Denver Health Medical Plan

Please read the following statements carefully and select the one that applies to you. By selecting any of the following, 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 dis-enrolled. If none of these qualifying events apply to you or you are not sure, please contact Denver Health Medical Plan at 303-602-2999. TTY users should call 711 to see if you are eligible to enroll.

What is the qualifying life event?

Annual Enrollment Period (AEP)(Oct 15-Dec 7)

MAOEP (Jan 1-Mar 31)

ICEP-I'm new to Medicare and eligible through my 65th birthday.

ICEP-I'm new to Medicare and eligible through my 25th month of disability.

IEP-I already have Hospital (Part A) and recently signed up for Medical (Part B). I want to join a Medicare Advantage Plan.

SEP-I moved to a new address that’s outside my current plan’s service area, or I recently moved and this plan is a new option for me.

SEP-I recently was released from incarceration.

SEP-I recently returned to the United States after living permanently outside of the U.S.

SEP-I recently obtained lawful presence status in the United States.

SEP-I live in a long-term care facility, like a nursing home or a rehabilitation hospital.

SEP-I recently moved out of a long-term care facility, like a nursing home or a rehabilitation hospital.

SEP-I recently had a change in my Medicaid (newly got Medicaid, had a change in level of Medicaid assistance, or lost Medicaid).

SEP-I recently had a change in my Extra Help paying for my drug costs (newly got Extra Help, had a change in my level of Extra Help, or lost Extra Help).

SEP-I have both Medicare and Medicaid (or my state helps pay for my Medicare premiums) or I get Extra Help paying for my Medicare prescription drug coverage, but I haven’t had a change.

SEP-I recently left a PACE (Programs of All-Inclusive Care for the Elderly) program.

SEP-I lost other, non-Medicare drug coverage that’s as good as Medicare drug coverage (creditable coverage), or my other, non-Medicare coverage changed and is no longer considered creditable.

SEP-I'm enrolling in a 5-star Medicare plan.

SEP-I’m in a plan that’s had a star rating of less than 3 stars for the last 3 years. I want to join a plan with a star rating of 3 stars or higher.

SEP-I'm leaving employer or union coverage (including COBRA coverage).

SEP-I’m in a plan that was recently taken over by the state because of financial issues. I want to switch to another plan.

SEP-I belong to a pharmacy assistance program provided by my state (SPAP), or I’m losing help from a State Pharmaceutical Assistance Program.

SEP-I lost my coverage because my plan no longer covers the area that I live or it ended its contract with Medicare.

SEP-I want to join a Special Needs Plan that tailors its benefits to my chronic condition.

SEP-I was affected by an emergency or a major disaster (as declared by the Federal Emergency Management Agency, or by Federal, my state, or my local government). One of the other statements on this page applied to me, but I was unable to make my request because of the disaster.

SEP-I’m in a Medicare Advantage Plan and have had Medicare for less than 3 months. I want to make a change.

SEP-I was affected by an emergency or a major disaster related to Covid-19 (as declared by the Federal Emergency Management Agency, or by Federal, my state, or my local government). One of the other statements on this page applied to me, but I was unable to make my request because of the disaster.

SEP-CMS determined that I have demonstrated to CMS that my plan which I am a member substantially violated a material provision of its contract.

SEP-CMS determines that changes to my plan’s provider network are significant.

SEP-CMS determined that I was not adequately informed of the creditable status of drug coverage provided by my Plan as required to give such notice, or a loss of creditable coverage. (Different from marketing mis-representation)

SEP-I have recently received a notice telling me that I have been approved for Medicare for a “retroactive” date.

SEP-I was enrolled or disenrolled in a Plan based on misleading or incorrect information, or I was enrolled or disenrolled into a Plan without my knowledge or consent.

When did this event occur?

Other Details

Who's Enrolling?

Address

Applicant

Medicare Number

What is the qualifying life event?

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