How to Enroll in TotalCare

You will have no or low copays for prescriptions covered under the drug benefit. You should only receive services from in-network providers. If you receive care from an out-of-network provider, the service may not be covered unless it’s an emergency or has been approved by the Alliance. If the provider is out of network, they may not understand the TotalCare plan or the plan’s billing rules. If you receive a bill for Medicare-covered services, please call Member Services.

Who can use the enrollment form?
People with Medicare who want to join a Medicare Advantage Plan.

To join a plan you must:

• Be a United States citizen or be lawfully present in the U.S.
• Live in the plan's service area.

Important: To join a Medicare Advantage Dual Eligible Special Needs Plan, you must also have:

• Medicare Part A (Hospital Insurance).
• Medicare Part B (Medical Insurance).
• Full-scope Medi-Cal (The state of California's Medicaid insurance for low-income individuals) with the Alliance.

When do I use this form?

You can join a plan:

• Between Oct. 15 - Dec. 7 each year (for coverage starting Jan. 1).
• Within 3 months of first getting Medicare.
• In certain situations where you're allowed to join or switch plans. Exclusively-Aligned Enrollment (EAE) D-SNP members can join an EAE during any month of the year. TotalCare is an EAE D-SNP.

Visit Medicare.gov to learn more about when you can sign up for a plan.

What do I need to complete this form?

• Your Medicare Number (the number on your red, white, and blue Medicare card).
• Your permanent address and phone number.

Note: You must complete all items marked as required (with a red asterisk). The other items are optional - you can't be denied coverage because you don't fill them out.

Reminders:

• If you want to join a plan during fall open enrollment (Oct. 15 - Dec. 7), the plan must get your completed form by Dec. 7.

Your submitted form will be sent to TotalCare. Once they process your request to join, they'll contact you.

How do I get help with this form?
Call TotalCare Member Services at 833-530-9015 (TTY: 800-735-2929 (Dial 711)). Or call Medicare at 800-MEDICARE (800-633-4227). TTY users can call 877-486-2048.

Individuals experiencing homelessness
If you want to join a plan but have no permanent residence, a Post Office Box, an address of a shelter or clinic, or the address where you receive mail (e.g., social security checks) may be considered your permanent residence address.