Steps for Applying for Medicare Select

The information below walks you through how to apply for a Medicare Select policy.

Printer Friendly Instructions

1. Complete the Medicare Select Enrollment Application

Section 1: Information About You
Fill in the non-shaded areas with your personal information.

• Your 1st month’s premium is due at the time of applying. This policy is issued on a calendar year basis. Premium rates are as follows:
• • Females
    

    Age	Monthly Premium	Quarterly Premium	Annual Premium
    0-64	$214	$642	$2,568
    65-69	$122	$366	$1,464
    70-74	$139	$417	$1,668
    75-79	$158	$474	$1,896
    80-84	$183	$549	$2,196
    85+	$221	$663	$2,652

    
    
  • Males

    Age	Monthly Premium	Quarterly Premium	Annual Premium
    0-64	$235	$705	$2,820
    65-69	$125	$375	$1,500
    70-74	$148	$444	$1,776
    75-79	$172	$516	$2,064
    80-84	$208	$624	$2,496
    85+	$237	$711	$2,844

    
    
• Make sure to indicate in the “effective date requested” box what day you would like to start your policy. Whichever month you choose, you need to start your policy on the 1st day of that month.
• If you would like to have your payment automatically withdrawn from your account each month, complete the information about electronic funds transfer or send along a voided check. Make sure to provide a signature and date at the end of that section. If you do not want to do electronic funds transfer, you can skip that section.

Section 3: Information About Other Insurance Coverage You May Have

• It’s important to complete all the questions that apply to you in this section.
• Also, be sure to complete the effective dates for your Federal Medicare plan as well as your Federal Medicare ID number.

Section 4: Health Questionnaire
You need to fill this section out only if you don’t have an open enrollment (the one-time only six month period when you can purchase a Medicare supplement policy that starts when you sign up for Medicare Part B and you are 65) or guaranteed issue (certain situations when insurance companies are required to accept your application for a Medicare supplement policy and cannot deny you coverage or place conditions on a policy).

Section 5: Signature and Consent To Release Medical Information
Make sure to sign and date the end of this section.

2. Complete the Medicare Notice Application Section: Statement to Applicant By Issuer, Agent, Broker or Other Representative

• Please tell us why you are looking for a Medicare supplement policy.
• If you are working with an agent, please have him/her sign the last page. You will also need to sign and date the application.

3. Write a check for the first month’s payment.
(The check will not be cashed unless your application is approved.)

4. Mail the enrollment application, the Medicare Notice and the check for the first month’s payment to:

Unity Health Insurance
840 Carolina Street
Sauk City, WI 53583-1374
Attn: Medicare Select Enrollment

Unity Health Plans Insurance Corporation and its representatives are not connected with Medicare. This is an advertisement for health insurance through Unity Health Plans Insurance Corporation.