Page 45 - ITDR Benefits & Resources guide 2019

Important Information Regarding Your Medicare Advantage Plan
I understand that I need to keep my Medicare Parts A & B. I must maintain my Medicare Part B insurance by continuing to pay the Part B premium, if applicable.
I understand that by enrolling in this Medicare Advantage plan, I will automatically be disenrolled
by the Centers for Medicare & Medicaid Services (CMS) from any other Medicare Advantage plan of which I am currently a member. I can only be in one Medicare Advantage plan at a time. It is my responsibility to inform you of any prescription drug coverage that I have or may get in the future.
I will read the Evidence of Coverage document from this Medicare Advantage plan when I receive it to know which rules I must follow in order to receive coverage with this Medicare Advantage plan.
I understand that beneficiaries of Medicare generally are not covered under Medicare while out of the country except for limited coverage near the U.S. border.
Release of Information: By joining this Medicare health plan, I acknowledge that the Medicare health plan will release my information to Medicare and other plans as is necessary for treat- ment, payment and health care operations.
Once I am a member of this Medicare Advantage plan, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage from the plan when I receive it to know which rules I must follow to receive coverage with this Medicare Advantage plan.
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