Enrollment eForm - NHRMC Health Advantage

Thank you for choosing New Hanover Health Advantage!

To get started, please select the county you live in from the list below, enter your zip code, then click the next button.
County*
- New Hanover
- Brunswick
- Pender
Zip Code*

Good News! We offer plans in your area. Now Let's check eligibility.
Do you have Medicare Part A & B?*
- Yes
- No
We're sorry! You must currently have Medicare Part A & B to proceed.

Typically, you may enroll in a Medicare Advantage plan only during the annual enrollment period from October 15 through December 7 of each year. There are exceptions that may allow you to enroll in a Medicare Advantage plan outside of this period.

Please read the following statements carefully and check the box if the statement applies to you. By checking any of the following boxes you are certifying that, to the best of your knowledge, you are eligible for an Enrollment Period. If we later determine that this information is incorrect, you may be disenrolled.
Check all that apply*
- I am new to Medicare.
- I am enrolled in a Medicare Advantage plan and want to make a change during the Medicare Advantage Open Enrollment Period (MA OEP).
- I recently moved outside of the service area for my current plan or I recently moved and this plan is a new option for me.
- I was recently released from incarceration.
- I recently returned to the United States after living permanently outside of the U.S.
- I recently obtained lawful presence status in the United States.
- I recently had a change in my Medicaid (newly got Medicaid, had a change in level of Medicaid assistance, or lost Medicaid).
- I recently had a change in my Extra Help paying for Medicare prescription drug coverage (newly got Extras Help, had a change in the level of Extra Help, or lost Extra Help).
- I have both Medicare and Medicaid (or my state helps pay for my Medicare premiums), or I get Extra Help paying for Medicare prescription drug coverage, but I haven't had a change.
- I am moving into, live in, or recently moved out of a Long-Term Care Facility (for example, a nursing home or a long-term care facility).
- I recently left a PACE program.
- I recently involuntary lost my creditable prescription drug coverage (coverage as good as Medicare).
- I am leaving employer or union coverage.
- I belong to a pharmacy assistance program provided by my state.
- My plan is ending its contract with Medicare, or Medicare is ending its contract with my plan.
- I was enrolled in a plan by Medicare (or my state) and I want to choose a different plan.
- I was enrolled in a Special Needs Plan (SNP) but I have lost the special needs qualifications required to be in that plan.
- I was affected by a weather-related emergency or major disaster (as declared by the Federal Emergency Management Agency (FEMA)). One of the other statements here applied to me, but I was unable to make my enrollment because of the natural disaster.
New Hanover Health FirstMedicare, a product of FirstCarolinaCare Insurance Company of North Carolina, Inc., is a Medicare Advantage organization with a Medicare contract. Enrollment in New Hanover Health FirstMedicare depends on contract renewal.

Thank you. You have chosen to enroll in:
New Hanover Health Advantage Select HMO-POS
New Hanover Health Advantage Platinum HMO-POS
New Hanover Health Advantage Freedom HMO-POS
Now you can:
- Continue your application by clicking the "Next" button below
  - or -
- Change your selections by clicking the "Previous" button below

Please Provide Your Medicare Insurance Information

Please take our your red, white, and blue Medicare card to complete this section.
- Fill out this information as it appears on your Medicare card
  - or -
- Attach a copy of your Medicare card or your letter from Social Security or the Railroad Retirement Board
You must have Medicare Part A and Part B to join a Medicare Advantage plan.
First Name*
Last Name*
Is Entitled To
Medicare Number*
HOSPITAL (Part A), Effective Date*
MM slash DD slash YYYY
MEDICAL (Part B), Effective Date*
MM slash DD slash YYYY
File Attachment
Drop files here or

Accepted file types: doc, docx, pdf, Max. file size: 300 MB.

Paying Your Plan Premium

If we determine that you owe a late enrollment penalty (or if you currently have a late enrollment penalty), we need to know how you would prefer to pay it. You can pay by mail or "Electronic Funds Transfer (EFT)" each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month. If you are assessed a Part D-Income Related Monthly Adjustment Amount, you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security benefit check or be billed directly by Medicare or RRB. DO NOT pay New Hanover Health Advantage the Part D-IRMAA.

You can pay your monthly plan premium (including any late enrollment penalty that you currently have or may owe) by mail or "Electronic Funds Transfer (EFT)" each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month.

If you are assessed a Part D-Income Related Monthly Adjustment Amount, you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security benefit check or be billed directly by Medicare or RRB. DO NOT pay New Hanover Health Advantage the Part D-IRMAA.

People with limited incomes may qualify for Extra Help to pay for his/her prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or late enrollment penalty. Many people are eligible for these savings and don't even know it. For more information about this Extra Help, contact your local Social Security office, or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for extra help online at www.socialsecurity.gov/prescriptionhelp.

If you qualify for Extra Help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn't cover.

If you don't select a payment option, you will get a bill each month.
Please Select a premium payment option*
- Get a bill monthly.
- Electronic funds transfer (EFT) from your bank account each month.
- Automatic deduction from your monthly Social Security or Railroad Retirement Board (RRB) benefit check.
(The Social Security/RRB deduction may take two or more months to begin after Social Security or RRB approves the deduction. In most cases, if Social Security or RRB accepts your request for automatic deduction, the first deduction from your Social Security or RRB benefit check will include all premiums due from your enrollment effective date up to the point withholding begins. If Social Security or RRB does not approve your request for automatic deduction, we will send you a paper bill for your monthly premiums.)
Please provide the following:
Account Holder Name*
Account Type*
- Checking
- Savings
Bank Routing Number*
Bank Account Number*

Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal employee health benefits coverage, VA Benefits, or State pharmaceutical assistance programs.
Will you have other prescription drug coverage in addition to New Hanover Health FirstMedicare Health Plan?*
- Yes
- No
If 'yes,' please list your other current coverage and your identification (ID) number(s) for this coverage:
Name of other coverage
ID # for this coverage
Group # for this coverage
Are you a resident in a long-term care facility, such as a nursing home?*
- Yes
- No
If 'yes,' please provide the following information:
Name of Institution
Institution Phone Number
Institution Address
Street Address City State Zip Code
Are you enrolled in your State Medicaid program?*
- Yes
- No
If 'yes,' please provide the folowing information:
Medicaid Number
Please contact New Hanover Health Advantage at XXX_XXX_XXXX, if you need information in another format or language than what is listed above. TTY users should call 711.
Do you or your spouse work?*
- Yes
- No
Please check one of the boxes below if you would prefer us to send your information in a language other than English or in another format:
- Spanish

Please Read This Important Information

If you currently have health coverage from an employer or union, joining New Hanover Health FirstMedicare could affect your employer or union health benefits. You could lose your employer or union health coverage if you join New Hanover Health FirstMedicare. Read the communications your employer or union sends you. If you have questions, visit their website, or contact the office listed in their communications. If there isn't any information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.

Enrollment E-form

Step 1 of 11

Thank you for choosing New Hanover Health Advantage!

Please check which plan you want to enroll in:

Please Provide Your Medicare Insurance Information

Is Entitled To

Paying Your Plan Premium

Please provide the following: