HomeMy WebLinkAboutInformation for Medicare Eligible Participants Final.pdf Rev. 10/2023
Information for Medicare Eligible Participants
Becoming Medicare Eligible
If you will become Medicare Eligible soon, it is important for you to reach out to Medicare at least 2
months before your 65th birthday in order to enroll in Medicare Parts A and B and get your Medicare ID
Card so that you will be eligible for the Otay Water District Medicare Benefit Plans (e.g. Blue Shield Gold
PPO Supplement Plan or the Kaiser Permanente Senior Advantage HMO 15 Medicare Supplement Plan).
Once you or your spouse (if your spouse is enrolled in our plan) become Medicare Eligible, the Medicare
Eligible participant must enroll in either the Blue Shield Gold PPO Supplement Plan or the Kaiser
Permanente Senior Advantage (KPSA) HMO 15 Medicare Supplement Plan. If you have a split situation
where a participant in the family is not Medicare Eligible, the participant without Medicare will be
covered under the regular Blue Shield Gold PPO or Kaiser Traditional HMO 15 plan respectively. The Blue
Shield HMO and EPO plans are not available for Medicare Eligible participants. A few months before you
become Medicare Eligible, you will be receiving a letter with further instructions from our Retiree Billing
Administrator or Otay Water District.
If you (and/or your spouse) are currently are on a Medicare Eligible plan offered by Otay Water District
and you do not want to change medical plans, no action is required from you. However, if you would
like to change medical plans, the following plans are available to Medicare Retirees (and their spouses).
Please follow the instructions below. All enrollment forms are on the Otay Website under the Open
Enrolment portal. All Forms must be typed.
How to Enroll into a Medicare Eligible Plan:
To enroll in the Kaiser Permanente Senior Advantage (KPSA) HMO 15 Medicare Supplement Plan:
If you (and/or your spouse) wish to join Kaiser, you will need to fill out the following forms based on
your situation (e.g. Retiree Only, Retiree + 1, etc). Please note, in all instances below, the Otay Water
District Medical/Dental Enrollment form must be filled out with complete information of all retirees
being enrolled (e.g. names of participants, date of birth, address, etc.):
1) If you have Retiree Only Coverage: Fill out the KPSA Enrollment form and the Otay Water
District Medical/Dental Enrollment Form. Indicate in the Otay Enrollment form that you are
selecting Kaiser Senior Advantage HMO 15 Plan and indicate Retiree Only Coverage.
2) If you have Retiree +1 Coverage and both participants are Medicare Eligible: Each participant
must fill out a KPSA Enrollment form (with their individual information) and only one Otay
Water District Medical/Dental Enrollment form indicating you are selecting Kaiser Senior
Advantage HMO 15 Plan and indicate Retiree +1 Coverage.
3) If you have Retiree +1 Coverage and one participant is Medicare Eligible and the other is not:
Only the participant that is Medicare Eligible should fill out the KPSA form and only one Otay
Water District Medical/Dental Enrollment form indicating you are selecting Kaiser Senior
Advantage HMO 15 Plan and indicate Retiree +1 Coverage.
DO NOT make any changes to the pre-populated Employer Group Number or Employer Name sections
on the KPSA Form if you live in San Diego County. They should remain as: “Employer or Union Name”:
PRISM – SDRMA/GSRMA South. “Employer Group #”: 233392-102. If you live outside of San Diego
Rev. 10/2023
County, please delete that information. Otay Human Resources will fill in the appropriate information
after you submit your completed form.
Do NOT send any enrollment forms to Kaiser. Please send the KPSA Enrollment form, and the Otay
Water District Medical/Dental Enrollment form back to Otay Water District if you wish to join the Kaiser
Senior Advantage HMO Plan. Otay will forward all necessary forms directly to Kaiser.
To enroll in the Gold PPO Medicare Supplement Plan:
If you are joining the Gold PPO Medicare Supplement Plan as a new participant for January 1st, you only
need to fill out the Otay Water District Medical/Dental Enrollment Form. Participants who join the Gold
PPO Medicare Supplement Plan must also enroll in the Express Scripts Medicare Prescription Plan (PDP)
by also filling out the Express Scripts Enrollment Form (located in the Open Enrollment Website Portal).
Send all forms to Otay Water District, Attention Human Resources via email at hr@otaywater.gov, or
fax to: 619-660-7288 or mail to 2554 Sweetwater Springs Blvd., Spring Valley, CA 91978