code.

City *

Please provide a valid City.

MAILING ADDRESS (only if different than Permanent Residence Address)

Address

Please provide a valid Address.

State

Please provide a valid State.

Zip code

Please provide a valid Zip code.

City

Please provide a valid City.

ENROLL IN ENHANCED BENEFITS OPTION A, B, OR C
If you wish to enroll in Option A, B, or C please check the appropriate box below to indicate the option you’ve
elected. You must continue to pay your Medicare Part B premium.

Option A — includes preventive and comprehensive dental and vision
Option B — includes preventive and comprehensive dental, vision, hearing, 14 post-discharge meals for 7
days, and 10 one-way rides to appointments
Option C — includes comprehensive dental, vision, hearing, 14 post-discharge meals for 7 days,
and 10 one-way rides to appointments

Aspire Health Protect (HMO) ($0)

Plan *

with Enhanced Benefits — Option A = $55 + $0 = $55/month

with Enhanced Benefits — Option B = $60 + $0 = $60/month

with Enhanced Benefits — Option A = $55 + $65 = $120/month

with Enhanced Benefits — Option B = $60 + $65 = $125/month

with Enhanced Benefits — Option C = $52 + $204 = $256/month

with Enhanced Benefits — Option A = $55 + $382 = $437/month

with Enhanced Benefits — Option B = $60 + $382 = $442/month

Please choose one option for Plan.

Aspire Health Value (HMO) ($65)

Aspire Health Advantage (HMO) ($204)

Aspire Health Plus (HMO-POS) ($382)

Proposed effective date of coverage *

Please provide a valid Proposed effective date of coverage.

H8764_ENR_EnhancedHealthEnrlForm_0726_C

By signing, I agree to the enrollment election and acknowledge that my monthly premium will change.
(Please read page two and sign)

Member signature *

Please sign Member signature.

Date *

Please provide a valid Date.

For individuals helping enrollee with completing this form only
If you’re completing this form for someone else, complete the section below. Your signature certifies that
you’re authorized under State law to fill out this participation form and have documentation of this
authority available if Medicare asks for it.

Relationship to enrollee

Please provide a valid Relationship to enrollee.

Name

Please provide a valid Name.

Signature

Please sign Signature.

National Producer Number

Please provide a valid National Producer Number.

(Agents/Brokers only)

Proposed effective date of coverage

Please provide a valid Proposed effective date of coverage.

(M M / D D / Y Y Y Y)

Agent receipt date

Please provide a valid Agent receipt date.

Agent ID

Please provide a valid Agent ID.

(M M / D D / Y Y Y Y)

PRIVACY ACT STATEMENT
The Centers for Medicare & Medicaid Services (CMS) collects information from Medicare plans to
track beneficiary enrollment in Medicare Advantage (MA) Plans, improve care, and for the payment of
Medicare benefits. Sections 1851 of the Social Security Act and 42 CFR §§ 422.50 and 422.60 authorize
the collection of this information. CMS may use, disclose and exchange enrollment data from Medicare
beneficiaries as specified in the System of Records Notice (SORN) “Medicare Advantage Prescription
Drug (MARx)”, System No. 09-70-0588. Your response to this form is voluntary. However, failure to
respond may affect enrollment in the plan.

We are open 8 a.m.–8 p.m. PT Monday through Friday from April 1 through September 30 and
8 a.m.–8 p.m. PT seven days a week from October 1 through March 31 (except certain holidays). Medicare
beneficiaries may also enroll in Aspire Health Plan through the CMS Medicare Online Enrollment Center
located at http://www.medicare.gov.

H8764_ENR_EnhancedHealthEnrlForm_0726_C