Permanent Residence Street Address (P.O. Box is not allowed):
Mailing Address (only if different from your Permanent Residence Address):
Emergency Contact Information:
Please provide your medicare insurance information:
Please take out your Medicare card to complete this section.
Please fill in these blanks so they match your red, white and blue Medicare card
Attach a copy of your Medicare card or your letter from Social Security or the Railroad Retirement Board.
You must have Medicare Part A and Part B to join a Medicare Advantage plan.
Medicare Health Insurance
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 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, 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 or Railroad Retirement Board (RRB) benefit check or be billed directly by Medicare or the RRB. DO NOT pay Great Plains Medicare Advantage 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 to 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 office, 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
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.
If you don’t select a payment option, you will get a bill each month.
Please select a premium payment option:
Please read and answer these important questions:
1. 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 attach 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.
2. Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal employee health benefits coverage, VA benefits, or State pharmaceutical assistance programs.
Will you have other prescription drug coverage in addition to Great Plains?
If "yes", please list your other coverage and your identification (ID) number(s) for this coverage:
3. Are you a resident in a long-term care facility, such as a nursing home?
If "yes", please provide the following information:
Name of Institution:
—Please choose an option— August Place - A Prospera Community Brookestone View Skilled Nursing and Rehabilitation Brookefield Park Brookestone Acres Brookestone Meadows Rehabilitation and Care Center Brookestone Village Rehabilitation and Care Center Cloverlodge Care Center David Place Good Samaritan Society - Albion Good Samaritan Society - Alma Good Samaritan Society - Arapahoe Good Samaritan Society - Atkinson Good Samaritan Society - Auburn Good Samaritan Society - Beatrice Good Samaritan Society - Bloomfield Good Samaritan Society - Canistota Good Samaritan Society - Canton Good Samaritan Society - Corsica Good Samaritan Society - Deuel County Good Samaritan Society - Grand Island Village Good Samaritan Society - Hastings Village Good Samaritan Society - Howard Good Samaritan Society - Lakota Good Samaritan Society - Larimore Good Samaritan Society - Lennox Good Samaritan Society - Luther Manor Good Samaritan Society - Millard Good Samaritan Society - Miller Good Samaritan Society - Mohall Good Samaritan Society - Oakes Good Samaritan Society - Osceola Good Samaritan Society - Park River Good Samaritan Society - Ravenna Good Samaritan Society - Sioux Falls Center Good Samaritan Society - Sioux Falls Village Good Samaritan Society - St. John's Good Samaritan Society - St. Luke's Good Samaritan Society – Scotland Good Samaritan Society - Superior Good Samaritan Society - Syracuse Good Samaritan Society - Tyndall Good Samaritan Society - Wagner Good Samaritan Society - Wood River Heritage Care Center Heritage Crossings Heritage of Bel Air Heritage of Emerson, Inc. Heritage of Red Cloud Hooper Care Center Miller Pointe - A Prospera Community Papillion Manor Ridgewood Rehabilitation & Care Center Rose Lane Home Souris Valley Care Center South Haven Living Center Southlake Village Rehabilitation & Care Center St Vincents - A Prospera Community Sunset Drive - A Prospera Community Tiffany Square Care Center
4. Are you enrolled in your State Medicaid program? Yes No
If yes, please provide your Medicaid number:
5. Do you or your spouse work?
6. Do you have health coverage through you or your spouse's current or former employer?
If yes, please provide the following information:
7. Have you been a resident in a long-term facility, such as a nursing home, in the Great Plains Medicare Advantage network for more than 90 days?
Please choose the name of a Primary Care Physician (PCP), clinic or healthcare center:
Please Read This Important Information
If you currently have health coverage from an employer or union, joining Great Plains Medicare Advantage could affect your employer or union health benefits. You could lose your employer or union health coverage if you join Great Plains Medicare Advantage. 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.
Please Read and Sign Below
By completing this enrollment application, I agree to the following:
Great Plains Medicare Advantage 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.
Great Plains Medicare Advantage serves a specific service area. If I move out of the area that Great Plains Medicare Advantage 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 Great Plains Medicare Advantage, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from Great Plains Medicare Advantage 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 Great Plains Medicare Advantage coverage begins, I must get all of my health care from Great Plains Medicare Advantage except for emergency or urgently needed services or out-of-area dialysis services. Services authorized by Great Plains Medicare Advantage and other services contained in my Great Plains Medicare Advantage Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered.
NEITHER MEDICARE NOR GREAT PLAINS MEDICARE ADVANTAGE 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 Great Plains Medicare Advantage, he/she may be paid based on my enrollment in Great Plains Medicare Advantage.
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 treatment, payment and health care operations. I also acknowledge that Great Plains Medicare Advantage will release my information, including my prescription drug event data, to Medicare who may release it for research and other purposes which 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 provide false information on this form, I will be disenrolled from the plan.
I understand that my signature (or the signature of the person authorized to act on my behalf under State law where I live) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (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 Great Plains Medicare Advantage or by Medicare.
If you are the authorized representative, you must sign above and provide the following information:
All information you'll provide here is strictly confidential, secure, and will only be used to enroll you in your chosen plan.