Online Enrollment

Whether you’re enrolled in a premium or non-premium plan, you can pay your plan premium and any applicable late enrollment penalty (LEP) and/or OSB by automatic deduction from your Social Security Administration (SSA) or Railroad Retirement Board (RRB) benefit check. You can also choose to pay by electronic funds transfer (EFT) or check via mail each month. The payment option you select here will override any previous payment option you might have made, and will determine how you pay your total premium, which may include a plan premium as well as the OSB premium and any LEP that’s applicable.

If you don’t select an option on the next page, you’ll default to direct pay and will receive a monthly invoice, unless you currently pay your premiums and/or LEP via SSA or RRB benefit check, in which case your OSB premium will also be withheld via this method.

Select a premium payment option:

Automatic deduction from your monthly SSA or RRB benefit check

I get monthly benefits from:

Social Security RRB

It can take up to 90 days to receive SSA/RRB withhold acceptance. SSA/RRB will begin deducting on the date of acceptance. Members will receive an invoice for any months prior to the withhold acceptance date by SSA/RRB, which will be their responsibility to pay. In limited circumstances, Medicare may not allow for the SSA/RRB deduction option and may instruct the plan to directly bill the member. If this occurs, you’ll be notified in writing.

Electronic Funds Transfer (EFT) from your bank account each month

If you choose to have the funds taken directly out of your checking account, this is referred to as an electronic funds transfer (EFT). If you elect this method of payment, you’ll get a letter from the plan requesting that a voided check be returned with the letter for account setup. Don’t submit a voided check at the time of enrollment. Your request will be processed within 60 business days of the receipt of a returned voided check and letter. Premiums are deducted from your bank account on the second day of the month for the current month’s coverage.

Direct Pay

You’ll receive a monthly invoice containing payment instructions.

By completing this application form:

I understand this enrollment for OSB is in addition to my current BayCarePlus Medicare Advantage plan benefits and that the monthly premium for OSB is in addition to my Medicare premium, BayCarePlus Medicare Advantage plan premiums and any applicable LEP that may apply.

I understand the OSB are only available to members enrolled in a BayCarePlus Medicare Advantage plan and that disenrollment from a BayCarePlus Medicare Advantage plan will result in automatic disenrollment from the OSB.

I understand the Delta Dental plan will pay benefits for covered services provided by a non-participating provider. However, a non-participating provider may charge me more than the maximum plan allowance payable under this Medicare Advantage plan and I’ll be responsible for all cost-sharing charges.

I understand that if I disenroll from OSB, I won’t be eligible to enroll again until the next BayCarePlus Medicare Advantage valid OSB enrollment period.

I understand that if I fail to pay the monthly premium for OSB, I’ll lose OSB but will remain enrolled in BayCarePlus Medicare Advantage.

I understand I only have one dental option. The purchase of this plan replaces the base plan, which has an annual maximum of up to $3,000, depending on your plan.

• I understand this enrollment for OSB is in addition to my current BayCare Plus Medicare Advantage plan benefits and that the monthly premium for OSB is in addition to my Medicare premium, BayCare Plus Medicare Advantage plan premiums and any applicable late enrollment penalty (LEP) that may apply.

• I understand the OSB are only available to members enrolled in a BayCare Plus Medicare Advantage plan and that disenrollment from a BayCare Plus Medicare Advantage plan will result in automatic disenrollment from the OSB.

• I understand the Delta Dental plan will pay benefits for covered services provided by a non-participating provider. However, a non-participating provider may charge me more than the maximum plan allowance payable under this Medicare Advantage plan and I’ll be responsible for all cost-sharing charges.

• I understand that if I disenroll from OSB, I won’t be eligible to enroll again until the next BayCare Plus Medicare Advantage valid OSB enrollment period.

• I understand that if I fail to pay the monthly premium for OSB, I’ll lose OSB but will remain enrolled in BayCare Plus Medicare Advantage.

• I understand I only have one dental option. The purchase of this plan replaces the base plan, which has an annual maximum of $2,000.

I understand that my signature (or the signature of the person legally authorized to act on my behalf) on this application means that I''ve read and understand the contents of this application. If signed by an authorized representative (as described above), this signature certifies that:

This person is authorized under state law to complete this enrollment.
And
Documentation of this authority is available upon request by Medicare.

Signature

Today's date

If you are the authorized representative, sign above and fill out these fields:

Name

Phone

Address

City

State

Zip

Relationship to enrollee

1-877-549-1741

Daily 8:00am - 8.00pm

Optional Supplemental Benefits (OSB) Enrollment Form For Comprehensive Dental