AGE 65 AND OLDER? P ACE AND PACENET ... - Pennsylvania …

QUESTIONS?

CALL CARDHOLDER SERVICES

1-800-225-7223 --

Hearing Impaired Callers Using

TTY/TDD should call: 1-800-222-9004 --

24 HOUR FAX NUMBER 1-888-656-0372 -- EMAIL ADDRESS

papace@

TerTeosma OWsoblof rne SECRGETOAVREYRONOF RAGING

Robert Torres SECRETToAmRYWOoFlf AGING

GOVERNOR

3/2019

AGE 65 AND OLDER? NEED PRESCRIPTION HELP?

APPLY ANYTIME * APPLICATION ENCLOSED *

PACE AND PACENET

WORKS WITH: ? MEDICARE PART D PLANS ? RETIREE/UNION COVERAGE ? EMPLOYER PLANS ? VETERANS' BENEFITS WE OFFER LOW PRESCRIPTION COPAYS

1-800-225-7223

PACE AND PACENET ELIGIBILITY

? 65 Years of age or older ? Pennsylvania resident for at least 90

consecutive days ? Must meet income requirements as listed

below

IT'S EASY TO APPLY! FOLLOW OUR HANDY CHECKLIST: ? Complete both sides of the application form ? Complete the section marked for spouse

even if your spouse is not applying ? Complete your Health Survey ? Make sure your application contains a

signature in Section E

HOW YOU CAN APPLY

? CALL US AT 1-800-225-7223

(Please have your income and insurance information available.)

? APPLY ONLINE AT:

? FILL OUT THE ENCLOSED APPLICATION

? Mail to: PACE/PACENET, PO BOX 8806 HARRISBURG PA 17105-8806

? Fax to: 1-888-656-0372

? E-mail the application to: papace@

Important Information: You can be enrolled in PACE/PACENET even if you have health insurance or another prescription plan...Sign up today!

Social Security Medicare Part B premiums are now excluded from income.

PACE FACTS

? ?

A single person's total income from last year must be $14,500 or less. A married couple's total combined income from last year must be $17,700 or less.

? Covered drugs (based on 30-day supply):

$6 Generic co-pay

$9 Brand co-pay

PACENET FACTS

? A single person's total income from last year must be between $14,501 and $27,500.

? A married couple's total combined income from last year must be between $17,701 and $35,500.

? Covered drugs (based on 30-day supply):

$8 Generic co-pay

$15 Brand co-pay

(PACENET members may have a monthly premium to pay at the pharmacy.)

PACE/PACENET INCOME REQUIREMENTS --INCOME INCLUDES, BUT IS NOT LIMITED

TO, THE FOLLOWING:

? Gross Social Security & SSI (excluding Medicare Premiums)

? Railroad Retirement (RRB1099 & RRB1099R) ? Gross Pensions ? Salaries/Wages/Commissions ? Self-Employment or partnership income ? Alimony and Spousal Support Money ? Taxable Amount of Annuities and IRAs ? Unemployment ? Cash Public Assistance ? Interest/Dividends/Capital Gains ? Net Rental Income ? Royalties ? Workers' Compensation ? Life Insurance Benefits (death benefits over

$10,000) ? Spouse's income if married, living together ? Gift and inheritance of cash or property over

$300 ? Any amount of money or the fair market

value of a prize, such as a car or trip won in a lottery, contest, or gambling winnings

IMPORTANT INFORMATION REGARDING THE SALE OF A HOME/PROPERTY

? If you sold your home, all capital gains must be declared as income within two (2) years of the sale date even if you did not file a State or Federal tax return. If you sold your home to pay for nursing home costs or used these proceeds to purchase another residence deeded in your name, it is not considered income.

PACE/PACENET EXCLUDABLE INCOME (DO NOT COUNT)

? Aid & Attendance payments from VA ? Veterans' Disability Payments ? Certain AmeriCorps* Vista payments may be

excluded ? Property Tax/Rent Rebates ? Other people's income living with you other

than your spouse ? Damages received in a civil suit/settlement

agreement ? Benefits granted under 306c of Workers'

Compensation Act ? Food Stamps ? LIHEAP payments ? Black or White Lung Benefits ? Assets ? Medicare Part B Premiums ? Housing allowance for members of religious

orders

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INSTRUCTIONS FOR COMPLETING THE APPLICATION --NEED ASSISTANCE CALL 1-800-225-7223

SECTION A -- APPLICANT INFORMATION Please complete all fields in this section of the application. Helpful Hints: ?? AApppplliiccaanntt PPeennnnssyyllvvaanniiaa AAddddrreessss--?TThheePPeennnnssyyllvvaanniiaa ssttrreeeett aaddddrreessss wwhheerree yyoouu rreessiiddee.. ?? MMaaiilliinngg AAddddrreessss--?IIffyyoouurrmmaaiill ggooeess ttoo aa PPOO BBooxx rraatthheerr tthhaann yyoouurr rreessiiddeennttiiaall aaddddrreessss,, pplleeaassee ffiillll tthhiiss ouot.uOt. tOhethrewriwseis,ele, alevaevbelabnlakn.k. ? Veteran's Status ? Circle the answer that best describes your status. SECTION B -- SPOUSE INFORMATION ISf EyCouTIaOreNmBa--rrieSdP, OyoUuSr EspINouFsOeR'sMinAfoTrImOaNtion must be completed even if your spouse is not applying fIof ryocuovaerreagmea.rrPielde,asyeoucrosmppolueste'salilnffioerldmsaitniotnhims ussetctbioencomf tphleetaepdpelicvaetnioinf .your spouse is not applying for coverage. Please complete all fields in this section of the application. S? EVCetTeIrOanN'sCS--tatuPsR?EVCIiOrcUleSthYeEaAnRswINeCr tOhMatEbest describes your status. Include all income that you and your spouse (if married, living together) received during the previous ySeEaCr.TPIOleNasCe i--nclPuRdeEVgrIoOsUsSSYocEiaAlRSeINcCurOityM&E SSI (We will exclude the Medicare Premiums). Include all income that you and your spouse (if married, living together) received during the previous SyeEaCr.TPIOleNasDe --incSluPdEeCgIrAosLsSSToAcTiaUl SSeINcuDrIiCtyA&TOSSRI (We will exclude the Medicare Premiums). PSrEoCviTdIeOtNheDre--quSePsEteCdIAinLfoSrmTAaTtioUnSifINyoDuIChAaTvOe Rbeen diagnosed with end-stage renal disease. SPEroCviTdIeOtNheEr--equSeIGstNedATinUfoRrEmation if you have been diagnosed with end-stage renal disease. TShEiCs TSIeOcNtioEn --is rSeIqGuNirAedT.URPlEease sign and date the application after you have read the "Certification aTnhdisASuetchtoiorinzaistiorenq" usitraetde.mPelenat sinecsluigdnedanindtdhaeteapthpelicaaptipolnicabtoioonkleatf.terIfyyoouurhaPvOeAresaigdntshefo"rCyeoruti,ficyaotuion manudstAiuntchluodriezaatiocno"msptaletteemceonptyinocfluthdeedPOinAthdeoacupmpliecnatt.ion booklet. If your POA signs for you, you must include a complete copy of the POA document. SECTION F -- POWER OF ATTORNEY (POA) CSEomCTplIeOteN tFhi--s sPeOctWionERif yOoFu AhTaTveOaRNPEowYe(rPoOfAA) PCowmeprleotfeAthttiosrnsecy,tiobne isfuyroeutohacvheecakPthoewebroxofaAntdtoirnnceluy.dIef yaocuowmapnlettaellccoopryreosfptohnedPenOcAe dsoecnut mtoeynot.ur Power of Attorney, be sure to check the box and include a complete copy of the POA document. SECTION G -- WITNESS/PREPARER ISf EsComTIeOoNneGe--lseWcoITmNpEleStSed/PtRheEPaAppRliEcRation for you, please provide their name and telephone number. If someone else completed the application for you, please provide their name and telephone number.

MEDICARE PART D & OTHER PRESCRIPTION COVERAGE -- Complete the Health & Other Prescription Form

We work with all Part D plans and other prescription drug plans such as Retiree, Union, Employer, Medicare Advantage (HMO, PPO) and Veterans' (VA).

PACE/PACENET may help pay your premium directly to your Part D plan, including the full Late Enrollment Penalty (LEP).

Contact us at 1-800-225-7223 for more details.

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FILL

OUT

SPOUSE

INFORMATION

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1. Are you a veteran? (circle one)

1. No or 2. Yes

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INFORMATION

1/2017

SECTION C ? INCOME VErIFICaTION

If you (or your spouse, if mSSaEErrCiCeTdTIaOInOdNNlivCiCng??toINgIeNCthCOerOM) rMEecEeVivEVerEinIrcFoIImCFeIaCfTroaImOTaINOnyNof the sources listed below,

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Please do not subtract losses from income

applicant

Spouse

Total

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TotalTotal

1. Gross Social Security and Gross SSI 12.. GRaroilsrosaSdoRcieatlirSeemceunritty(RaRnBd 1G0r9o9ssanSdSIRRB1099R)

2. Railroad Retirement (RRB1099 and RRB1099R)

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Employees' Retirement System Employees' Retirement System

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4.4. 4.

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6.

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Applicant: TDTriraaalnnynsssspipsplallaSanntntattDrtDDaDtaaeatt:eete:: _______________-_--___-____________-__--__-_____________

Spouse: TraTDnriasaapnlnyslssapipnslaltaSnDnttaatDrttDaeDt:aea_t:e_te:_____-____________--_-___-____________-_--____________

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SECTION E ? SIGNATURE SECTION E ? SIGNaTUrE SECTION E ? SIGNaTUrE By signing, I acknowledge that I have read the certification and authorization on the back of the Health & Prescription form and agree to the terms as stated, and that

I have lived in Pennsylvania for at least 90 days prior to the date on this application, and that the age and income information listed is true, correct and complete.

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Emergency Contact Phone #: ________S__E_C__T_DI_Oa_tN_e___F___?-___P__O-__W_ ErEOmFergaeTncTyOCronNtaEcYt Phone #: _____________D__a_te____-______- ___

SECTION F ? POWEr OF aTTOrNEY

Check box if you want all correspondence sent to your

Check box if you want all correspondence sent to your

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NPAOadmad;erecsosmplete POa documents are required if box is checked. AdNPdOaremas;secomplete POa documents are required if box is checked.

NACdadmityre/s:Sstate / ZIP

CitNAyda/dmSretas:tse / ZIP

ACPditydhor/enSsesta#:te / ZIP

PhACodintyder/#eSssta:te / ZIP

CPhityon/eS#tate / ZIP:

CPhityon/eS#tate / ZIP:

Phone # :

SECTION G ? WITNEPShSo/nPer#E: ParEr

Witness/Preparer's Name (If not the AppliScaEntC) TION G ? WITWNiEtneSsSs/P/PrerpaErePr'as NraEmer(If not the Applicant)

WNitanmeses/Preparer's Name (If not the ApplSicaEnCt) TION G ? WITNNaWEmiSetnSes/sP/PrreEpParaerr'sENrame (If not the Applicant)

NWPaithmnoeenses/#Preparer's Name (If not the Applicant)

PhWNoanitmene#ess/Preparer's Name (If not the Applicant)

PNhaomnee: # Phone # :

NPhaomnee: # Phone # :

1

1

1/2017

1

Your Survey on Health and Well-Being

Social Security Number

Gender: ____Male ____Female

We would appreciate it if you would answer the following questions about your current health and well-being. (Even if you have completed a similar survey in the past, it is important to complete this one, as some of the questions have changed.) However, you are under no obligation to complete the survey, nor will your decision in any way affect your eligibility for enrollment in PACE/PACENET. All information is confidential and will be used only for research about the needs of people who enroll in PACE/PACENET. Your answers are important in helping us to improve upon the delivery of health services and benefits for you and other older Pennsylvanians.

1. Are the questions in this survey being answered by the person applying for PACE/PACENET, or is someone else answering for this person? 1. I am the applicant listed above, and I am answering these questions.

2. I am someone who is helping the applicant, but they are participating in answering the questions.

3. I am answering these questions for the applicant, and they are not participating in answering.

2. If you are not the PACE/PACENET applicant, what is your relationship to the applicant?

a. Spouse or Partner

b. Son or Daughter

c. Another Relative

d. Friend or Neighbor

e. Care Provider

f. Other

3. Would you say that in general your health is:

1. Excellent

2. Very good

3. Good

4. Fair

5. Poor

4. Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good? days (If none, enter zero on the line.)

5. Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good? days (If none, enter zero on the line.)

6. During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?

days (If none, enter zero on the line.)

7. Compared to other persons your age, how would you describe your physical health?

1. Excellent

2. Very good

3. Good

4. Fair

5. Poor

8. In general, how much has your health changed in the past year?

1. Much worse

2. Somewhat worse

3. About the same

4. Somewhat better

5. Much better

9. What is your approximate height and weight? Height: ___ ft ____ in Weight: ______ pounds

10. What is your educational level? Please give highest grade completed.

11. During the last 12 months, how many times did you decide not to fill a prescription because it was too expensive?

a. None

b. 1 time

c. 2 times

d. 3-5 times e. 6-9 times f. 10 or more times

PLEASE TURN THE PAGE OVER AND CONTINUE

1/2017

 ................
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