How to Enroll in TotalCare

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.