To speak with a licensed agent call 1-844-324-0691 (TTY 711)

Member Enrollment


Please read the following information very carefully.

Please Read This Important Information

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If you currently have health coverage from an employer or union, joining Vibra Health Plan could affect your employer or union health benefits. You could lose your employer or union health coverage if you join Vibra Health Plan.

Read the communications your employer or union sends you. If you have questions, visit their website, or contact the office listed in their communications. If there isn’t any information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.

By completing this enrollment application, I agree to the following:

Vibra Health Plan 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 another Medicare health plan or prescription drug plan. It is my responsibility to inform you of any prescription drug coverage 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.

Vibra Health Plan serves a specific service area. If I move out of the area that Vibra Health Plan 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 Vibra Health Plan, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from Vibra Health Plan when I get it to know which rules I must follow to get coverage with 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 U.S. border.

I understand that beginning on the date Vibra Health Plan coverage begins, using services in-network can cost less than using services out-of-network, except for emergency or urgently needed services or out-of-area dialysis services. If medically necessary, Vibra Health Plan provides refunds for all covered benefits, even if I get services out-of-network. Services authorized by Vibra Health Plan and other services contained in my Vibra Health Plan Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR VIBRA HEALTH PLAN WILL PAY FOR THE SERVICES.

I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or contracted with Vibra health Plan, he/she may be paid based on my enrollment in Vibra Health Plan.

Release of Information: By joining this Medicare health plan, I acknowledge that Vibra Health Plan will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that Vibra Health Plan will release my information including my prescription drug event data to Medicare, who may release it for research and other purposes which will 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 provided false information on this form, I will be disenrolled from the plan.

I understand that by clicking ‘Submit’ on this page means that I (or the person authorized to act on my behalf under the laws of the State where I live) have read and understand the contents for this application. If submitted by an authorized individual (as described above), 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
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Leaving so soon?

We want to make sure that you know you are exiting our site and going to an external website.

Tell us where you live.

Medicare beneficiaries may also enroll in Vibra Health Plan through the CMS Medicare Online Enrollment Center located at https://www.medicare.gov.

To view your coverage options, enter your zip code and county below.

Your location

We're sorry, but you have either entered an incorrect zip code or you are out of our service area.

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Vibra Health Plan is a PPO with a Medicare contract. Enrollment in Vibra Health Plan depends on contract renewal.

A woman waiting to enroll

Before you enroll

To make sure you are eligible we'll need a few more pieces of information.

Before your enroll

You must have Medicare Part A and Part B to join a Medicare Advantage Plan.

Generally you are not eligible to enroll in our plan if you have been medically determined to have ESRD. If you have had a successful kidney transplant and/or you don’t need regular dialysis any more, you are eligible to enroll, we will need to contact you to obtain additional information.

Are you new to Medicare?

Are you already entitled to Part A and enrolled in Part B?

Do you have end-stage renal disease ESRD?

If you have had a successful kidney transplant and/or you don't need regular dialysis any more, please mail a note or records from your doctor showing you have had a successful kidney transplant or you don't need dialysis, otherwise we may need to contact you to obtain additional information.

Vibra Health Plan, Inc.

4000 Crums Mill Rd.

Suite 201

Harrisburg, PA 17112
To speak with a licensed agent call 1-844-324-0691 (TTY 711)

8 am - 8 pm Mon - Fri (Mon - Sun from 10/15/16 to 2/14/17)

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View Plan Options

Please select one of our coverage options below.

Your options
Plan Monthly Premium Primary Care Copay Out-of-pocket Max Select
$0In $10 | Out $35$6,700
$49.50In $5 | Out $25$4,800

Do you want to add optional dental coverage?

Your monthly rate will increase by $33.30.

For more details pertaining to the optional dental benefits, please see the Summary of Benefits.

Your monthly rate will increase by $28.00.

For more details pertaining to the optional dental benefits, please see the Summary of Benefits.

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Ready to Enroll?

It looks like you are interested in the plan outlined below. By clicking the “Enroll Now” button, you are confirming your intent to complete an actual enrollment request to join Vibra Health Plan.

You will want to have your Medicare card available to help complete the application.

If you need assistance during this process, our contact information is listed below.

Plan Breakdown

  • Primary Care Copay In $10 | Out $35
  • Out-of-pocket Max $6,700

Estimated monthly payment:

  • Monthly Premium $0
  • Monthly Dental Premium (Optional) $33.30

  • Monthly Total ${[{ mec.formatMonthlyTotal('Essential_Coverage_PPO') }]}
  • Primary Care Copay In $5 | Out $25
  • Out-of-pocket Max $4,800
  • Monthly Premium $49.50
  • Monthly Dental Premium (Optional) $28.00

  • Monthly Total ${[{ mec.formatMonthlyTotal('Enhanced_Coverage_PPO') }]}
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Important Information

You may enroll in only one Medicare Advantage Plan at a time.

You may join or leave that plan only at certain times of the year or in special circumstances.

The Annual Election Period occurs October 15 through December 7. During this time, eligible individuals may enroll in or change Medicare Advantage Plans. Coverage will begin January 1.

Other Enrollment Methods

Fax: 1-844-260-7923
For Phone Applications (please call to speak with a licensed agent)
Phone: 1-844-324-0691 (TTY 711)
Phone: 1-800-MEDICARE (1-800-633-4227)
Hours: 8 am - 8 pm Mon - Fri (Mon - Sun from 10/15/16 to 2/14/17)
Online: Medicare beneficiaries may also enroll in Vibra Health Plan through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.

Note

You must continue to pay your Medicare Part B premium.

Vibra Health Plan is a PPO with a Medicare contract. Enrollment in Vibra Health Plan depends on contract renewal.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year.


Last Updated Nov. 11th, 2016 (H9408_17_49134_Webenroll Approved)