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Beneficiary Information


Please enter Last Name and First Name as it appears on your Medicare Card.


Permanent Resident Street Address

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Medicare Insurance Information



Paying Your Plan Premium


You can pay your monthly plan premium (including any late enrollment penalty that you currently have or may owe) by mail, "Electronic Funds Transfer (EFT)", or credit card each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month. If you are assessed a Part D-Income Related Monthly Adjustment Amount (IRMAA), you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security benefit check or be billed directly by Medicare or the RRB. DO NOT pay Vibra Health Plan the Part D-IRMAA.

People with limited incomes may qualify for extra help to pay for their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles and co-insurance. Additionally, those who qualify will not be subject the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don't even know it. For more information about this extra help, contact your local Social Security offices or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for extra help online at https://www.ssa.gov/prescriptionhelp/.

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 a portion of this premium, we will bill you for the amount that Medicare doesn't cover.

You can pay your monthly plan premium (including any late enrollment penalty that you currently have or may owe) by mail, "Electronic Funds Transfer (EFT)" each month. You can also choose to pay your premium by having it automatically taken out of your Social Security or Railroad Retirement Board (RRB) benefit each month.

If you have to pay a Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA), you must pay this extra amount in addition to your plan premium. The amount is usually taken out of your Social Security benefit, or you may get a bill from Medicare (or the RRB). DON'T pay Vibra Health Plan the Part D-IRMAA.

(The Social Security/RRB deduction may take two or more months to begin after Social Security or RRB approves the deduction. 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.)

NOTE: Other payment options offered are: Credit Card payments and Electronic funds transfer (EFT). To enroll in these options, after your enrollment application has been approved, please contact Vibra Health Plan at 1-844-388-8268 (TTY users should call 711). We are available with extended hours from 8 AM to 8 PM, 7 days a week, from October 1st - February 14th. You can also visit Vibra Health Plan's member portal to sign-up. Further details will follow in your Member Welcome Kit. We will send you a paper bill for your monthly premiums until the Credit Card or EFT option is effective.

To request automatic deductions from your Social Security or Railroad Retirement Board (RRB) benefit each month, please contact Member Services once you receive confirmation of your enrollment.

Privacy Act Statement : The Centers for Medicare & Medicaid Services (CMS) collects information from Medicare plans to track beneficiary enrollment in Medicare Advantage (MA) or Prescription Drug Plans (PDP), improve care, and for the payment of Medicare benefits. Sections 1851 and 1860D-1 of the Social Security Act and 42 CFR ยงยง 422.50, 422.60, 423.30 and 423.32 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.


Important Questions


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.


Your Primary Care Physician (PCP) (Optional)



Applicant Demographic Information



Authorized Representative/Legal Guardian

If you are the authorized representative, you must provide the following information



Attestation of Eligibility


Typically, you may enroll in a Medicare Advantage plan only during the annual enrollment period from October 15 through December 7 of each year. There are exceptions that may allow you to enroll in a Medicare Advantage plan outside of this period.

Please read the following statements carefully and check the box if the statement applies to you. By checking any of the following boxes you are certifying that, to the best of your knowledge, you are eligible for an Enrollment Period. If we later determine that this information is incorrect, you may be disenrolled.

If none of these statements applies to you or you're not sure, please contact Vibra Health Plan at 1-844-388-8268 (TTY users should call 711) to see if you are eligible to enroll. 8 AM to 8 PM, 7 days a week from Oct 1-Mar 31. 8 AM to 8 PM, 5 days a week from Apr 1-Sep 30, with secure voicemail on weekends and Federal holidays.


Review


Plan Information

Beneficiary Information

Medicare Insurance Information

Important Questions

Your Primary Care Physician

Applicant Demographic Information

Authorized Representative/Legal Guardian


Important Notice


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
  • I must keep both Hospital (Part A) and Medical (Part B) to stay in Vibra Health Plan.
  • By joining this Medicare Advantage Plan, I acknowledge that Vibra Health Plan will share my information with Medicare, who may use it to track my enrollment, to make payments, and for other purposes allowed by Federal law that authorize the collection of this information (see Privacy Act on the prior page).
  • Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan.
  • The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan.
  • I understand that people with Medicare are generally not covered under Medicare while out of the country, except for limited coverage near the U.S. border.
  • I understand that when my Vibra Health Plan coverage begins, I must get all of my medical and prescription drug benefits from Vibra Health Plan. Benefits and services provided by Vibra Health Plan and contained in my Vibra Health Plan Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Neither Medicare nor Vibra Health Plan will pay for benefits or services that are not covered.
  • By providing a telephone number and/or an email address, I hereby authorize Vibra Health Plan to communicate with me by phone, text messages, faxes, and/or emails for billing, transactional, informational, marketing, or any other purposes including, without limitation, calls or messages made or sent using an automatic telephone dialing system or artificial/prerecorded voice. I understand that I may opt out at any time.
  • 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 signed by an authorized representative (as described above), this signature certifies that:
  1. This person is authorized under State law to complete this enrollment, and
  2. Documentation of this authority is available upon request by Medicare.


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Your Progress:

Medicare beneficiaries may also enroll in Vibra Health Plan Enhanced/Essential PPO through CMS Medicare Enrollment Center located at http://www.medicare.gov.

Updated October 1, 2021
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