Update to Medicare Automatic Premium Payment Program Form

As we shared in May, we’re taking steps to better meet data security requirements and protect our members’ data. As part of this initiative, we’ve updated the Medicare Automatic Premium Payment Program Form. The new versions can be viewed here:

Brochure and form for Health Alliance™ beneficiaries

Brochure and form for Health Alliance Northwest™ beneficiaries

Brochure and form for Reid Health Alliance Medicare beneficiaries

Brochure and form for OSF MedAdvantage beneficiaries

Brochure and form for Simplete™ beneficiaries

This form is often used by your clients at the time of enrollment onto our Medicare plans. In the updated version, we’ve replaced the process for collecting and submitting the applicant’s credit card information to make payment more secure. For that reason, all agents should immediately remove older versions and replace them with this updated version, which is available for order or print within the Medicare Forms section of Forms & Resources at YourHealthAlliance.org.

Applicants still have the ability to use the form to submit requests for automatic premium payments made through their Checking or Savings bank accounts. If your clients would prefer to use their credit card to pay, however, please direct them to visit HealthAlliance.org/Payment to set up their member account and payment.

As always, if you have any questions, please contact Broker Services at BrokerServices@healthalliance.org or by calling (877) 917-8489.