2024 MA/MAPD Enrollment Form (Platino / No Platino)

After having received orientation about the different options available at MCS Classicare (HMO), you may fill out the Enrollment Form.

Before making an enrollment decision, it is important that you fully understand our benefits and rules. To understand our benefits:

• Review the full list of benefits found in the Evidence of Coverage (EOC), especially for those services for which you routinely see a doctor. Visit www.mcsclassicare.com or call 787-620-2530 (Metro Area) or 1-866-627-8183 (Toll Free) to view a copy of the EOC.
• Review the Provider Directory (or ask your doctor) to make sure the doctors you see now are in the network. If they are not listed, it means you will likely have to select a new doctor.
• Does not apply to MCS Classicare Patriot (HMO) - Review the Pharmacy Directory to make sure the pharmacy you use for any prescription drug is in the network. If the pharmacy is not listed, you will likely have to select a new pharmacy for your prescriptions.
• Does not apply to MCS Classicare Patriot (HMO) - Review the List of Covered Drugs (Formulary) to make sure that the drug that you use is covered. If your drug is not on the Drug List or if your drug is restricted, you may be able to get a temporary supply of the drug (only members in certain situations can get a temporary supply), change to another drug or request an exception.

Understanding Important Rules

• You must continue to pay your Medicare Part B premium. This premium is normally taken out of your Social Security check each month.
• Benefits, premiums and/or copayments/coinsurance may change on January 1, 2025.
• Except in emergency or urgent situations, we do not cover services by out-of-network providers (doctors who are not listed in the Provider Directory).

For MCS Classicare Essential (HMO-POS) and MAPD groups (HMO-POS) plans, you should know:

• Our plan allows you to see providers outside of our network (non-contracted providers). However, while we will pay for certain covered services provided by a non-contracted provider, the provider must agree to treat you. Except in an emergency or urgent situation, non-contracted providers may deny care. In addition, you will pay a higher co-pay or coinsurance for services received by non-contracted providers.

For MCS Classicare Primero (HMO C-SNP) , you should know:

• This plan is a chronic condition special needs plan (C-SNP). Your ability to enroll will be based on verification that you have a qualifying specific severe or disabling chronic condition.

For MCS Classicare Excede (HMO), you should know:

• Your ability to enroll and your benefits will depend on the geographic region applicable to your municipality or place of residence.
• Región 1: Aguada, Aguadilla, Añasco, Arecibo, Camuy, Hatillo, Isabela, Mayagüez, Moca, Quebradillas, Rincón, San Sebastián y Utuado.
• Región 2: Adjuntas, Barceloneta, Cabo Rojo, Ciales, Corozal, Florida, Guánica, Hormigueros, Jayuya, Lajas, Lares, Las Marías, Manatí, Maricao, Morovis, Orocovis, Sabana Grande, San Germán, Vega Alta, Vega Baja and Yauco.
• Your municipality or residence region will NOT limit your ability to receive services from any participant provider in our network throughout Puerto Rico.

For MCS Classicare Metro (HMO) , you should know:

• Your ability to enroll will depend on whether you reside in any of the following 8 municipalities: Bayamón, Caguas, Canóvanas, Carolina, Cataño, Guaynabo, San Juan and Trujillo Alto.
• Your municipality or residence region will NOT limit your ability to receive services from any participant provider in our network throughout Puerto Rico.

For MCS Classicare Firme (HMO), you should know:

• Your ability to enroll will depend on whether you reside in any of the following 39 municipalities: Adjuntas, Aguada, Aguadilla, Añasco, Arecibo, Barceloneta, Cabo Rojo, Camuy, Ciales, Corozal, Florida, Guánica, Guayanilla, Hatillo, Hormigueros, Isabela, Jayuya, Juana Diaz, Lajas, Lares, Las Marías, Manatí, Maricao, Mayagüez, Moca, Morovis, Orocovis, Peñuelas, Ponce, Quebradillas, Rincón, Sábana Grande, San Germán, San Sebastián, Utuado, Vega Alta, Vega Baja, Villalba and Yauco.
• Your municipality or residence region will NOT limit your ability to receive services from any participant provider in our network throughout Puerto Rico.

For MCS Classicare Del Caribe (HMO), you should know:

• Your ability to enroll will depend on whether you reside in any of the following 8 municipalities: Coamo, Guayanilla, Juana Diaz, Peñuelas, Ponce, Salinas, Santa Isabel and Villalba.
• Your municipality or residence region will NOT limit your ability to receive services from any participant provider in our network throughout Puerto Rico.

For Platino plans, you should know:

• This plan is a dual eligible special needs plan (D-SNP). Your ability to enroll will be based on verification that you are entitled to both Medicare and medical assistance from a state plan under Medicaid.

For Classicare Platino Del Sur (HMO D-SNP), you should know:

• Your ability to enroll will depend on whether you reside in any of the following 8 municipalities: Coamo, Guayanilla, Juana Diaz, Peñuelas, Ponce, Salinas, Santa Isabel y Villalba.
• Your municipality or residence region will NOT limit your ability to receive services from any participant provider in our network throughout Puerto Rico.

For Classicare Platino Máximo (HMO D-SNP), you should know:

• Your ability to enroll and your benefits will depend on the geographic region applicable to your municipality or place of residence.
• Region 1: Aguada, Aguadilla, Añasco, Arecibo, Camuy, Hatillo, Isabela, Mayagüez, Moca, Quebradillas, Rincón, San Sebastián and Utuado.
• Region 2: Adjuntas, Barceloneta, Cabo Rojo, Ciales, Corozal, Florida, Guánica, Hormigueros, Jayuya, Lajas, Lares, Las Marías, Manatí, Maricao, Morovis, Orocovis, Sabana Grande, San Germán, Vega Alta, Vega Baja and Yauco.
• Region 3: Aguas Buenas, Aibonito, Arroyo, Barranquitas, Bayamón, Caguas, Canóvanas, Carolina, Cataño, Cayey, Ceiba, Cidra, Coamo, Comerío, Culebra, Dorado, Fajardo, Guayama, Guayanilla, Guaynabo, Gurabo, Humacao, Juana Diaz, Juncos, Las Piedras, Loiza, Luquillo, Maunabo, Naguabo, Naranjito, Patillas, Peñuelas, Ponce, Río Grande, Salinas, San Juan, San Lorenzo, Santa Isabel, Toa Alta, Toa Baja, Trujillo Alto, Vieques, Villalba and Yabucoa.
• Your municipality or residence region will NOT limit your ability to receive services from any participant provider in our network throughout Puerto Rico.

The following instructions can help you in the process of filling out the Enrollment Form.

SELECT THE BENEFITS PLAN YOU WANT TO JOIN

Choose the Plan you want and select it. Also, let us know the name of your previous medical plan.

BENEFICIARY INFORMATION

Fill out all the sections related to the information of the beneficiary:

• Write your full name, exactly as it appears on your Medicare card.
• Date of birth (month/day/year) and sex.
• Home phone number and alternate phone number (cell phone number or other than home phone number).
• Write the permanent residential and mailing address (only if different from the residential).

YOUR MEDICARE INFORMATION

Fill out the section related to your Original Medicare:

• Use your Original Medicare card to fill out the following information: full name (exactly as it appears on your Medicare card), Medicare number, and effective date for Medicare Parts A and/or B.

PAYING YOUR PLAN PREMIUM / PREMIUM PAYMENT METHOD, IF APPLICABLE

Please read this important information and select the payment method for the monthly premium and/or late enrollment penalty. This is only applicable if the plan that you selected has a monthly premium or if we determine that you owe a late enrollment penalty or if you currently have a late enrollment penalty. If not, omit this part.

ANSWER THESE IMPORTANT QUESTIONS

Read and answer all the questions in this section of the Enrollment Form.

PRIMARY CARE PHYSICIAN (PCP) INFORMATION

Select your primary care physician (PCP) from the MCS Classicare provider network and write down the name of the physician in the space provided. If you do not have a primary care physician, MCS Classicare will assign one for you, which you may change later on if you wish to do so. In order to obtain the Providers Directory, access our webpage at www.mcsclassicare.com.

INFORMATIONAL MATERIALS

• Indicate whether you wish to receive information in another language different from English (for example, in Spanish) or in another accessible format such as audio CD, braille or large print.
• Select if you agree or do not agree to receive plan information by email. If yes, please provide email address.
• Select if you agree or do not agree to receive text messages related to your health services. If yes, please provide cell phone number.

CHRONIC SPECIAL NEEDS PLAN (C-SNP)

• If you chose MCS Classicare Primero (HMO C-SNP), it is important that you complete the Pre Enrollment Qualification Assessment Tool, once completed with the Enrollment Form.

IMPORTANT: READ BELOW

• Read all the information in this part.
• You (or your authorized representative) must sign and include the date when you have completed the application.