Forms

To learn more about CarePlus Health Plans, Inc. Medicare Advantage HMO Benefit Plans, then please call 1-800-793-9808 to speak with one of our benefit consultants. The links below will take you to the enrollment form that may be printed in advance, and will also be provided by the benefit consultant should you decide to enroll.

Enrollment Form for CY 2007
Enrollment Form for CY 2008

Please remember that if you are already enrolled in CarePlus Health Plans, Inc. Medicare Advantage Plan, you may not enroll in a stand-alone Part D plan (PDP). Enrollment into a PDP plan will automatically disenroll you from your CarePlus Health Plans, Inc. Medicare Advantage Plan.

CarePlus Health Plans, Inc. is a Medicare Advantage Organization with a Medicare contract. You must be enrolled in Medicare Part B and entitled to Part A. You must reside in the service area of the plan. You must continue to pay your Medicare Part B premium, if not otherwise paid for under Medicaid or by another third-party.

Potential for Contract Termination
Beneficiaries’ and Plan’s Rights and Responsibilities Upon Disenrollment

Exceptions, Grievance, and Appeals Information

• Grievance, Exceptions, Coverage Determinations and Appeals Procedures 
• Request for Medicare Prescription Drug Coverage Determination Form and Instructions 
• Medicare Redetermination Request Form and Instructions 
• Grievance Form  
• Instructions for completing and submitting the Grievance Form  
• Appointment of Representative Form (CMS Form 1696) 
• Appointment of Representative Form: Instructions on how to appoint a representative and How to submit the Form 
• Prior Authorization/Medical Exception Form (Provider Use Only) 
• Instructions for completing and submitting the Prior Authorization/Medical Exception Form 
• Contact numbers for Enrollees and Physicians who have Questions and need to Inquire about the status of the Grievance, Coverage Determination and Appeal processes
• How to Obtain an Aggregate Number of Grievances, Appeals and Exceptions Filed with the Plan

For the CarePlus Health Plans, Inc. Benefit Plans (MA-PD Plans) that have Medicare Part D Prescription Drug Benefits Coverage, please go to Section 10 of the Evidence of Coverage (EOC). This section provides detailed information about the Grievance, Coverage Determination (including exceptions), and Appeal processes that it may be beneficial when requesting or filing one of the above forms.

Learn more about CarePlus Health Plans, Inc.’s Medicare Advantage plans by calling:1-800-793-9808. We are open 8:00 a.m. to 8:00 p.m, Monday through Sunday. Alternative technical assistance will be available on holidays to return your call within one business day. Hearing impaired call
TTY:1-877-245-7930

This Website is for individual Medicare coverage only.

CarePlus Health Plans, Inc. is a Medicare Advantage Organization with a Medicare contract. You must be enrolled in Medicare Part B and entitled to Part A. You must reside in the service area of the Plan. You must continue to pay your Medicare Part B premium, if not otherwise paid for under Medicaid or by another third party. Limitations and co-payments apply.

For Access to Exceptions, Grievance, Appeals, and Coverage Determinations/Redeterminations Information , please see our  Forms  page.

The information in these pages is accurate as of 12/12/2007, and is subject to change without notice.

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