• Retirees receiving a pension under a state-sponsored retirement plan and continues enrollment in the Retiree health, dental, or vision plan.
• Long-Term Disability (LTD) participants collecting benefits under a state-sponsored plan.
• Eligible former elected officials and their qualified dependents if the elected official has at least 5 years of credited service in the Elected Officials Retirement Plan; was covered under a group health or accident plan at the time of leaving office; served as an elected official on or after January 1, 1983; and applies for enrollment within 31 days of leaving office or retiring.
• Surviving spouses and qualified dependents provided they were covered at the time of the Retiree’s death.
• Surviving spouse of a former elected official provided they were covered at the time of the official’s death.

Eligible dependents includes:

• Your legal spouse or qualified domestic partner, natural, adopted and/or stepchildren under age 19, or under 25 if a full-time student at an accredited educational institution.
• Natural, adopted and/or stepchildren who were disabled prior to age 19 as defined by Social Security Administration (SSA) guidelines.
• Children placed in the employee member’s home by court order pending adoption, minors under the age of 19 for whom the employee or legal spouse has court-ordered guardianship or Foster children under the age of 18.

First, you will need to contact the Social Security Administration and fill out the appropriate paperwork to sign up for Medicare.

You will then need to fill out an enrollment form (located here http://www.benefitoptions.az.gov/liaison/Docs/2007_retiree_oe_form.pdf) and choose a Medicare plan.

If you select Pacificare you will need to fill out a Statement of Understanding (SOU). Please call ADOA at 602-542-5008 or toll free 800-304-3687 and request a SOU be mailed to you.

If you need additional help filling out your paperwork you may come into the ADOA office located at: ADOA, 100 N. 15th Avenue, Suite 103, Phoenix, AZ 85007 and a member service representative will gladly assist you.

Any Retirees, LTD members, Surviving Spouse, and/or dependents who have Medicare Parts A and B and who are enrolling in the PacifiCare Medicare Advantage HMO Plan (Secure Horizons) must complete the Statement of Understanding. The completed SOU must be submitted to ADOA Benefits Office prior to the first day of the month in which coverage becomes effective. The form may only be submitted between Monday and Friday. Your signature on the SOU form confirms to PacifiCare and CMS that you, your spouse and Dependent (s) understand:

• Member(s) must maintain Medicare Parts A and B by continuing to pay the Part B premiums, and if applicable, the Part A premiums.
• All medical services, with the exception of emergency or out-of-area urgently needed services must be provided by or arranged by PacifiCare Secure Horizons contracted providers.
• Services rendered without precertification from PacifiCare (Secure Horizons), with the exception of emergency and out-of-area urgently needed services, will not be reimbursed by PacifiCare or Medicare.
• The member(s) is bound by the benefits, co payments, exclusions, limitations and other terms of the PacifiCare (Secure Horizons) Evidence or Coverage.
• The member(s) may only be enrolled in one Medicare Advantage HMO Plan at any one time.
• The effective date of the Medicare Advantage HMO Plan (Secure Horizons) selection will be the first of the month following the date that PacifiCare (Secure Horizons) receives the completed enrollment form and SOU, unless the requested effective date is at a later date.
• If you are currently enrolled in the PacifiCare Secure Horizons plan and wish to change to one of the other plans offered during Open Enrollment, it will be necessary for you to submit a statement of voluntary disenrollment.

You are eligible for the Advantage Plan if you:

• are the primary Retiree
• live in Coconino, Cochise, Graham, Greenlee, La Paz, Maricopa, Pinal, Pima, Santa Cruz, Yavapai, and Yuma counties
• have Medicare Part A and Part B coverage