1. Full Legal Name
  2. Medicare # (Can be found on the red, white, and blue Medicare card.)
  3. Date of Birth
  4. Home Address on file with the Social Security Administration.
  5. Primary care doctor full name and zip code should be selected at the time of enrollment (may be required for some plans).
  6. Ascertain if any of the following special need situations pertain to you:
  • Chronic Condition SNP (C-SNP):You have one or more of these severe or disabling chronic conditions:
    • Chronic alcohol and other dependence
    • Autoimmune disorders
    • Cancer (excluding pre-cancer conditions)
    • Cardiovascular disorders
    • Chronic heart failure
    • Dementia
    • Diabetes mellitus
    • End-stage liver disease
    • End-Stage Renal Disease (ESRD) requiring dialysis (any mode of dialysis)
    • Severe hematologic disorders
    • HIV/AIDS
    • Chronic lung disorders
    • Chronic and disabling mental health conditions
    • Neurologic disorders
    • Stroke
  • Institutional SNP (I-SNP):You live in an institution (like a nursing home), or you require nursing care at home.
  • Dual Eligible SNP (D-SNP):You have both Medicare and Medicaid.