Knights of Columbus
Enrollment Guide for
Medicare-eligible individuals
LOOK INSIDE TO LEARN MORE ABOUT:
• Connecting with a benefits counselor
• Exploring your new healthcare coverage options
• Enrolling in a plan that meets your needs and budget
This Enrollment Guide contains important information on how your current Knights of Columbus-sponsored retiree
healthcare coverage for you and any eligible dependents will be changing. It is important that you read through all
pages carefully. You must take action by enrolling in your new healthcare plan — with a benefits counselor — in order
to have the coverage you need.
Mercer Marketplace 365+
SM*
Retiree
P.O. Box 14401, Des Moines, IA 50306-3401
Online: retiree.mercermarketplace.com/kofc
Toll-Free: 855.254.1187
For deaf or hard of hearing: Dial 711 for
Telecommunications Relay Service
Fax: 857.362.2999
* Services provided by Mercer Health &
Benefits Administration LLC.
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SUCCESSFUL ENROLLMENT USING A STEP-BY-STEP PROCESS — Following these steps will help you
understand what to expect, what is needed, and how to get ready for a smooth transition. Page 2
PREPARING FOR YOUR CONSULTATION — Using this guideline will help you get the most out of your
appointment with your benefits counselor. Page 4
COVERAGE AND PLAN TYPES — Utilize these pages for understanding which plan options may best fit
your needs and budget. Page 6
OTHER INSURANCE OPTIONS — Understand how you can build complete coverage with Dental and
Vision insurance. Page 7
HRA INFORMATION — Understand important facts about the Health Reimbursement Arrangement
(HRA) account your former employer will be providing. Page 8
ASSISTANCE BEYOND ENROLLMENT — Our team is available year-round to answer any questions or
concerns you may have regarding any healthcare plan related matter. Page 9
ADDITIONAL MEDICARE RESOURCES — The Centers for Medicare and Medicaid Services provides a
variety of learning opportunities you may wish to explore. Page 10
FREQUENTLY ASKED QUESTIONS — Review these FAQs to help guide the transition to your new
healthcare plan. Page 11
HEALTHCARE PROVIDER AND PRESCRIPTION DRUG INFORMATION — Record this important
information and send to us as soon as possible, but at least 10 days before your consultation. Page 15
This guide has
been organized to
provide you with a
clear roadmap for
your upcoming
healthcare plan
change.
Medicare Enrollment Guide | 1
Having the right healthcare coverage to meet your
needs and budget during retirement is important.
That's why Knights of Columbus has engaged Mercer
Marketplace 365+ Retiree to help you evaluate your
options and enroll in a new healthcare plan. You
will need to enroll in a new medical plan if you want
to continue to have medical coverage (other than
Medicare Part A and Part B). The enclosed letter
discusses the upcoming changes to your retiree
health coverage benefits.
This change is intended to provide retirees and
eligible Medicare dependents (if applicable) with
more flexibility and assistance with:
• Spending your healthcare dollars.
• Providing access to a greater variety of plans in
the marketplace.
• Connecting you with an experienced, licensed
benefits counselor who will assist you in making
a new healthcare plan election.
You will shop for and enroll in your new
healthcare coverage through Mercer
Marketplace 365+ Retiree. You now have several
options to choose from to meet your healthcare
and prescription drug needs. Mercer Marketplace
365+ Retiree and its benefits counselors are ready
to support you before, during, and long after your
health plan changes. They will help you understand
the dierent individual plans oered to you, assist
you in determining which plans provide the coverage
you need, and complete your enrollment when ready.
When you enroll in new medical coverage
through Mercer Marketplace 365+ Retiree,
Knights of Columbus will provide an HRA
(Health Reimbursement Arrangement) account
to oset the cost of your healthcare plan. This
HRA is a special, tax-free account that you may use
to reimburse yourself for eligible healthcare plan
expenses as defined by your employer and the IRS.
For a retiree and any applicable dependent(s) to
be eligible for the HRA, you must enroll in medical
coverage through Mercer Marketplace 365+ Retiree.
To continue to be eligible for the HRA, you must
maintain your medical plan enrollment though
Mercer Marketplace 365+ Retiree. A Reimbursement
Instructional Guide will be provided in a separate
mailing upon your enrollment in medical coverage
through Mercer.
You will have assistance from a benefits
counselor at every step. A counselor will help
you compare your health and prescription drug
coverage options, and complete your enrollment when
you are ready. You may also visit our website
to learn more about the dierent plans and
compare your coverage options. Refer to page 4
for more information about connecting with a benefits
counselor.
In the meantime, review this Enrollment Guide.
It contains tools and exercises to help you start
learning about your new healthcare plan options.
Completing the information requested in this guide
will make it easy for you and a benefits counselor to
evaluate your options and help you enroll on time.
Our team is excited to serve you in this new
program. Benefits counselors are available to
support you during your enrollment period. You
may reach Mercer Marketplace 365+ Retiree:
• Online at retiree.mercermarketplace.com/kofc
at your convenience, 24 hours a day, seven days a
week.
• Any business day, from 8:00 a.m. to
5:30 p.m. ET at 1-855-254-1187 toll-free (deaf or
hard of hearing individuals should dial 711) to set
up a consultation.
For additional information about Mercer Marketplace
365+ Retiree, including our compensation and privacy
practices, please see the enclosed document.
We look forward to working with you.
Mercer Marketplace 365+ Retiree
Welcome to Mercer Marketplace 365+
Retiree
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This transition will be an easy one if you review the
steps below and gather the requested information
prior to your consultation. Doing so ensures you will
be accurately and eciently enrolled in the plan that
best fits your needs and budget.
STEP 1: Upon receipt
• Review this Enrollment Guide.
• Because you are 65 and older or Medicare
eligible, be sure you have enrolled in coverage
for Medicare Parts A and B. You must
have already enrolled in both in order to
enroll in healthcare coverage with Mercer
Marketplace 365+ Retiree. Contact the Social
Security Administration at www.ssa.gov or by
calling 1-800-772-1213 (TTY 1-800-325-0778) if
you have not yet enrolled in Medicare Part B.
STEP 2: Schedule your consultation
Consult with a licensed benefits counselor
Go online at retiree.mercermarketplace.com/
kofc to schedule a one-on-one consultation with
a licensed benefits counselor. From the navigation
bar at the top of the page, click “Schedule a
Consultation.” If you prefer, you may also call to
schedule. It is important to act NOW to select your
date and time. Don’t wait until the end of your
enrollment period approaches before making this
appointment; doing so may leave you with a short
amount of time in which to make a decision. If you
have signed up for text messages or email updates,
you will receive a text/email confirmation once your
have scheduled your consultation.
STEP 3: Prepare now
Preparing for your consultation
Start by keeping track of your individual healthcare
coverage needs. Providing correct and complete
information will help your benefits counselor analyze
your health plan coverage specifics:
• Use the worksheet on page 15 to list your
important healthcare providers and prescription
drugs; you may enter your prescription drugs
online by visiting retiree.mercermarketplace.
com/kofc
• Think about plan features that are important to you.
• Prepare any questions you may have for your
benefits counselor.
• Have your Medicare insurance card handy, but do
not mail or fax this information.
• Gather any documentation that pertains to a
Power of Attorney, if applicable to you.
• Go online to visit our website: retiree.
mercermarketplace.com/kofc. Our online
tools are easy to use, and utilizing them can help
you feel more comfortable with this process and
also reduce the amount of time you spend on the
phone with your benefits counselor.
• If you have signed up for text messages or email
updates, you will receive a text/email 24 hours
before your consultation with a reminder of the
steps listed above.
STEP 4: The consultation
Explore your new plan options when you
consult with your benefits counselor
Please take this opportunity to utilize your benefits
counselor and his or her health insurance expertise.
He or she will present you with all of your options
so you can feel confident about the decision you
are making.
What steps do I have to take to successfully
enroll in my new plan?
Medicare Enrollment Guide | 3
STEP 5: Avoid a gap in coverage
Enroll in your new plan with your benefits
counselor
When you are ready to enroll in your new plan(s),
you will:
• Have your benefits counselor complete your
enrollment over the phone; online self-
enrollment is available only with certain
carriers and not all plans are available to be
viewed on the website.
• Provide information to set up payment for
your premium.
• Be sent any forms that are required; please review,
sign, date, and return promptly.
STEP 6: After enrolling in your new plan(s)
After your eective date, you:
• May be contacted by your new insurance carrier
in order to verify your enrollment; please do not
ignore this request, as doing so could delay or
nullify your coverage.
• Will receive your new insurance cards by mail from
your insurance carrier(s) after your enrollment has
been processed; please review them for accuracy.
• Will receive a confirmation of enrollment with
helpful next steps and FAQs if you have signed up
for text message/email updates.
STEP 7: Preparing to use your subsidy
Set up your HRA
You will receive additional information in a future
mailing outlining how to set up and utilize your HRA.
STEP 8: Ongoing
Please retain this Enrollment Guide as it will serve
as on ongoing reference for your health insurance
transition.
Open your camera on
your smartphone or
tablet and place your
camera over this code.
You will be directed
to our website where
you can schedule a
consultation, chat
with our experts, or
research your plan
options.
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Follow these steps to ensure that you are prepared for your phone consultation with your Mercer
Marketplace 365+ Retiree benefits counselor.
GO ONLINE AT RETIREE.MERCERMARKETPLACE.COM/KOFC TO SCHEDULE A CONSULTATION
WITH A BENEFITS COUNSELOR. From the navigation bar at the top of the page, click “Schedule a
Consultation.” If you prefer, you may call 1-855-254-1187 (Monday through Friday, 8:00 a.m. to 5:30
p.m. ET) to schedule your consultation. If your spouse is also eligible to enroll, we recommend calling to
schedule your consultations so they can be scheduled close to one another. Jot down the date and time
for this appointment below:
Consultation Date: ________________________________________________________
Time: ___________________________________________________________________
COMPLETE THE HEALTHCARE PROVIDER AND PRESCRIPTION DRUG INFORMATION FORM
included in this guide on page 15 and mail, fax, or email the following information as soon as possible,
but at least 10 days before your consultation.
Address: Mercer Marketplace 365+ Retiree
P.O. Box 14401
Des Moines, IA 50306-3401
Secure fax: 857-362-2999
Email: rx.tracker@mercer.com
OR, YOU CAN SAVE TIME BY GOING ONLINE!
You can shorten the amount of time you spend on the consultation call by submitting
your prescription drug information and healthcare providers through the website by
following these steps:
• Start by visiting the homepage at retiree.mercermarketplace.com/kofc
• At the top of the page, click on ‘Shop & Compare’, then in the pull-down menu, click on ‘Shop
for Medicare plans.’
• When you are ready to begin reviewing plan options, scroll to the bottom and click
'GET STARTED.' When you follow the step-by-step instructions, you will be
directed to a location where you will enter prescription drug information.
• Your prescription drug information will be pre-loaded to your profile and available
to your benefits counselor prior to your consultation.
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2
How do I schedule an appointment with a
benets counselor and how should I prepare
for my consultation?
Medicare Enrollment Guide | 5
CONSIDER YOUR ANSWERS TO THE FOLLOWING QUESTIONS PRIOR TO YOUR CONSULTATION:
• Do you have end stage renal disease (ESRD)?
• Do you currently reside in a Nursing Home or Assisted Living Facility?
• Do you anticipate spending considerable time away from your primary residence during which you
would seek non-emergency medical care?
• Are you comfortable with an HMO/PPO network which may include some, but not all, of your
providers and may not provide care outside your area without additional higher fees?
• Do you use healthcare providers that do not accept Medicare? (You can call your providers and ask
the billing department.)
• Are you entitled to TRICARE For Life, other prescription drug/health benefits through the VA, or any
other health or prescription drug benefits not listed here?
• Has Medicare or the Social Security Administration notified you that you are eligible for assistance
with paying for Medicare prescription drug plan costs?
• Are you currently receiving Medicaid benefits?
BE READY ON THE DATE AND TIME YOU SELECTED FOR YOUR CONSULTATION, AND:
• Have your Medicare (red, white, and blue) ID card available for your
consultation. You will need to provide both your Part A and Part B eective
dates. Please do not email or fax this card or Medicare number.
• Allow enough time for the consultation, approximately 60-90 minutes.
• Make certain any family member or caregiver is available for the call if desired.
• If you do not receive your consultation call within 30 minutes of the scheduled time,
please contact Mercer Marketplace 365+ Retiree.
• Promptly reschedule the consultation if you find you cannot keep the appointment you originally
scheduled by going online at retiree.mercermarketplace.com/kofc or by calling
1-855-254-1187; those who are deaf or hard of hearing should dial 711 for Telecommunications Relay
Service.
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4
Your benefits counselor will ask you the following questions during your
consultation, but it helps to have them in front of you and be better prepared
for your call. Your answers to these questions will help your benefits counselor
discuss healthcare insurance plans that best fit your needs.
How do I schedule an appointment with a
benets counselor and how should I prepare
for my consultation?
6
In most cases, when a person enrolls, they will choose between these options.
Use this chart to help you decide which option is right for you.
Step 1: Decide if you want
Original Medicare
WITH MEDICARE SUPPLEMENT
Medicare Advantage Plan
LIKE AN HMO OR PPO NETWORK
PART A (HOSPITAL INSURANCE)
PART B (MEDICAL INSURANCE)
PART C: INCLUDES BOTH PART A (HOSPITAL
INSURANCE) & PART B (MEDICAL
INSURANCE)
Medicare provides this coverage.
You have your choice of doctors, hospitals, and
other providers that accept Medicare.
Most people pay a monthly premium for Part
B. In addition, you will pay deductibles for
services covered under Parts A and B and pay
co-insurance for all Medicare-covered services.
IN ADDITION, YOU MAY ADD A MEDICARE
SUPPLEMENT POLICY TO YOUR PART A AND B
MEDICARE COVERAGE.
These plans are oered by private insurance
companies that pay all or part of the
deductibles and co-insurance with predictable
out-of-pocket expenses.
Note: You can enroll in either a Medicare
Advantage Plan that oers prescription drug
coverage as part of the plan, or a Medicare
Supplement policy and a free-standing
prescription drug plan.
No network restrictions, as long as the provider
accepts Medicare.
Private insurance companies approved by
Medicare provide this coverage.
In most plans, you need to use approved
network doctors, hospitals, and other providers
or you will pay more.
You pay a monthly premium (depending upon
the plan), your Part B premium, and
co-payments for covered services.
Costs, rules, and coverage beyond what’s
covered in Medicare Parts A and B will vary by
plan.
Note: If you join a Medicare Advantage Plan,
you cannot have a Medicare Supplement
policy or enroll in a free-standing prescription
drug plan.
Normally you will see lower monthly premium
costs, but higher out-of-pocket expenses
when services are rendered.
Step 2: Decide if you want Prescription Drug Coverage (Part D)
If you want this coverage, you must choose a
Medicare Prescription Drug Plan.
These plans are run by private insurance
companies approved by Medicare.
You must pay the monthly plan premium and
drug co-payments.
Most Medicare Advantage Plans include
prescription drug coverage (Part D).
The prescription drug premium is included in
your monthly Medicare Advantage premium.
You will be responsible for co-payments and
any other plan costs.
How can I learn more about my Medicare
options?
Medicare Enrollment Guide | 7
During your consultation with your benefits counselor, he or she will review all of your benefits options with
you, discuss your personal situation, and answer any questions you may have. Your benefits counselor will
help educate you about additional insurance options available that you may wish to consider in order to make
the best possible decision for you and your family.
DENTAL INSURANCE THROUGH
MERCER MARKETPLACE 365+ RETIREE:
Enrolling in dental insurance can be
a cost-eective way to address the
costs of annual exams and related
services such as fillings and extractions.
Dental insurance can play an important role in
your health. Since people with dental insurance
are more likely to visit the dentist, a solid
insurance plan can help you maintain good oral
health, which promotes your overall health.
VISION INSURANCE THROUGH
MERCER MARKETPLACE 365+ RETIREE:
Vision insurance is a type of supplemental
insurance that can help pay for yearly
eyesight exams, glasses and/or contact
lenses. With vision insurance, you will
also have access to eye doctors who are focused
on keeping your eyes healthy by detecting
conditions such as glaucoma or cataracts.
You may go online to view your additional insurance options and enroll in a plan of your choice.
• Start by visiting the homepage at retiree.mercermarketplace.com/kofc
• In the ‘Shop & Compare’ section, click on the box to the far right titled ‘DENTAL, VISION, & OTHER
OPTIONS ’ (Please see the area in red box below.) You may explore other insurance options such as Dental
and Vision.
• Enroll in the Dental and/or Vision plan(s) of your choice online or with the assistance of your benefits
counselor.
What other insurance options should I be
considering to round out my coverage?
8
Your former employer is providing a Health Reimbursement Arrangement (HRA) account for their eligible
retirees. This HRA may be used for reimbursement of healthcare premiums and eligible out-of-pocket
healthcare expenses as defined by your former employer.
You pay your premium(s) or out-of-pocket expenses directly to your insurance carrier(s) or provider(s), then
you will be reimbursed with available funds from your HRA account.
You will receive additional information in a future mailing outlining how to set up and utilize your HRA.
How does my HRA work and how will I be
reimbursed?
Medicare Enrollment Guide | 9
We are here to help beyond your initial enrollment
Once you have enrolled in your medical plan(s) through Mercer Marketplace 365+ Retiree team, your benefits
counselor is available to provide assistance with any healthcare plan related matter. If you have questions
about your plan or problems resolving an issue with a carrier, help is just a click online or a phone call away.
What to expect in the years to come
Typically, if you like your healthcare plan(s), and the carrier continues to oer the plan(s), you do not need to
re-enroll each year. However, there are a few things you will need to consider each fall:
• We will send you a reminder that the Open Enrollment Period is approaching. If you do wish to make a
new healthcare plan election, keep in mind the Medicare Open Enrollment Period is typically October 15–
December 7.
• By law, your insurance carrier is required to send you information about plan or pricing changes. Please be
certain to open, review, and save all of this documentation.
• If you are considering making a change to your healthcare plan, please be certain to contact a Mercer
Marketplace 365+ Retiree benefits counselor BEFORE making any changes on your own. There are
implications you will need to consider, and our benefits counselors are trained at making sure you
understand these prior to enrolling in a new plan.
How you can reach us
• Go online for 24/7 assistance: retiree.mercermarketplace.com/kofc
• Call: 1-855-254-1187; those who are deaf or hard of hearing should dial 711 for Telecommunications Relay
Service.
• Fax: 857-362-2999
• Mailing address: P.O. Box 14401, Des Moines, IA 50306-3401
Make sure your email, phone number and mailing addresses are
up-to-date with us, as we may send you dierent communications
throughout the year and want to have the most accurate way of
reaching you.
What type of assistance is available to me
after I enroll?
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If you are new to Medicare, or just want to better understand the Medicare program and dierent benefits,
you may visit CMS (The Centers for Medicare and Medicaid Services) at https://www.cms.gov.
CMS produces a comprehensive publication each year that discusses the Medicare program in its entirety.
You may request a printed copy of this book by calling 1-800-MEDICARE (1-800-633-4227); TTY users should
call 1-877-486-2048. You may also access this publication online by visiting https://www.medicare.gov/
pubs/pdf/10050-Medicare-and-You.pdf.
MEDICARE
• Go online www.medicare.gov
• Call 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048), available 24 hours a day, 7 days a week
SOCIAL SECURITY
• Visit your local Social Security oce
• Go online www.ssa.gov
• Call 1-800-772-1213 (TTY 1-800-325-0778)
Where can I nd out more information about
the Medicare program?
Medicare Enrollment Guide | 11
We recognize your health plan choices and costs are important to you. If you have questions, we encourage
you to speak to your benefits counselor. Below you will find answers to many questions frequently asked by
retirees and their dependents.
HOW IS MY HEALTH INSURANCE CHANGING?
You will soon turn 65 and become eligible to enroll in
Medicare, OR you are already enrolled in Medicare and
will soon be retiring from the company where you are
currently employed. As such, your current health
plan coverage will end and you will need to choose a
new plan to ensure you have the coverage you need
going forward.
HOW WILL I OBTAIN MY NEW
HEALTH INSURANCE?
In order to help you find the plan that best fits
your needs and budget, your company has
partnered with Mercer Marketplace 365+ Retiree to
guide you through the process from beginning to
end. Mercer Marketplace 365+ Retiree will be your
single point of contact for healthcare insurance
issues — before, during and after the transition to
your new healthcare plan.
HOW WILL I PAY FOR MY NEW
HEALTH INSURANCE?
You will now pay your premiums directly to the
insurance carrier for your retiree healthcare
coverage and you will be reimbursed from your HRA.
You can be reimbursed for your premiums via direct
deposit into your bank account or a paper check.
For additional details about your HRA, you may refer to the Reimbursement Instructional Guide you will receive
after enrolling in medical coverage through Mercer.
WILL I BE REQUIRED TO CHOOSE A NEW DOCTOR?
It depends on the health insurance strategy that you choose. Medicare Supplement plans allow you to choose
any doctor that accepts Medicare, while Medicare Advantage uses networks of doctors who accept only certain
plans. Your Mercer Marketplace 365+ Retiree benefits counselor will help you find a plan that works with your
doctor.
Where can I nd answers to additional
questions I may have?
12
HOW LONG WILL THE APPOINTMENT WITH MY BENEFITS COUNSELOR LAST?
In general, you’ll spend about 60 to 90 minutes on the phone speaking with your benefits counselor. The length of
the call will depend on whether you enroll that day or want to include a family member or caregiver, or a power of
attorney on the call. The length of your appointment will also depend on how much preparation you wish to do in
advance.
Remember, your benefits counselor is an excellent resource and will take as much time on the phone or in a future
conversation as you need to feel comfortable with your enrollment decision.
If you go online to the Mercer Marketplace 365+ Retiree website prior to your consultation to enter your
prescription drugs, your appointment could be much shorter. See the checklist in this Enrollment Guide for
details on how to prepare for your call.
IF I NEED ASSISTANCE WITH ENROLLING, CAN SOMEONE SPEAK WITH MY BENEFITS COUNSELOR
ON MY BEHALF?
If you complete and sign a Personal Information Authorization form, anyone listed on the form can assist you with
your plan information and/or selections. However, a durable Power of Attorney (POA) document must be
on file at Mercer Marketplace 365+ Retiree for anyone but the retiree to enroll in healthcare coverage.
Anyone who is listed on the durable POA can act on behalf of the retiree in all insurance capacities, including HRA
paperwork.
Where can I nd answers to additional
questions I may have?
continued
Medicare Enrollment Guide | 13
IF I LIKE THE BENEFITS COUNSELOR
I HAVE MY CONSULTATION WITH, CAN
I REQUEST THAT SAME PERSON AGAIN?
The person you enjoyed dealing with
before may not be available due to other
scheduled appointments when you call.
Every benefits counselor must, by law,
be licensed, certified, and appointed to
talk with you about the plans in your
specific geographic area.
Please be assured that if you can’t reach
the benefits counselor you request, all of
your information is available in our secure
system, and another benefits counselor
will be able to assist you.
DO I NEED TO ENROLL IN MEDICARE
PART B?
Yes, in order to qualify for a Medicare
Supplement or Medicare Advantage
plan, you must be enrolled in both
Medicare Part A and Part B, and continue
to pay for those premiums.
DO I NEED TO ENROLL IN A MEDICARE
PART D PLAN?
Medicare recommends that you enroll
in a plan when you are first eligible,
both to gain access to discounted
prescriptions and to avoid Medicare’s
permanent late enrollment penalty.
Where can I nd answers to additional
questions I may have?
continued
WILL MY NEW COVERAGE COVER ME IF I TRAVEL?
When traveling domestically, as long as a hospital, clinic, or doctor accepts Original Medicare, Part A, and Part B,
healthcare providers will accept your Medicare supplement plan. For Medicare Advantage plans such as HMOs
and PPOs, there will be network restrictions when traveling outside of your plan’s area. Your licensed benefits
counselor can provide additional details on healthcare benefits while traveling during your consultation or at any
point throughout the year.
IF I DON’T LIKE THE PLAN I’M ENROLLED IN, WHEN CAN I CHANGE?
Medicare Supplement plans can be changed at any point during the course of the year, but may require
underwriting to do so. Underwriting is when an insurance carrier collects your medical history to determine
whether or not to accept your application for insurance and how much to charge you. There is a one-time window
of guaranteed insurability after your initial enrollment into Medicare or after you leave a terminating group plan.
After that window closes, carriers may ask you underwriting questions if you are changing your plan. Each carrier
has its own rules, so it is important to discuss any changes you may wish to make with your licensed
benefits counselor. There is no medical underwriting for changing Medicare Advantage plans, however, Medicare
Advantage and Medicare Advantage Prescription Drug plans only accept enrollments during the Annual Enrollment
Period (October 15th–December 7th) for a January 1st eective date. Additionally, Part D prescription drug plans
can only be changed during the same Annual Enrollment Period for a January 1st eective date.
14
Where can I nd answers to additional
questions I may have?
continued
Medicare Enrollment Guide | 15
HEALTHCARE PROVIDER INFORMATION
YOUR NAME___________________________________________ PHONE__________________
Please list your current healthcare providers below. Some healthcare plans like HMOs and PPOs use networks.
Gathering your healthcare providers’ information here will help your benefits counselor compare access to
your current providers. You may also contact your providers and ask them which plans they accept.
CURRENT HEALTHCARE PROVIDERS PRIMARY CARE, SPECIALISTS, ETC.
Name Address Phone Number
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
PRESCRIPTION DRUG INFORMATION
In order to construct an accurate cost analysis, we will need your complete and correct drug information. For
example, it is important to indicate the name of the drug that you are taking, and whether you are taking a
BRAND or GENERIC version. Please note, over-the-counter medications, vitamins, and supplements are not
covered by prescription drug plans and therefore are not required on this form.
CURRENT PRESCRIPTIONS, DOSAGES, FREQUENCY AND WHERE/HOW YOU OBTAIN THE MEDICATION
Medication Dosage Frequency Pharmacy or Mail Order
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Please complete one form per person. If you have additional healthcare providers or prescription drugs to
share with your benefits counselor, please make a copy of this page (prior to completing) and use it to record
your additional entries.
What information do I need to provide?
16
[ The remainder of this page is intentionally left blank so that if you
submit this information by mail, you won’t be mailing
anything important that you may need later.]
REMEMBER! You may go online to enter your prescription drug information as soon as possible, but at least
10 days prior to your consultation; doing so will shorten the amount of time you spend on the consultation call.
Follow the step-by-step instructions listed in the blue box on page 4.
If you are unable to go online, please mail, fax, or email this worksheet as soon as possible, but at least 10 days
prior to your scheduled appointment to:
Mercer Marketplace 365+ Retiree
P.O. Box 14401, Des Moines, IA 50306-3401
Fax: 857-362-2999
Email: rx.tracker@mercer.com
Medicare Enrollment Guide | 17
Questions for my benets counselor
The insurers whose policies you may enroll in are separate and independent from Mercer Marketplace 365+ Retiree.
Mercer Marketplace 365+ Retiree is not responsible for any insurer’s or service provider’s failure to provide coverage or
service, including but not limited to any failure resulting from the insurer’s or service provider’s current or future financial
condition or solvency. From time to time, insurance companies may become insolvent and fall into receivership with the
state’s insurance regulatory authority. In addition to potential access to state guarantee funds, these state departments
also may provide financial information. See your state’s department of insurance website for any information they may
provide. While each state does impose its own minimum capital and surplus requirements on insurers, Mercer
Marketplace 365+ Retiree also advises that you consider the ratings of an independent agency. Independent agencies,
such as A.M. Best (www.ambest.com), may also issue ratings describing their evaluation of an insurer’s financial ability to
honor its insuring obligations. Insurers receive dierent ratings. Some insurers available to you fail to achieve the agency’s
rating for superior or excellent. Mercer Marketplace 365+ Retiree recommends that you carefully consider financial
information provided by both state insurance regulators and independent rating agencies when purchasing insurance
coverage.
KOFC-AGE-MED-HRA
