{"id":37252,"date":"2025-08-19T10:41:47","date_gmt":"2025-08-19T14:41:47","guid":{"rendered":"https:\/\/www.elderplan.org\/?page_id=37252"},"modified":"2025-10-15T07:38:31","modified_gmt":"2025-10-15T11:38:31","slug":"2026-enrollment-application","status":"publish","type":"page","link":"https:\/\/elderplan0.wpengine.com\/es\/2026-enrollment-application\/","title":{"rendered":"2026 Enrollment Application &#8211; Spanish"},"content":{"rendered":"\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f37249-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"37249\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/es\/wp-json\/wp\/v2\/pages\/37252#wpcf7-f37249-o1\" method=\"post\" class=\"wpcf7-form init cf7mls-no-moving-animation wpcf7-acceptance-as-validation\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"37249\"><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\"><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\"><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f37249-o1\"><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\"><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\"><input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"[]\"><input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"[]\"><input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"[]\"><input type=\"hidden\" name=\"_wpcf7cf_repeaters\" value=\"[]\"><input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\"><input type=\"hidden\" name=\"_wpcf7cf_options\" value='{\"form_id\":37249,\"conditions\":[{\"then_field\":\"group-life-changing\",\"and_rules\":[{\"if_field\":\"enrollment-reason\",\"operator\":\"equals\",\"if_value\":\"Ocurri\\u00f3 un evento que cambi\\u00f3 mi vida.\"}]},{\"then_field\":\"group-change-in-coverage\",\"and_rules\":[{\"if_field\":\"enrollment-reason\",\"operator\":\"equals\",\"if_value\":\"Recientemente tuve un cambio en la cobertura actual.\"}]},{\"then_field\":\"group-currently-enrolled\",\"and_rules\":[{\"if_field\":\"enrollment-reason\",\"operator\":\"equals\",\"if_value\":\"Actualmente, estoy inscrito en un plan.\"}]},{\"then_field\":\"group-authorized\",\"and_rules\":[{\"if_field\":\"radio-authorized\",\"operator\":\"equals\",\"if_value\":\"Soy el representante autorizado del inscrito en esta solicitud\"}]},{\"then_field\":\"group-preferred-language\",\"and_rules\":[{\"if_field\":\"preferred-language-gate\",\"operator\":\"equals\",\"if_value\":\"Otro \\u2013 especifique\"}]},{\"then_field\":\"group-extra-help\",\"and_rules\":[{\"if_field\":\"plan-join\",\"operator\":\"equals\",\"if_value\":\"Elderplan Extra Help (HMO-POS)\"}]},{\"then_field\":\"group-plan-flex\",\"and_rules\":[{\"if_field\":\"plan-join\",\"operator\":\"equals\",\"if_value\":\"Elderplan Flex (HMO-POS)\"}]},{\"then_field\":\"group-plan-medicaid\",\"and_rules\":[{\"if_field\":\"plan-join\",\"operator\":\"equals\",\"if_value\":\"Elderplan For Medicaid Beneficiaries (HMO-POS D-SNP)\"}]},{\"then_field\":\"group-eft\",\"and_rules\":[{\"if_field\":\"payment-options\",\"operator\":\"equals\",\"if_value\":\"Transferencia electr\\u00f3nica de fondos (EFT) de su cuenta bancaria todos los meses\"}]},{\"then_field\":\"group-credit-card\",\"and_rules\":[{\"if_field\":\"payment-options\",\"operator\":\"equals\",\"if_value\":\"Tarjeta de cr\\u00e9dito\"}]},{\"then_field\":\"group-automatic-deduction\",\"and_rules\":[{\"if_field\":\"payment-options\",\"operator\":\"equals\",\"if_value\":\"Deducci\\u00f3n autom\\u00e1tica de su cheque de beneficios mensual del Seguro Social o de la Junta de Jubilaci\\u00f3n para Ferroviarios (RRB)\"}]},{\"then_field\":\"group-medicaid-yes\",\"and_rules\":[{\"if_field\":\"medicaid-enrollment\",\"operator\":\"equals\",\"if_value\":\"S\\u00ed\"}]},{\"then_field\":\"group-additional-drug\",\"and_rules\":[{\"if_field\":\"prescription-drug-coverage\",\"operator\":\"equals\",\"if_value\":\"S\\u00ed\"}]},{\"then_field\":\"group-spouse-work\",\"and_rules\":[{\"if_field\":\"marital\",\"operator\":\"equals\",\"if_value\":\"Casado\\\/a\"}]},{\"then_field\":\"group-mailing-same-no\",\"and_rules\":[{\"if_field\":\"mailing-address-same\",\"operator\":\"equals\",\"if_value\":\"No\"}]},{\"then_field\":\"group-medicaid-no\",\"and_rules\":[{\"if_field\":\"medicaid-enrollment\",\"operator\":\"equals\",\"if_value\":\"No\"}]},{\"then_field\":\"group-if-email\",\"and_rules\":[{\"if_field\":\"checkbox-no-email\",\"operator\":\"is empty\",\"if_value\":\"\"}]},{\"then_field\":\"group-moved\",\"and_rules\":[{\"if_field\":\"radio-life-changing-selection\",\"operator\":\"equals\",\"if_value\":\"Hace poco me mud\\u00e9 fuera del \\u00e1rea de servicio de mi plan actual o hace poco me mud\\u00e9 y este plan es una nueva opci\\u00f3n para m\\u00ed.\"}]},{\"then_field\":\"group-facility\",\"and_rules\":[{\"if_field\":\"radio-life-changing-selection\",\"operator\":\"equals\",\"if_value\":\"Me estoy yendo, voy a vivir o vivo en un centro de atenci\\u00f3n a largo plazo (por ejemplo, un hogar de personas mayores o centro de atenci\\u00f3n a largo plazo), o hace poco me fui de un centro de este tipo.\"}]},{\"then_field\":\"group-released\",\"and_rules\":[{\"if_field\":\"radio-life-changing-selection\",\"operator\":\"equals\",\"if_value\":\"Hace poco sal\\u00ed de prisi\\u00f3n.\"}]},{\"then_field\":\"group-returned\",\"and_rules\":[{\"if_field\":\"radio-life-changing-selection\",\"operator\":\"equals\",\"if_value\":\"Hace poco volv\\u00ed a los Estados Unidos despu\\u00e9s de vivir en forma permanente fuera de los EE. UU.\"}]},{\"then_field\":\"group-lawful\",\"and_rules\":[{\"if_field\":\"radio-life-changing-selection\",\"operator\":\"equals\",\"if_value\":\"Hace poco obtuve la ciudadan\\u00eda de los Estados Unidos.\"}]},{\"then_field\":\"group-leaving\",\"and_rules\":[{\"if_field\":\"radio-life-changing-selection\",\"operator\":\"equals\",\"if_value\":\"Voy a dejar de tener la cobertura de un empleador o sindicato.\"}]},{\"then_field\":\"group-medicaid-change\",\"and_rules\":[{\"if_field\":\"radio-change-in-coverage-selection\",\"operator\":\"equals\",\"if_value\":\"Hace poco tuve un cambio en Medicaid (reci\\u00e9n obtuve Medicaid, tuve un cambio en el nivel de la asistencia de Medicaid o perd\\u00ed Medicaid).\"}]},{\"then_field\":\"group-extra-help-change\",\"and_rules\":[{\"if_field\":\"radio-change-in-coverage-selection\",\"operator\":\"equals\",\"if_value\":\"Hace poco tuve un cambio en la Ayuda adicional para pagar la cobertura de medicamentos con receta de Medicare (reci\\u00e9n obtuve Ayuda adicional, tuve un cambio en el nivel de la Ayuda adicional o perd\\u00ed la Ayuda adicional).\"}]},{\"then_field\":\"group-drug-coverage-change\",\"and_rules\":[{\"if_field\":\"radio-change-in-coverage-selection\",\"operator\":\"equals\",\"if_value\":\"Hace poco y en forma involuntaria perd\\u00ed mi cobertura acreditable para medicamentos con receta (una cobertura tan buena como la de Medicare).\"}]},{\"then_field\":\"group-disenrolled\",\"and_rules\":[{\"if_field\":\"radio-change-in-coverage-selection\",\"operator\":\"equals\",\"if_value\":\"Estaba inscrito en un Plan de necesidades especiales (Special Needs Plan, SNP), pero ya no califico para participar en dicho plan.\"}]},{\"then_field\":\"group-pace\",\"and_rules\":[{\"if_field\":\"radio-change-in-coverage-selection\",\"operator\":\"equals\",\"if_value\":\"Hace poco dej\\u00e9 de participar en un programa PACE.\"}]},{\"then_field\":\"group-chose-new\",\"and_rules\":[{\"if_field\":\"radio-currently-enrolled-selection\",\"operator\":\"equals\",\"if_value\":\"Fui inscrito en un plan por Medicare (o mi estado) y quiero cambiar a un plan diferente.\"}]},{\"then_field\":\"group-sms-opt-in\",\"and_rules\":[{\"if_field\":\"cell-phone\",\"operator\":\"not empty\",\"if_value\":\"\"}]},{\"then_field\":\"group-medicaid-yes\",\"and_rules\":[{\"if_field\":\"plan-join\",\"operator\":\"equals\",\"if_value\":\"Elderplan For Medicaid Beneficiaries (HMO-POS D-SNP)\"}]},{\"then_field\":\"group-medicaid-question\",\"and_rules\":[{\"if_field\":\"plan-join\",\"operator\":\"equals\",\"if_value\":\"Elderplan Extra Help (HMO-POS)\"}]},{\"then_field\":\"group-medicaid-question\",\"and_rules\":[{\"if_field\":\"plan-join\",\"operator\":\"equals\",\"if_value\":\"Elderplan Flex (HMO-POS)\"}]},{\"then_field\":\"group-not-flex\",\"and_rules\":[{\"if_field\":\"plan-join\",\"operator\":\"not equals\",\"if_value\":\"Elderplan Flex (HMO-POS)\"}]},{\"then_field\":\"group-speak-english\",\"and_rules\":[{\"if_field\":\"preferred-language-gate\",\"operator\":\"not equals\",\"if_value\":\"I prefer to speak in English\"}]},{\"then_field\":\"group-benefits-yes\",\"and_rules\":[{\"if_field\":\"veterans-benefits-question\",\"operator\":\"equals\",\"if_value\":\"S\\u00ed\"}]},{\"then_field\":\"group-other-information\",\"and_rules\":[{\"if_field\":\"preferred-language-information\",\"operator\":\"equals\",\"if_value\":\"Otro \\u2013 especifique\"}]},{\"then_field\":\"group-spouse-work\",\"and_rules\":[{\"if_field\":\"marital\",\"operator\":\"equals\",\"if_value\":\"Casado\\\/a|Married\"}]}],\"settings\":{\"animation\":\"yes\",\"animation_intime\":200,\"animation_outtime\":200,\"conditions_ui\":\"normal\",\"notice_dismissed\":false,\"notice_dismissed_update-cf7-5.9.8\":true,\"notice_dismissed_update-cf7-6.0\":true,\"notice_dismissed_update-cf7-6.0.1\":true,\"notice_dismissed_update-cf7-6.0.2\":true,\"notice_dismissed_update-cf7-6.0.3\":true,\"notice_dismissed_update-cf7-6.0.6\":true,\"notice_dismissed_update-cf7-6.1.1\":true,\"notice_dismissed_update-cf7-6.1.3\":true}}'><input type=\"hidden\" name=\"_wpcf7dtx_version\" value=\"5.0.5\"><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\">\n<\/fieldset>\n<div class=\"fieldset-cf7mls-wrapper\" data-transition-effects><fieldset class=\"fieldset-cf7mls cf7mls_current_fs\"><div class=\"form-hero\">\n\t<div class=\"screen-reader-response\">\n\t\t<div role=\"status\" aria-live=\"polite\">\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"form-hero__mobile-bg\">\n\t<\/div>\n\t<div class=\"form-hero__content\">\n\t\t<h1 class=\"form-hero__heading\">\u00a1Bienvenido a la inscripci\u00f3n en l\u00ednea!\n\t\t<\/h1>\n\t<\/div>\n<\/div>\n<div class=\"white-bg\">\n\t<h2 class=\"font-24 text-centered page-heading\">Vamos a llevarle el lugar correcto\n\t<\/h2>\n\t<div class=\"large-radios\">\n\t\t<div class=\"large-radio\">\n\t\t\t<p><br>\n<label class=\"large-radio-label\"><br>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"plan-join\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first last\"><input type=\"radio\" name=\"plan-join\" value=\"Elderplan For Medicaid Beneficiaries (HMO-POS D-SNP)\"><span class=\"wpcf7-list-item-label\">Elderplan For Medicaid Beneficiaries (HMO-POS D-SNP)<\/span><\/span><\/span><\/span><br>\n<em>$22.70 por mes<\/em><br>\n<span class=\"btn-outline\">SELECCIONAR ESTE PLAN<\/span><br>\n<\/label>\n\t\t\t<\/p>\n\t\t\t<details class=\"tablet-only\">\n\t\t\t\t<summary>Vea los materiales del plan\n\t\t\t\t<\/summary>\n\t\t\t\t<ul>\n\t\t\t\t\t<li>\n\t\t\t\t\t\t<p><a href=\"\/files\/summary-of-benefits-elderplan-for-medicare-beneficiaries-spa-2026\/\" class=\"pdf-download-link\">Resumen de beneficios \u2013 Elderplan For Medicaid Beneficiaries<\/a> (PDF)\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/li>\n\t\t\t\t\t<li>\n\t\t\t\t\t\t<p><a href=\"\/files\/part-c-and-d-mapd-2026-spa-2026\/\" class=\"pdf-download-link\">Calificaciones de estrellas de las Partes C y D (medicamentos con receta de Medicare Advantage [MAPD])<\/a> (PDF)\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/details>\n\t\t<\/div>\n\t\t<div class=\"large-radio\">\n\t\t\t<p><br>\n<label class=\"large-radio-label\"><br>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"plan-join\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first last\"><input type=\"radio\" name=\"plan-join\" value=\"Elderplan Extra Help (HMO-POS)\"><span class=\"wpcf7-list-item-label\">Elderplan Extra Help (HMO-POS)<\/span><\/span><\/span><\/span><br>\n<em>$58.80 por mes<\/em><br>\n<span class=\"btn-outline\">SELECCIONAR ESTE PLAN<\/span><br>\n<\/label>\n\t\t\t<\/p>\n\t\t\t<details class=\"tablet-only\">\n\t\t\t\t<summary>Vea los materiales del plan\n\t\t\t\t<\/summary>\n\t\t\t\t<ul>\n\t\t\t\t\t<li>\n\t\t\t\t\t\t<p><a href=\"\/files\/summary-of-benefits-elderplan-extra-help-spa-2026\/\" class=\"pdf-download-link\">Resumen de beneficios \u2013 Elderplan Extra Help<\/a> (PDF)\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/li>\n\t\t\t\t\t<li>\n\t\t\t\t\t\t<p><a href=\"\/files\/part-c-and-d-mapd-2026-spa-2026\/\" class=\"pdf-download-link\"><br>\nCalificaciones de estrellas de las Partes C y D (medicamentos con receta de Medicare Advantage [MAPD])<\/a> (PDF)\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/details>\n\t\t<\/div>\n\t\t<div class=\"large-radio\">\n\t\t\t<p><br>\n<label class=\"large-radio-label\"><br>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"plan-join\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first last\"><input type=\"radio\" name=\"plan-join\" value=\"Elderplan Flex (HMO-POS)\"><span class=\"wpcf7-list-item-label\">Elderplan Flex (HMO-POS)<\/span><\/span><\/span><\/span><br>\n<em>$0.00 por mes<\/em><br>\n<span class=\"btn-outline\">SELECCIONAR ESTE PLAN<\/span><br>\n<\/label>\n\t\t\t<\/p>\n\t\t\t<details class=\"tablet-only\">\n\t\t\t\t<summary>Vea los materiales del plan\n\t\t\t\t<\/summary>\n\t\t\t\t<ul>\n\t\t\t\t\t<li>\n\t\t\t\t\t\t<p><a href=\"\/summary-of-benefits-elderplan-flex-spa-2026\/\">Resumen de beneficios \u2013 Elderplan Flex<\/a> (PDF)\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/li>\n\t\t\t\t\t<li>\n\t\t\t\t\t\t<p><a href=\"\/files\/part-c-and-d-mapd-2026-spa-2026\/\">Calificaciones de estrellas de las Partes C y D (medicamentos con receta de Medicare Advantage [MAPD])<\/a> (PDF)\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/details>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"desktop-only three-column\">\n\t\t<details>\n\t\t\t<summary>Vea los materiales del plan\n\t\t\t<\/summary>\n\t\t\t<ul>\n\t\t\t\t<li>\n\t\t\t\t\t<p><a href=\"\/files\/summary-of-benefits-elderplan-for-medicare-beneficiaries-spa-2026\/\" class=\"pdf-download-link\">Resumen de beneficios \u2013 Elderplan For Medicaid Beneficiaries<\/a> (PDF)\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/li>\n\t\t\t\t<li>\n\t\t\t\t\t<p><a href=\"\/files\/part-c-and-d-mapd-2026-spa-2026\/\" class=\"pdf-download-link\">Calificaciones de estrellas de las Partes C y D (medicamentos con receta de Medicare Advantage [MAPD])<\/a> (PDF)\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/li>\n\t\t\t<\/ul>\n\t\t<\/details>\n\t\t<details>\n\t\t\t<summary>Vea los materiales del plan\n\t\t\t<\/summary>\n\t\t\t<ul>\n\t\t\t\t<li>\n\t\t\t\t\t<p><a href=\"\/files\/summary-of-benefits-elderplan-extra-help-spa-2026\/\" class=\"pdf-download-link\">Resumen de beneficios \u2013 Elderplan Extra Help<\/a> (PDF)\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/li>\n\t\t\t\t<li>\n\t\t\t\t\t<p><a href=\"\/files\/part-c-and-d-mapd-2026-spa-2026\/\" class=\"pdf-download-link\">Calificaciones de estrellas de las Partes C y D (medicamentos con receta de Medicare Advantage [MAPD])<\/a> (PDF)\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/li>\n\t\t\t<\/ul>\n\t\t<\/details>\n\t\t<details>\n\t\t\t<summary>Vea los materiales del plan\n\t\t\t<\/summary>\n\t\t\t<ul>\n\t\t\t\t<li>\n\t\t\t\t\t<p><a href=\"\/files\/summary-of-benefits-elderplan-flex-spa-2026\/\" class=\"pdf-download-link\">Resumen de beneficios \u2013 Elderplan Flex<\/a> (PDF)\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/li>\n\t\t\t\t<li>\n\t\t\t\t\t<p><a href=\"\/files\/part-c-and-d-mapd-2026-spa-2026\/\" class=\"pdf-download-link\">Calificaciones de estrellas de las Partes C y D (medicamentos con receta de Medicare Advantage [MAPD])<\/a> (PDF)\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/li>\n\t\t\t<\/ul>\n\t\t<\/details>\n\t<\/div>\n<\/div>\n<div class=\"grey-bg\">\n\t<h2 class=\"font-24 text-centered font-bolder\">Planes adicionales para tener en cuenta\n\t<\/h2>\n\t<div class=\"three-up three-up--line-seperator \">\n\t\t<div>\n\t\t\t<p><br>\n<span class=\"font-bold font-24\">Elderplan Advantage For Nursing Home Residents (HMO-POS I-SNP)<\/span>$44.80 por mes\n\t\t\t<\/p>\n\t\t\t<details>\n\t\t\t\t<summary>Vea los materiales del plan\n\t\t\t\t<\/summary>\n\t\t\t\t<ul>\n\t\t\t\t\t<li>\n\t\t\t\t\t\t<p><a href=\"\/files\/summary-of-benefits-elderplan-advantage-for-nursing-home-residents-spa-2026\/\" class=\"pdf-download-link\">Resumen de beneficios \u2013 Elderplan Advantage for Nursing Home Residents<\/a> (PDF)\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/li>\n\t\t\t\t\t<li>\n\t\t\t\t\t\t<p><a href=\"\/files\/part-c-and-d-mapd-2026-spa-2026\/\" class=\"pdf-download-link\">Calificaciones de estrellas de las Partes C y D (medicamentos con receta de Medicare Advantage [MAPD])<\/a> (PDF)\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/details>\n\t\t\t<p>Llame al <a href=\"tel:1-844-642-4115\">1-844-642-4115<\/a> para obtener m\u00e1s informaci\u00f3n y ayuda con la inscripci\u00f3n en este plan.\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<p><span class=\"spacer\"><\/span>\n\t\t<\/p>\n\t\t<div>\n\t\t\t<p><br>\n<span class=\"font-bold font-24\">Elderplan Plus Long-Term Care (HMO-POS D-SNP)<\/span>$0.00 por mes\n\t\t\t<\/p>\n\t\t\t<details>\n\t\t\t\t<summary>Vea los materiales del plan\n\t\t\t\t<\/summary>\n\t\t\t\t<ul>\n\t\t\t\t\t<li>\n\t\t\t\t\t\t<p><a href=\"\/files\/summary-of-benefits-elderplan-plus-long-term-care-spa-2026\/\" class=\"pdf-download-link\">Resumen de beneficios \u2013 Elderplan Plus Long-Term Care<\/a> (PDF)\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/li>\n\t\t\t\t\t<li>\n\t\t\t\t\t\t<p><a href=\"\/part-c-and-d-map-2026-spa-2026\/\" class=\"pdf-download-link\">Calificaciones de estrellas de las Partes C y D (medicamentos con receta de Medicare Advantage [MAPD])<\/a> (PDF)\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/details>\n\t\t\t<p>Llame al <a href=\"tel:1-866-360-1934\">1-866-360-1934<\/a> para obtener m\u00e1s informaci\u00f3n y ayuda con la inscripci\u00f3n en este plan.\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<p><span class=\"spacer\"><\/span>\n\t\t<\/p>\n\t\t<div>\n\t\t\t<p><br>\n<span class=\"font-bold font-24\">Elderplan Select (HMO-POS I-SNP\/IE-SNP)<\/span>$0.00 por mes\n\t\t\t<\/p>\n\t\t\t<details>\n\t\t\t\t<summary>Vea los materiales del plan\n\t\t\t\t<\/summary>\n\t\t\t\t<ul>\n\t\t\t\t\t<li>\n\t\t\t\t\t\t<p><a href=\"\/files\/summary-of-benefits-elderplan-select-spa-2026\/\" class=\"pdf-download-link\">Resumen de beneficios \u2013 Elderplan Select<\/a> (PDF)\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/li>\n\t\t\t\t\t<li>\n\t\t\t\t\t\t<p><a href=\"\/files\/part-c-and-d-mapd-2026-spa-2026\/\" class=\"pdf-download-link\">Calificaciones de estrellas de las Partes C y D (medicamentos con receta de Medicare Advantage [MAPD])<\/a> (PDF)\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/details>\n\t\t\t<p>Llame al <a href=\"tel:1-844-642-4115\">1-844-642-4115<\/a> para obtener m\u00e1s informaci\u00f3n y ayuda con la inscripci\u00f3n en este plan.\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p class=\"text-centered\"><br>\n\u00bfNo est\u00e1 seguro de cu\u00e1l es el plan es adecuado para usted? <a href=\"\/es\/medicare-advantage-plan-options\/2026-options\/\">Obtenga m\u00e1s informaci\u00f3n sobre nuestros planes.<\/a>\n\t<\/p>\n<\/div>\n<div class=\"cf7mls-btns \"><button type=\"button\" class=\"cf7mls_next cf7mls_btn action-button\" name=\"cf7mls_next\" id=\"cf7mls-next-btn-cf7mls_step-1\">Continuar<img decoding=\"async\" src=\"https:\/\/elderplan0.wpengine.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" alt=\"Step Loading\" data-lazy-src=\"https:\/\/elderplan0.wpengine.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" style=\"display: none;\"><\/button><\/div><p><\/p><\/fieldset><fieldset class=\"fieldset-cf7mls\">\n\n<div class=\"form-layout\">\n\t<div class=\"screen-reader-response\">\n\t\t<p role=\"status\" aria-live=\"polite\">\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"form-sidebar\">\n\t\t<div data-id=\"group-extra-help\" data-orig_data_id=\"group-extra-help\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><br>\n<span>Usted se est\u00e1 inscribiendo en el plan<\/span><span>Elderplan Extra Help(HMO-POS)<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div data-id=\"group-plan-flex\" data-orig_data_id=\"group-plan-flex\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><br>\n<span>Usted se est\u00e1 inscribiendo en el plan<\/span><span>Elderplan Flex(HMO-POS)<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div data-id=\"group-plan-medicaid\" data-orig_data_id=\"group-plan-medicaid\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><br>\n<span>Usted se est\u00e1 inscribiendo en el plan<\/span><span>Elderplan For Medicaid Beneficiaries (HMO-POS D-SNP)<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div class=\"form-tracker\">\n\t\t\t<div class=\"step\">\n\t\t\t\t<p><i class=\"fa-solid fa-check\"><\/i> Elegibilidad\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step\">\n\t\t\t\t<p><i class=\"fa-solid fa-circle-user\"><\/i> Informaci\u00f3n personal\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step\">\n\t\t\t\t<p><i class=\"fa-solid fa-file-lines\"><\/i> Inscripci\u00f3n\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step\">\n\t\t\t\t<p><i class=\"fa-solid fa-magnifying-glass\"><\/i> Confirmaci\u00f3n\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"form-content\">\n\t\t<p class=\"font-50\">Qu\u00e9 puede esperar\n\t\t<\/p>\n\t\t<p class=\"font-24\">Espere al menos 20 minutos para completar la informaci\u00f3n.\n\t\t<\/p>\n\t\t<div class=\"large-list-item\">\n\t\t\t<p><span>1<\/span>\n\t\t\t<\/p>\n\t\t\t<p>Le haremos una serie de preguntas para confirmar su elegibilidad en el plan que eligi\u00f3. Necesitar\u00e1 su <strong>tarjeta y n\u00famero de Medicare<\/strong> y, seg\u00fan el plan en el que se est\u00e9 inscribiendo, es posible que necesite su <strong>n\u00famero de Medicaid<\/strong> tambi\u00e9n.\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"large-list-item\">\n\t\t\t<p><span>2<\/span>\n\t\t\t<\/p>\n\t\t\t<p>Recopilaremos su <strong>informaci\u00f3n personal<\/strong> y sus <strong>preferencias personales<\/strong>. Si su<br>\nplan tiene una prima, tambi\u00e9n recopilaremos informaci\u00f3n sobre c\u00f3mo desea realizar sus pagos mensuales.\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"large-list-item\">\n\t\t\t<p><span>3<\/span>\n\t\t\t<\/p>\n\t\t\t<p>Una vez que env\u00ede su solicitud, recibir\u00e1 un n\u00famero de confirmaci\u00f3n y comenzaremos a procesar su.\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"cf7mls-btns \"><button type=\"button\" class=\"cf7mls_back action-button\" name=\"cf7mls_back\" id=\"cf7mls-back-btn-cf7mls_step-2\">Atr\u00e1s<\/button><button type=\"button\" class=\"cf7mls_next cf7mls_btn action-button\" name=\"cf7mls_next\" id=\"cf7mls-next-btn-cf7mls_step-2\">Continuar<img decoding=\"async\" src=\"https:\/\/elderplan0.wpengine.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" alt=\"Step Loading\" data-lazy-src=\"https:\/\/elderplan0.wpengine.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" style=\"display: none;\"><\/button><\/div><p><\/p><\/fieldset><fieldset class=\"fieldset-cf7mls\">\n\n<div class=\"form-layout\">\n\t<div class=\"screen-reader-response\">\n\t\t<p role=\"status\" aria-live=\"polite\">\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"form-sidebar\">\n\t\t<div data-id=\"group-extra-help\" data-orig_data_id=\"group-extra-help\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><br>\n<span>Usted se est\u00e1 inscribiendo en el plan<\/span> <span>Elderplan Extra Help(HMO-POS)<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div data-id=\"group-plan-flex\" data-orig_data_id=\"group-plan-flex\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><br>\n<span>Usted se est\u00e1 inscribiendo en el plan<\/span><span>Elderplan Flex(HMO-POS) Plan<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div data-id=\"group-plan-medicaid\" data-orig_data_id=\"group-plan-medicaid\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><br>\n<span>Usted se est\u00e1 inscribiendo en el plan<\/span><span>Elderplan For Medicaid Beneficiaries (HMO-POS D-SNP) Plan<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div class=\"form-tracker\">\n\t\t\t<div class=\"step in-progress\">\n\t\t\t\t<p><i class=\"fa-solid fa-check\"><\/i> Elegibilidad\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step\">\n\t\t\t\t<p><i class=\"fa-solid fa-circle-user\"><\/i> Informaci\u00f3n personal\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step\">\n\t\t\t\t<p><i class=\"fa-solid fa-file-lines\"><\/i> Inscripci\u00f3n\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step\">\n\t\t\t\t<p><i class=\"fa-solid fa-magnifying-glass\"><\/i> Confirmaci\u00f3n\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"percentage\">\n\t\t\t<p><strong>10%<\/strong> completado\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"form-content\">\n\t\t<h2 class=\"font-32\">Encuentre la opci\u00f3n que mejor se adapte al motivo por el que se est\u00e1 inscribiendo ahora.\n\t\t<\/h2>\n\t\t<details class=\"secondary\">\n\t\t\t<summary><br>\n<span>M\u00e1s informaci\u00f3n<\/span><span>Ocultar<\/span>\n\t\t\t<\/summary>\n\t\t\t<div class=\"details-content\">\n\t\t\t\t<p><br>\n<strong>Declaraci\u00f3n de elegibilidad<\/strong><br>\nPor lo general, puede inscribirse en un plan Medicare Advantage \u00fanicamente durante el per\u00edodo de inscripci\u00f3n anual (AEP), que se extiende del 15 de octubre al 7 de diciembre de cada a\u00f1o. No obstante, existen excepciones que pueden permitirle inscribirse fuera de este per\u00edodo.\n\t\t\t\t<\/p>\n\t\t\t\t<p><br>\nPor favor lea atentamente las siguientes declaraciones y marque el recuadro si alguna aplica a usted.\n\t\t\t\t<\/p>\n\t\t\t\t<p><br>\nAl marcar cualquiera de los recuadros, usted certifica que, seg\u00fan su leal saber y entender, es elegible para un Per\u00edodo de Inscripci\u00f3n.\n\t\t\t\t<\/p>\n\t\t\t\t<p><br>\nSi posteriormente determinamos que esta informaci\u00f3n es incorrecta, su inscripci\u00f3n podr\u00eda ser cancelada.\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/details>\n\t\t<div class=\"large-radios mb-24\">\n\t\t\t<div class=\"large-radio large-radio--description\">\n\t\t\t\t<p><label class=\"large-radio-label\"><span class=\"wpcf7-form-control-wrap\" data-name=\"enrollment-reason\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first last\"><input type=\"radio\" name=\"enrollment-reason\" value=\"Soy un miembro nuevo de Medicare.\"><span class=\"wpcf7-list-item-label\">Soy un miembro nuevo de Medicare.<\/span><\/span><\/span><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"large-radio large-radio--description\">\n\t\t\t\t<p><label class=\"large-radio-label\"><span class=\"wpcf7-form-control-wrap\" data-name=\"enrollment-reason\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first last\"><input type=\"radio\" name=\"enrollment-reason\" value=\"Me inscribo durante el per\u00edodo de inscripci\u00f3n anual del 15 de octubre al 7 de diciembre\"><span class=\"wpcf7-list-item-label\">Me inscribo durante el per\u00edodo de inscripci\u00f3n anual del 15 de octubre al 7 de diciembre<\/span><\/span><\/span><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"large-radio large-radio--description\">\n\t\t\t\t<p><label class=\"large-radio-label\"><span class=\"wpcf7-form-control-wrap\" data-name=\"enrollment-reason\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first last\"><input type=\"radio\" name=\"enrollment-reason\" value=\"Actualmente, estoy inscrito en un plan Medicare Advantage y quiero hacer un cambio durante la inscripci\u00f3n abierta del 1 de enero al 31 de marzo.\"><span class=\"wpcf7-list-item-label\">Actualmente, estoy inscrito en un plan Medicare Advantage y quiero hacer un cambio durante la inscripci\u00f3n abierta del 1 de enero al 31 de marzo.<\/span><\/span><\/span><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"large-radio\">\n\t\t\t\t<p><label class=\"large-radio-label\"><span class=\"wpcf7-form-control-wrap\" data-name=\"enrollment-reason\"><span class=\"wpcf7-form-control wpcf7-radio moregroup\"><span class=\"wpcf7-list-item first last\"><input type=\"radio\" name=\"enrollment-reason\" value=\"Ocurri\u00f3 un evento que cambi\u00f3 mi vida.\"><span class=\"wpcf7-list-item-label\">Ocurri\u00f3 un evento que cambi\u00f3 mi vida.<\/span><\/span><\/span><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"large-radio\">\n\t\t\t\t<p><label class=\"large-radio-label\"><span class=\"wpcf7-form-control-wrap\" data-name=\"enrollment-reason\"><span class=\"wpcf7-form-control wpcf7-radio moregroup\"><span class=\"wpcf7-list-item first last\"><input type=\"radio\" name=\"enrollment-reason\" value=\"Recientemente tuve un cambio en la cobertura actual.\"><span class=\"wpcf7-list-item-label\">Recientemente tuve un cambio en la cobertura actual.<\/span><\/span><\/span><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"large-radio\">\n\t\t\t\t<p><label class=\"large-radio-label\"><span class=\"wpcf7-form-control-wrap\" data-name=\"enrollment-reason\"><span class=\"wpcf7-form-control wpcf7-radio moregroup\"><span class=\"wpcf7-list-item first last\"><input type=\"radio\" name=\"enrollment-reason\" value=\"Actualmente, estoy inscrito en un plan.\"><span class=\"wpcf7-list-item-label\">Actualmente, estoy inscrito en un plan.<\/span><\/span><\/span><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div data-id=\"group-life-changing\" data-orig_data_id=\"group-life-changing\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<div class=\"group-green-box\">\n\t\t\t\t<h2 class=\"font-24 text-centered\">Ocurri\u00f3 un <strong>evento que cambi\u00f3 mi vida.<\/strong>\n\t\t\t\t<\/h2>\n\t\t\t\t<h3 class=\"font-22 text-centered\">Seleccione el mejor motivo para el cambio.\n\t\t\t\t<\/h3>\n\t\t\t\t<div class=\"form-row\">\n\t\t\t\t\t<div class=\"form-column\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-life-changing-selection\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first last\"><label><input type=\"radio\" name=\"radio-life-changing-selection\" value=\"Hace poco me mud\u00e9 fuera del \u00e1rea de servicio de mi plan actual o hace poco me mud\u00e9 y este plan es una nueva opci\u00f3n para m\u00ed.\"><span class=\"wpcf7-list-item-label\">Hace poco me mud\u00e9 fuera del \u00e1rea de servicio de mi plan actual o hace poco me mud\u00e9 y este plan es una nueva opci\u00f3n para m\u00ed.<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<div data-id=\"group-moved\" data-orig_data_id=\"group-moved\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t\t\t\t\t<p><label for=\"date-moved\">Me mud\u00e9 el*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"date-moved\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" id=\"date-moved\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-moved\"><\/span>\n\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-life-changing-selection\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first last\"><label><input type=\"radio\" name=\"radio-life-changing-selection\" value=\"Me estoy yendo, voy a vivir o vivo en un centro de atenci\u00f3n a largo plazo (por ejemplo, un hogar de personas mayores o centro de atenci\u00f3n a largo plazo), o hace poco me fui de un centro de este tipo.\"><span class=\"wpcf7-list-item-label\">Me estoy yendo, voy a vivir o vivo en un centro de atenci\u00f3n a largo plazo (por ejemplo, un hogar de personas mayores o centro de atenci\u00f3n a largo plazo), o hace poco me fui de un centro de este tipo.<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<div data-id=\"group-facility\" data-orig_data_id=\"group-facility\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t\t\t\t\t<p><label for=\"date-facility\">Me fui o ir\u00e9 a vivir al centro, o me fui o ir\u00e9 de \u00e9l, el*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"date-facility\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" id=\"date-facility\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-facility\"><\/span>\n\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-life-changing-selection\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first last\"><label><input type=\"radio\" name=\"radio-life-changing-selection\" value=\"Hace poco sal\u00ed de prisi\u00f3n.\"><span class=\"wpcf7-list-item-label\">Hace poco sal\u00ed de prisi\u00f3n.<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<div data-id=\"group-released\" data-orig_data_id=\"group-released\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t\t\t\t\t<p><label for=\"date-released\">Me liberaron el*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"date-released\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" id=\"date-released\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-released\"><\/span>\n\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-life-changing-selection\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first last\"><label><input type=\"radio\" name=\"radio-life-changing-selection\" value=\"Hace poco volv\u00ed a los Estados Unidos despu\u00e9s de vivir en forma permanente fuera de los EE. UU.\"><span class=\"wpcf7-list-item-label\">Hace poco volv\u00ed a los Estados Unidos despu\u00e9s de vivir en forma permanente fuera de los EE. UU.<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<div data-id=\"group-returned\" data-orig_data_id=\"group-returned\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t\t\t\t\t<p><label for=\"date-returned\">Regres\u00e9 a los EE. UU. en esta fecha*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"date-returned\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" id=\"date-returned\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-returned\"><\/span>\n\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"form-column\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-life-changing-selection\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first last\"><label><input type=\"radio\" name=\"radio-life-changing-selection\" value=\"Hace poco obtuve la ciudadan\u00eda de los Estados Unidos.\"><span class=\"wpcf7-list-item-label\">Hace poco obtuve la ciudadan\u00eda de los Estados Unidos.<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<div data-id=\"group-lawful\" data-orig_data_id=\"group-lawful\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t\t\t\t\t<p><label for=\"date-lawful\">Obtuve la ciudadan\u00eda el*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"date-lawful\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" id=\"date-lawful\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-lawful\"><\/span>\n\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-life-changing-selection\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first last\"><label><input type=\"radio\" name=\"radio-life-changing-selection\" value=\"Voy a dejar de tener la cobertura de un empleador o sindicato.\"><span class=\"wpcf7-list-item-label\">Voy a dejar de tener la cobertura de un empleador o sindicato.<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<div data-id=\"group-leaving\" data-orig_data_id=\"group-leaving\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t\t\t\t\t<p><label for=\"date-leaving\">Me voy el*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"date-leaving\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" id=\"date-leaving\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-leaving\"><\/span>\n\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-life-changing-selection\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first last\"><label><input type=\"radio\" name=\"radio-life-changing-selection\" value=\"Me vi afectado por una emergencia clim\u00e1tica o una cat\u00e1strofe (declaradas por la Agencia Federal para el Manejo de Emergencias (Federal Emergency Management Agency, FEMA)). Una de las declaraciones anteriores se aplica en mi caso, pero no pude inscribirme debido al desastre natural.\"><span class=\"wpcf7-list-item-label\">Me vi afectado por una emergencia clim\u00e1tica o una cat\u00e1strofe (declaradas por la Agencia Federal para el Manejo de Emergencias (Federal Emergency Management Agency, FEMA)). Una de las declaraciones anteriores se aplica en mi caso, pero no pude inscribirme debido al desastre natural.<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div data-id=\"group-change-in-coverage\" data-orig_data_id=\"group-change-in-coverage\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<div class=\"group-green-box\">\n\t\t\t\t<h2 class=\"font-24 text-centered\">Recientemente tuve un cambio en la cobertura actual.\n\t\t\t\t<\/h2>\n\t\t\t\t<h3 class=\"font-22 text-centered\">Seleccione el mejor motivo para el cambio.\n\t\t\t\t<\/h3>\n\t\t\t\t<div class=\"form-row\">\n\t\t\t\t\t<div class=\"form-column\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-change-in-coverage-selection\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first last\"><label><input type=\"radio\" name=\"radio-change-in-coverage-selection\" value=\"Hace poco tuve un cambio en Medicaid (reci\u00e9n obtuve Medicaid, tuve un cambio en el nivel de la asistencia de Medicaid o perd\u00ed Medicaid).\"><span class=\"wpcf7-list-item-label\">Hace poco tuve un cambio en Medicaid (reci\u00e9n obtuve Medicaid, tuve un cambio en el nivel de la asistencia de Medicaid o perd\u00ed Medicaid).<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<div data-id=\"group-medicaid-change\" data-orig_data_id=\"group-medicaid-change\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t\t\t\t\t<p><label for=\"date-medicaid\">Cambio en Medicaid el*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"date-medicaid\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" id=\"date-medicaid\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-medicaid\"><\/span>\n\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-change-in-coverage-selection\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first last\"><label><input type=\"radio\" name=\"radio-change-in-coverage-selection\" value=\"Hace poco tuve un cambio en la Ayuda adicional para pagar la cobertura de medicamentos con receta de Medicare (reci\u00e9n obtuve Ayuda adicional, tuve un cambio en el nivel de la Ayuda adicional o perd\u00ed la Ayuda adicional).\"><span class=\"wpcf7-list-item-label\">Hace poco tuve un cambio en la Ayuda adicional para pagar la cobertura de medicamentos con receta de Medicare (reci\u00e9n obtuve Ayuda adicional, tuve un cambio en el nivel de la Ayuda adicional o perd\u00ed la Ayuda adicional).<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<div data-id=\"group-extra-help-change\" data-orig_data_id=\"group-extra-help-change\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t\t\t\t\t<p><label for=\"date-extra-help\">Modificaci\u00f3n en mi Ayuda adicional el*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"date-extra-help\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" id=\"date-extra-help\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-extra-help\"><\/span>\n\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-change-in-coverage-selection\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first last\"><label><input type=\"radio\" name=\"radio-change-in-coverage-selection\" value=\"Hace poco y en forma involuntaria perd\u00ed mi cobertura acreditable para medicamentos con receta (una cobertura tan buena como la de Medicare).\"><span class=\"wpcf7-list-item-label\">Hace poco y en forma involuntaria perd\u00ed mi cobertura acreditable para medicamentos con receta (una cobertura tan buena como la de Medicare).<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<div data-id=\"group-drug-coverage-change\" data-orig_data_id=\"group-drug-coverage-change\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t\t\t\t\t<p><label for=\"date-drug-coverage\">Perd\u00ed mi cobertura para medicamentos el*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"date-drug-coverage\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" id=\"date-drug-coverage\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-drug-coverage\"><\/span>\n\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-change-in-coverage-selection\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first last\"><label><input type=\"radio\" name=\"radio-change-in-coverage-selection\" value=\"Estaba inscrito en un Plan de necesidades especiales (Special Needs Plan, SNP), pero ya no califico para participar en dicho plan.\"><span class=\"wpcf7-list-item-label\">Estaba inscrito en un Plan de necesidades especiales (Special Needs Plan, SNP), pero ya no califico para participar en dicho plan.<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<div data-id=\"group-disenrolled\" data-orig_data_id=\"group-disenrolled\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t\t\t\t\t<p><label for=\"date-disenrolled\">Cancelaron mi inscripci\u00f3n en el SNP el*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"date-disenrolled\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" id=\"date-disenrolled\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-disenrolled\"><\/span>\n\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"form-column\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-change-in-coverage-selection\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first last\"><label><input type=\"radio\" name=\"radio-change-in-coverage-selection\" value=\"Hace poco dej\u00e9 de participar en un programa PACE.\"><span class=\"wpcf7-list-item-label\">Hace poco dej\u00e9 de participar en un programa PACE.<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<div data-id=\"group-pace\" data-orig_data_id=\"group-pace\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t\t\t\t\t<p><label for=\"date-pace\">Dej\u00e9 el Programa de Atenci\u00f3n Integral para las Personas de Edad Avanzada (PACE) el*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"date-pace\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" id=\"date-pace\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-pace\"><\/span>\n\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-change-in-coverage-selection\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first last\"><label><input type=\"radio\" name=\"radio-change-in-coverage-selection\" value=\"Mi plan va a terminar su contrato con Medicare, o Medicare va a terminar su contrato con mi plan.\"><span class=\"wpcf7-list-item-label\">Mi plan va a terminar su contrato con Medicare, o Medicare va a terminar su contrato con mi plan.<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div data-id=\"group-currently-enrolled\" data-orig_data_id=\"group-currently-enrolled\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<div class=\"group-green-box\">\n\t\t\t\t<h2 class=\"font-24 text-centered\">Actualmente, estoy inscrito en un plan.\n\t\t\t\t<\/h2>\n\t\t\t\t<h3 class=\"font-22 text-centered\">Seleccione el mejor motivo para el cambio.\n\t\t\t\t<\/h3>\n\t\t\t\t<div class=\"form-row\">\n\t\t\t\t\t<div class=\"form-single-column\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-currently-enrolled-selection\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first last\"><label><input type=\"radio\" name=\"radio-currently-enrolled-selection\" value=\"Fui inscrito en un plan por Medicare (o mi estado) y quiero cambiar a un plan diferente.\"><span class=\"wpcf7-list-item-label\">Fui inscrito en un plan por Medicare (o mi estado) y quiero cambiar a un plan diferente.<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<div data-id=\"group-chose-new\" data-orig_data_id=\"group-chose-new\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t\t\t\t\t<p><label for=\"date-chose-new\">Mi inscripci\u00f3n en ese plan comenz\u00f3 el*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"date-chose-new\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" id=\"date-chose-new\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-chose-new\"><\/span>\n\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-currently-enrolled-selection\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first last\"><label><input type=\"radio\" name=\"radio-currently-enrolled-selection\" value=\"Tengo Medicare y recibo beneficios completos de Medicaid. Deseo inscribirme o cambiarme a un plan que coordine la cobertura entre mis planes de Medicare y Medicaid administrados (llamado Plan Especial Integrado para Personas con Doble Elegibilidad, o D-SNP por sus siglas en ingl\u00e9s).\"><span class=\"wpcf7-list-item-label\">Tengo Medicare y recibo beneficios completos de Medicaid. Deseo inscribirme o cambiarme a un plan que coordine la cobertura entre mis planes de Medicare y Medicaid administrados (llamado Plan Especial Integrado para Personas con Doble Elegibilidad, o D-SNP por sus siglas en ingl\u00e9s).<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-currently-enrolled-selection\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first last\"><label><input type=\"radio\" name=\"radio-currently-enrolled-selection\" value=\"Estoy inscrito en un Programa Estatal de Asistencia Farmac\u00e9utica calificado o estoy perdiendo la ayuda de un Programa Estatal de Asistencia Farmac\u00e9utica.\"><span class=\"wpcf7-list-item-label\">Estoy inscrito en un Programa Estatal de Asistencia Farmac\u00e9utica calificado o estoy perdiendo la ayuda de un Programa Estatal de Asistencia Farmac\u00e9utica.<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"cf7mls-btns \"><button type=\"button\" class=\"cf7mls_back action-button\" name=\"cf7mls_back\" id=\"cf7mls-back-btn-cf7mls_step-3\">Atr\u00e1s<\/button><button type=\"button\" class=\"cf7mls_next cf7mls_btn action-button\" name=\"cf7mls_next\" id=\"cf7mls-next-btn-cf7mls_step-3\">Continuar<img decoding=\"async\" src=\"https:\/\/elderplan0.wpengine.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" alt=\"Step Loading\" data-lazy-src=\"https:\/\/elderplan0.wpengine.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" style=\"display: none;\"><\/button><\/div><p><\/p><\/fieldset><fieldset class=\"fieldset-cf7mls\">\n\n<div class=\"form-layout\">\n\t<div class=\"form-sidebar\">\n\t\t<div data-id=\"group-extra-help\" data-orig_data_id=\"group-extra-help\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><span>Usted se est\u00e1 inscribiendo en el plan<\/span> <span>Elderplan Extra Help(HMO-POS)<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div data-id=\"group-plan-flex\" data-orig_data_id=\"group-plan-flex\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><span>Usted se est\u00e1 inscribiendo en el plan<\/span><span>Elderplan Flex(HMO-POS) Plan<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div data-id=\"group-plan-medicaid\" data-orig_data_id=\"group-plan-medicaid\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><span>Usted se est\u00e1 inscribiendo en el plan<\/span><span>Elderplan For Medicaid Beneficiaries (HMO-POS D-SNP) Plan<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div class=\"form-tracker\">\n\t\t\t<div class=\"step in-progress\">\n\t\t\t\t<p><i class=\"fa-solid fa-check\"><\/i> Elegibilidad\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step\">\n\t\t\t\t<p><i class=\"fa-solid fa-circle-user\"><\/i> Informaci\u00f3n personal\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step\">\n\t\t\t\t<p><i class=\"fa-solid fa-file-lines\"><\/i> Inscripci\u00f3n\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step\">\n\t\t\t\t<p><i class=\"fa-solid fa-magnifying-glass\"><\/i> Confirmaci\u00f3n\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"percentage\">\n\t\t\t<p><strong>20%<\/strong> completado\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"form-content\">\n\t\t<h2 class=\"font-32\">Elegibilidad\n\t\t<\/h2>\n\t\t<h3 class=\"font-24 text-centered\">Proporcione la informaci\u00f3n de su seguro.\n\t\t<\/h3>\n\t\t<p class=\"small-cf7 text-centered\">Todos los campos marcados con un * son obligatorios y se deben completar.\n\t\t<\/p>\n\t\t<div class=\"mb-24\">\n\t\t<\/div>\n\t\t<div class=\"box\">\n\t\t\t<h3>\u00bfCu\u00e1l es su n\u00famero actual de Medicare?\n\t\t\t<\/h3>\n\t\t\t<p class=\"mb-12\">Cuando ingrese su n\u00famero de Medicare a continuaci\u00f3n, su elegibilidad para Medicare se verificar\u00e1 utilizando informaci\u00f3n de los Centros de Servicios de Medicare y Medicaid (CMS). Si actualmente no es elegible para Medicare, es posible que se rechace su solicitud.\n\t\t\t<\/p>\n\t\t\t<p><label for=\"medicare-number\">N\u00famero de Medicare*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"medicare-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"medicare-number\" autocomplete=\"off\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"medicare-number\"><\/span>\n\t\t\t<\/p>\n\t\t\t<p class=\"small-cf7 input-help mb-24\">Es un n\u00famero de 11 d\u00edgitos\n\t\t\t<\/p>\n\t\t\t<div data-id=\"group-medicaid-question\" data-orig_data_id=\"group-medicaid-question\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t\t<p><label>\u00bfEst\u00e1 inscrito en el programa New York State Medicaid?*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"medicaid-enrollment\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"medicaid-enrollment\" value=\"S\u00ed\"><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"medicaid-enrollment\" value=\"No\" checked><span class=\"wpcf7-list-item-label\">No<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"medicaid-enrollment\" value=\"No s\u00e9\"><span class=\"wpcf7-list-item-label\">No s\u00e9<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div data-id=\"group-medicaid-yes\" data-orig_data_id=\"group-medicaid-yes\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"group-green-box-lt\">\n\t\t\t\t\t<p><label for=\"medicaid-number\">N\u00famero de Medicaid*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"medicaid-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"medicaid-number\" autocomplete=\"off\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"medicaid-number\"><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t\t<p class=\"small-cf7 input-help\">Son 2 letras, 5 n\u00fameros y 1 letra\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t<\/div>\n\t\t\t\t<p><label>\u00bfRe\u00fane los requisitos para recibir la asistencia de costo compartido de Medicare a trav\u00e9s del programa New York State Medicaid? *<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"medicaid-cost-sharing\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"medicaid-cost-sharing\" value=\"S\u00ed\"><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"medicaid-cost-sharing\" value=\"No\" checked><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<div data-id=\"group-medicaid-no\" data-orig_data_id=\"group-medicaid-no\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t\t<div data-id=\"group-plan-medicaid\" data-orig_data_id=\"group-plan-medicaid\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t\t\t<div class=\"mb-24 small-cf7 input-help content-width\">\n\t\t\t\t\t\t<p>Para inscribirse en <strong>Elderplan for Medicaid Beneficiaries (HMO-POS D-SNP)<\/strong>: debe tener derecho a Medicare y al programa New York State Medicaid; debe ser elegible para la cobertura de Medicaid y cumplir con los requisitos de elegibilidad para la inscripci\u00f3n en Elderplan for Medicaid Beneficiaries. El tipo de beneficios de Medicaid que recibe est\u00e1 determinado por el Estado de New York y puede variar seg\u00fan su ingreso y recursos. Si actualmente no recibe cobertura de Medicaid, es posible que tengamos otros planes para usted, como <strong>Elderplan Flex (HMO-POS)<\/strong> y <strong>Elderplan Extra Help (HMO-POS)<\/strong>.\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<div class=\"mb-24\">\n\t\t\t<\/div>\n\t\t\t<p><label for=\"prescription-drug-coverage\">\u00bfTiene otra cobertura de medicamentos recetados (como VA o TRICARE) adem\u00e1s de Elderplan?*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"prescription-drug-coverage\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"prescription-drug-coverage\" value=\"S\u00ed\"><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"prescription-drug-coverage\" value=\"No\" checked><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<div data-id=\"group-additional-drug\" data-orig_data_id=\"group-additional-drug\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"group-green-box-lt\">\n\t\t\t\t\t<p class=\"mb-12\">Si la respuesta es S\u00ed, proporcione la siguiente informaci\u00f3n:\n\t\t\t\t\t<\/p>\n\t\t\t\t\t<p><label for=\"other-coverage-name\">Nombre de la otra cobertura*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"other-coverage-name\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" id=\"other-coverage-name\" aria-required=\"true\" aria-invalid=\"false\" name=\"other-coverage-name\"><option value=\"Administraci\u00f3n de Veteranos (VA)\">Administraci\u00f3n de Veteranos (VA)<\/option><option value=\"Champus (Veterano)\">Champus (Veterano)<\/option><option value=\"EPIC (Programa Estatal de Asistencia Farmac\u00e9utica)\">EPIC (Programa Estatal de Asistencia Farmac\u00e9utica)<\/option><option value=\"Tricare (Veterano)\">Tricare (Veterano)<\/option><option value=\"Jubilado de sindicato\">Jubilado de sindicato<\/option><option value=\"Jubilado de empleador\">Jubilado de empleador<\/option><option value=\"Jubilado federal\">Jubilado federal<\/option><\/select><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<p><label>N\u00famero de miembro para esta cobertura*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"other-coverage-member-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" autocomplete=\"off\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-coverage-member-number\"><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<p><label for=\"other-coverage-group-number\">N\u00famero de grupo para esta cobertura*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"other-coverage-group-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"other-coverage-group-number\" autocomplete=\"off\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-coverage-group-number\"><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t\t<p class=\"small-cf7 input-help\"> Ejemplos: Otros seguros privados, TRICARE, cobertura para empleados federales, beneficios para veteranos (VA) o programas estatales.\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"cf7mls-btns \"><button type=\"button\" class=\"cf7mls_back action-button\" name=\"cf7mls_back\" id=\"cf7mls-back-btn-cf7mls_step-4\">Atr\u00e1s<\/button><button type=\"button\" class=\"cf7mls_next cf7mls_btn action-button\" name=\"cf7mls_next\" id=\"cf7mls-next-btn-cf7mls_step-4\">Continuar<img decoding=\"async\" src=\"https:\/\/elderplan0.wpengine.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" alt=\"Step Loading\" data-lazy-src=\"https:\/\/elderplan0.wpengine.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" style=\"display: none;\"><\/button><\/div><p><\/p><\/fieldset><fieldset class=\"fieldset-cf7mls\">\n\n<div class=\"form-layout\">\n\t<div class=\"screen-reader-response\">\n\t\t<p role=\"status\" aria-live=\"polite\">\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"form-sidebar\">\n\t\t<div data-id=\"group-extra-help\" data-orig_data_id=\"group-extra-help\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><span>Usted se est\u00e1 inscribiendo en el plan<\/span> <span>Elderplan Extra Help(HMO-POS)<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div data-id=\"group-plan-flex\" data-orig_data_id=\"group-plan-flex\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><span>Usted se est\u00e1 inscribiendo en el plan<\/span><span>Elderplan Flex(HMO-POS) Plan<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div data-id=\"group-plan-medicaid\" data-orig_data_id=\"group-plan-medicaid\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><span>Usted se est\u00e1 inscribiendo en el plan<\/span><span>Elderplan For Medicaid Beneficiaries (HMO-POS D-SNP) Plan<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div class=\"form-tracker\">\n\t\t\t<div class=\"step in-progress\">\n\t\t\t\t<p><i class=\"fa-solid fa-check\"><\/i> Elegibilidad\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step\">\n\t\t\t\t<p><i class=\"fa-solid fa-circle-user\"><\/i> Informaci\u00f3n personal\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step\">\n\t\t\t\t<p><i class=\"fa-solid fa-file-lines\"><\/i> Inscripci\u00f3n\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step\">\n\t\t\t\t<p><i class=\"fa-solid fa-magnifying-glass\"><\/i> Confirmaci\u00f3n\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"percentage\">\n\t\t\t<p><strong>35%<\/strong> completado\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"form-content\">\n\t\t<h2 class=\"font-32\">\u00bfEs usted un representante autorizado?\n\t\t<\/h2>\n\t\t<p class=\"small-cf7 text-centered\">Todos los campos marcados con un * son obligatorios y se deben completar.\n\t\t<\/p>\n\t\t<details class=\"secondary\">\n\t\t\t<summary><span>M\u00e1s informaci\u00f3n<\/span><span>Ocultar<\/span>\n\t\t\t<\/summary>\n\t\t\t<div class=\"details-content\">\n\t\t\t\t<p>Un representante autorizado es una persona o una entidad a la que se le ha dado permiso legal para actuar en nombre de otra persona en determinados asuntos. Esto puede incluir tomar decisiones, acceder a informaci\u00f3n y realizar acciones que la persona normalmente realizar\u00eda.\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/details>\n\t\t<div class=\"box box--top\">\n\t\t\t<p class=\"font-22 mb-16\">\u00bfCu\u00e1l es su relaci\u00f3n con la persona que se inscribe en esta solicitud?\n\t\t\t<\/p>\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-authorized\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-authorized\" value=\"Soy el inscrito en esta solicitud\" checked><span class=\"wpcf7-list-item-label\">Soy el inscrito en esta solicitud<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-authorized\" value=\"Soy el representante autorizado del inscrito en esta solicitud\"><span class=\"wpcf7-list-item-label\">Soy el representante autorizado del inscrito en esta solicitud<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div data-id=\"group-authorized\" data-orig_data_id=\"group-authorized\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<div class=\"box box--bottom\">\n\t\t\t\t<p class=\"font-22 mb-16 font-bolder\">Usted ha indicado que es un representante autorizado.\n\t\t\t\t<\/p>\n\t\t\t\t<p class=\"small-red-cf7 mb-16 content-width\"><i class=\"fa-solid fa-triangle-exclamation\"><\/i>Si firma como representante autorizado, significa que tiene el derecho legal seg\u00fan la ley estatal de firmar y puede mostrar pruebas por escrito de este derecho si Medicare lo solicita.\n\t\t\t\t<\/p>\n\t\t\t\t<p class=\"small-red-cf7 mb-24\">TENGA EN CUENTA LO SIGUIENTE: Toda la informaci\u00f3n en este formulario debe ser espec\u00edfica de la persona que recibir\u00e1 beneficios de Elderplan, no del representante autorizado.\n\t\t\t\t<\/p>\n\t\t\t\t<p><label for=\"authorized-representative-name\">Nombre completo*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"authorized-representative-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"authorized-representative-name\" autocomplete=\"off\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"authorized-representative-name\"><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t<\/div>\n\t\t\t\t<p><label for=\"relationship-to-enrollee\">Relaci\u00f3n con el inscrito*<\/label><br>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"relationship-to-enrollee\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" id=\"relationship-to-enrollee\" aria-required=\"true\" aria-invalid=\"false\" name=\"relationship-to-enrollee\"><option value=\"Hijo\">Hijo<\/option><option value=\"C\u00f3nyuge\">C\u00f3nyuge<\/option><option value=\"Padre\/madre\">Padre\/madre<\/option><option value=\"Amigo\">Amigo<\/option><option value=\"Familia extendida\">Familia extendida<\/option><option value=\"Tutor legal\">Tutor legal<\/option><option value=\"Otro\">Otro<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t<\/div>\n\t\t\t\t<p><label for=\"authorized-representative-street-address\">Direcci\u00f3n*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"authorized-representative-street-address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"authorized-representative-street-address\" autocomplete=\"off\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"authorized-representative-street-address\"><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t<\/div>\n\t\t\t\t<p><label for=\"authorized-representative-street-address-2\">Direcci\u00f3n, segundo rengl\u00f3n<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"authorized-representative-street-address-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" id=\"authorized-representative-street-address-2\" autocomplete=\"off\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"authorized-representative-street-address-2\"><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t<\/div>\n\t\t\t\t<p><label for=\"authorized-representative-city\">Ciudad*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"authorized-representative-city\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"authorized-representative-city\" autocomplete=\"off\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"authorized-representative-city\"><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t<\/div>\n\t\t\t\t<p><label for=\"authorized-representative-county\">Condado*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"authorized-representative-county\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" id=\"authorized-representative-county\" aria-required=\"true\" aria-invalid=\"false\" name=\"authorized-representative-county\"><option value=\"Bronx\">Bronx<\/option><option value=\"Dutchess\">Dutchess<\/option><option value=\"Kings\">Kings<\/option><option value=\"Livingston\">Livingston<\/option><option value=\"Monroe\">Monroe<\/option><option value=\"Nassau\">Nassau<\/option><option value=\"New York\">New York<\/option><option value=\"Ontario\">Ontario<\/option><option value=\"Orange\">Orange<\/option><option value=\"Orleans\">Orleans<\/option><option value=\"Putnam\">Putnam<\/option><option value=\"Queens\">Queens<\/option><option value=\"Richmond\">Richmond<\/option><option value=\"Rockland\">Rockland<\/option><option value=\"Seneca\">Seneca<\/option><option value=\"Suffolk\">Suffolk<\/option><option value=\"Ulster\">Ulster<\/option><option value=\"Westchester\">Westchester<\/option><option value=\"Yates\">Yates<\/option><option value=\"Onondaga\">Onondaga<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t<\/div>\n\t\t\t\t<p><label for=\"authorized-representative-state\">Estado*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"authorized-representative-state\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" id=\"authorized-representative-state\" aria-required=\"true\" aria-invalid=\"false\" name=\"authorized-representative-state\"><option value=\"New York\">New York<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t<\/div>\n\t\t\t\t<p><label for=\"authorized-representative-zip-code\">C\u00f3digo postal*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"authorized-representative-zip-code\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"authorized-representative-zip-code\" autocomplete=\"off\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"authorized-representative-zip-code\"><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t<\/div>\n\t\t\t\t<p><label for=\"authorized-representative-email\">Correo electr\u00f3nico*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"authorized-representative-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" id=\"authorized-representative-email\" autocomplete=\"off\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"authorized-representative-email\"><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t<\/div>\n\t\t\t\t<p><label for=\"authorized-representative-phone-number\">N\u00famero de tel\u00e9fono*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"authorized-representative-phone-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" id=\"authorized-representative-phone-number\" autocomplete=\"off\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"authorized-representative-phone-number\"><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p class=\"small-cf7 input-help mb-24\">Este es un n\u00famero de 10 d\u00edgitos\n\t\t\t\t<\/p>\n\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"cf7mls-btns \"><button type=\"button\" class=\"cf7mls_back action-button\" name=\"cf7mls_back\" id=\"cf7mls-back-btn-cf7mls_step-5\">Atr\u00e1s<\/button><button type=\"button\" class=\"cf7mls_next cf7mls_btn action-button\" name=\"cf7mls_next\" id=\"cf7mls-next-btn-cf7mls_step-5\">Continuar<img decoding=\"async\" src=\"https:\/\/elderplan0.wpengine.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" alt=\"Step Loading\" data-lazy-src=\"https:\/\/elderplan0.wpengine.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" style=\"display: none;\"><\/button><\/div><p><\/p><\/fieldset><fieldset class=\"fieldset-cf7mls\">\n\n<div class=\"form-layout\">\n\t<div class=\"screen-reader-response\">\n\t\t<p role=\"status\" aria-live=\"polite\">\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"form-sidebar\">\n\t\t<div data-id=\"group-extra-help\" data-orig_data_id=\"group-extra-help\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><span>Usted se est\u00e1 inscribiendo en el plan<\/span> <span>Elderplan Extra Help(HMO-POS)<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div data-id=\"group-plan-flex\" data-orig_data_id=\"group-plan-flex\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><span>Usted se est\u00e1 inscribiendo en el plan<\/span><span>Elderplan Flex(HMO-POS) Plan<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div data-id=\"group-plan-medicaid\" data-orig_data_id=\"group-plan-medicaid\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><span>Usted se est\u00e1 inscribiendo en el plan<\/span><span>Elderplan For Medicaid Beneficiaries (HMO-POS D-SNP) Plan<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div class=\"form-tracker\">\n\t\t\t<div class=\"step in-progress\">\n\t\t\t\t<p><i class=\"fa-solid fa-check\"><\/i> Elegibilidad\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step\">\n\t\t\t\t<p><i class=\"fa-solid fa-circle-user\"><\/i> Informaci\u00f3n personal\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step\">\n\t\t\t\t<p><i class=\"fa-solid fa-file-lines\"><\/i> Inscripci\u00f3n\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step\">\n\t\t\t\t<p><i class=\"fa-solid fa-magnifying-glass\"><\/i> Confirmaci\u00f3n\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"percentage\">\n\t\t\t<p><strong>40%<\/strong> completado\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"form-content\">\n\t\t<h2 class=\"font-32\">\u00bfQui\u00e9n se inscribe?\n\t\t<\/h2>\n\t\t<p class=\"small-cf7 text-centered mb-24\">Todos los campos marcados con un * son obligatorios y se deben completar.\n\t\t<\/p>\n\t\t<div class=\"mb-24\">\n\t\t<\/div>\n\t\t<div class=\"box\">\n\t\t\t<p class=\"font-24 mb-12\">Informaci\u00f3n personal\n\t\t\t<\/p>\n\t\t\t<p><label for=\"first-name\">Nombre*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"first-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"first-name\" autocomplete=\"off\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"first-name\"><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"mb-24\">\n\t\t\t<\/div>\n\t\t\t<p><label for=\"middle-initial\">Inicial del 2.\u00ba nombre<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"middle-initial\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" id=\"middle-initial\" autocomplete=\"off\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"middle-initial\"><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"mb-24\">\n\t\t\t<\/div>\n\t\t\t<p><label for=\"last-name\">Apellido*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"last-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"last-name\" autocomplete=\"off\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"last-name\"><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"mb-24\">\n\t\t\t<\/div>\n\t\t\t<p><label for=\"birth-date\">Fecha de nacimiento*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"birth-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" id=\"birth-date\" max=\"2006-10-15\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"birth-date\"><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"mb-24\">\n\t\t\t<\/div>\n\t\t\t<p><label>G\u00e9nero*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"sex\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"sex\" value=\"Hombre\" checked><span class=\"wpcf7-list-item-label\">Hombre<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"sex\" value=\"Mujer\"><span class=\"wpcf7-list-item-label\">Mujer<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"mb-24\">\n\t\t\t<\/div>\n\t\t\t<p><label>\u00bfUsted trabaja?*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"work\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"work\" value=\"S\u00ed\"><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"work\" value=\"No\" checked><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"mb-24\">\n\t\t\t<\/div>\n\t\t\t<p><label>Estado civil*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"marital\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"marital\" value=\"Casado\/a\"><span class=\"wpcf7-list-item-label\">Casado\/a<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"marital\" value=\"Soltero\/a\" checked><span class=\"wpcf7-list-item-label\">Soltero\/a<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"marital\" value=\"Divorciado\/a\"><span class=\"wpcf7-list-item-label\">Divorciado\/a<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"marital\" value=\"Viudo\/a\"><span class=\"wpcf7-list-item-label\">Viudo\/a<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"mb-24\">\n\t\t\t<\/div>\n\t\t\t<div data-id=\"group-spouse-work\" data-orig_data_id=\"group-spouse-work\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t\t<div class=\"group-green-box-lt\">\n\t\t\t\t\t<p><label>\u00bfSu c\u00f3nyuge o pareja trabaja?*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"spouse-work\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"spouse-work\" value=\"S\u00ed\"><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"spouse-work\" value=\"No\"><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"cf7mls-btns \"><button type=\"button\" class=\"cf7mls_back action-button\" name=\"cf7mls_back\" id=\"cf7mls-back-btn-cf7mls_step-6\">Atr\u00e1s<\/button><button type=\"button\" class=\"cf7mls_next cf7mls_btn action-button\" name=\"cf7mls_next\" id=\"cf7mls-next-btn-cf7mls_step-6\">Next<img decoding=\"async\" src=\"https:\/\/elderplan0.wpengine.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" alt=\"Step Loading\" data-lazy-src=\"https:\/\/elderplan0.wpengine.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" style=\"display: none;\"><\/button><\/div><p><\/p><\/fieldset><fieldset class=\"fieldset-cf7mls\">\n\n<div class=\"form-layout\">\n\t<div class=\"screen-reader-response\">\n\t\t<p role=\"status\" aria-live=\"polite\">\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"form-sidebar\">\n\t\t<div data-id=\"group-extra-help\" data-orig_data_id=\"group-extra-help\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><br>\n<span>Usted se est\u00e1 inscribiendo en el plan<\/span> <span>Elderplan Extra Help(HMO-POS)<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div data-id=\"group-plan-flex\" data-orig_data_id=\"group-plan-flex\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><br>\n<span>Usted se est\u00e1 inscribiendo en el plan<\/span><span>Elderplan Flex(HMO-POS) Plan<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div data-id=\"group-plan-medicaid\" data-orig_data_id=\"group-plan-medicaid\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><br>\n<span>Usted se est\u00e1 inscribiendo en el plan<\/span><span>Elderplan For Medicaid Beneficiaries (HMO-POS D-SNP) Plan<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div class=\"form-tracker\">\n\t\t\t<div class=\"step completed\">\n\t\t\t\t<p><i class=\"fa-solid fa-check\"><\/i> Elegibilidad\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step in-progress\">\n\t\t\t\t<p><i class=\"fa-solid fa-user\"><\/i> Informaci\u00f3n personal\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step\">\n\t\t\t\t<p><i class=\"fa-solid fa-file-lines\"><\/i> Inscripci\u00f3n\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step\">\n\t\t\t\t<p><i class=\"fa-solid fa-magnifying-glass\"><\/i> Confirmaci\u00f3n\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"percentage\">\n\t\t\t<p><strong>45%<\/strong> completado\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"form-content\">\n\t\t<h2 class=\"font-32\">\u00bfD\u00f3nde vive?\n\t\t<\/h2>\n\t\t<details class=\"secondary\">\n\t\t\t<summary><span>\u00bfPor qu\u00e9 necesita esta informaci\u00f3n?<\/span><span>Ocultar<\/span>\n\t\t\t<\/summary>\n\t\t\t<div class=\"details-content\">\n\t\t\t\t<p>En Elderplan, recopilamos su informaci\u00f3n para garantizar que brindamos una atenci\u00f3n \u00f3ptima y mantenemos su cobertura de manera efectiva. Dependiendo de su m\u00e9todo de comunicaci\u00f3n preferido, tambi\u00e9n lo utilizamos para comunicarle actualizaciones sobre la informaci\u00f3n del plan y enviarle avisos importantes para mantenerlo informado.\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/details>\n\t\t<p class=\"small-cf7 text-centered mb-24\">Este deber\u00eda ser el domicilio en el que vive actualmente y en donde recibir\u00eda los servicios. No ingrese una casilla de correo.\n\t\t<\/p>\n\t\t<div class=\"mb-24\">\n\t\t<\/div>\n\t\t<div class=\"box\">\n\t\t\t<p class=\"mb-24\">\u00bfCu\u00e1l es su direcci\u00f3n principal?\n\t\t\t<\/p>\n\t\t\t<p><label for=\"street-address\">Direcci\u00f3n*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"street-address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"street-address\" autocomplete=\"off\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"street-address\"><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"mb-24\">\n\t\t\t<\/div>\n\t\t\t<p><label for=\"street-address-2\">Direcci\u00f3n, segundo rengl\u00f3n<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"street-address-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" id=\"street-address-2\" autocomplete=\"off\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"street-address-2\"><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"mb-24\">\n\t\t\t<\/div>\n\t\t\t<p><label for=\"city\">Ciudad*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"city\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"city\" autocomplete=\"off\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"city\"><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"mb-24\">\n\t\t\t<\/div>\n\t\t\t<p><label for=\"state\">Estado*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"state\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" id=\"state\" aria-required=\"true\" aria-invalid=\"false\" name=\"state\"><option value=\"New York\">New York<\/option><\/select><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"mb-24\">\n\t\t\t<\/div>\n\t\t\t<p><label for=\"county\">Condado*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"county\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" id=\"county\" aria-required=\"true\" aria-invalid=\"false\" name=\"county\"><option value=\"Bronx\">Bronx<\/option><option value=\"Dutchess\">Dutchess<\/option><option value=\"Kings\">Kings<\/option><option value=\"Livingston\">Livingston<\/option><option value=\"Monroe\">Monroe<\/option><option value=\"Nassau\">Nassau<\/option><option value=\"New York\">New York<\/option><option value=\"Ontario\">Ontario<\/option><option value=\"Orange\">Orange<\/option><option value=\"Orleans\">Orleans<\/option><option value=\"Putnam\">Putnam<\/option><option value=\"Queens\">Queens<\/option><option value=\"Richmond\">Richmond<\/option><option value=\"Rockland\">Rockland<\/option><option value=\"Seneca\">Seneca<\/option><option value=\"Suffolk\">Suffolk<\/option><option value=\"Ulster\">Ulster<\/option><option value=\"Westchester\">Westchester<\/option><option value=\"Yates\">Yates<\/option><option value=\"Onondaga\">Onondaga<\/option><\/select><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"mb-24\">\n\t\t\t<\/div>\n\t\t\t<p><label for=\"zip-code\">C\u00f3digo postal*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"zip-code\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"zip-cod\" autocomplete=\"offe\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"zip-code\"><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"mb-24\">\n\t\t\t<\/div>\n\t\t\t<p><label>\u00bfSu direcci\u00f3n postal es la misma que su direcci\u00f3n principal?*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mailing-address-same\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"mailing-address-same\" value=\"S\u00ed\" checked><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"mailing-address-same\" value=\"No\"><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"mb-24\">\n\t\t\t<\/div>\n\t\t\t<div data-id=\"group-mailing-same-no\" data-orig_data_id=\"group-mailing-same-no\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t\t<div class=\"group-green-box-lt\">\n\t\t\t\t\t<p class=\"mb-12\">Si la respuesta es No, proporcione su direcci\u00f3n postal:\n\t\t\t\t\t<\/p>\n\t\t\t\t\t<p><label for=\"mailing-street-address\">Direcci\u00f3n*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mailing-street-address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"mailing-street-address\" autocomplete=\"off\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mailing-street-address\"><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<p><label for=\"mailing-street-address-2\">Direcci\u00f3n, segundo rengl\u00f3n<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mailing-street-address-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" id=\"mailing-street-address-2\" autocomplete=\"off\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mailing-street-address-2\"><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<p><label for=\"mailing-city\">Ciudad*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mailing-city\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"mailing-city\" autocomplete=\"off\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mailing-city\"><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<p><label for=\"mailing-state\">Estado*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mailing-state\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" id=\"mailing-state\" aria-required=\"true\" aria-invalid=\"false\" name=\"mailing-state\"><option value=\"New York\">New York<\/option><\/select><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<p><label for=\"mailing-county\">Condado*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mailing-county\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" id=\"mailing-county\" aria-required=\"true\" aria-invalid=\"false\" name=\"mailing-county\"><option value=\"\">\u2014Please choose an option\u2014<\/option><option value=\"Bronx\">Bronx<\/option><option value=\"Dutchess\">Dutchess<\/option><option value=\"Kings\">Kings<\/option><option value=\"Livingston\">Livingston<\/option><option value=\"Monroe\">Monroe<\/option><option value=\"Nassau\">Nassau<\/option><option value=\"New York\">New York<\/option><option value=\"Ontario\">Ontario<\/option><option value=\"Orange\">Orange<\/option><option value=\"Orleans\">Orleans<\/option><option value=\"Putnam\">Putnam<\/option><option value=\"Queens\">Queens<\/option><option value=\"Richmond\">Richmond<\/option><option value=\"Rockland\">Rockland<\/option><option value=\"Seneca\">Seneca<\/option><option value=\"Suffolk\">Suffolk<\/option><option value=\"Ulster\">Ulster<\/option><option value=\"Westchester\">Westchester<\/option><option value=\"Yates\">Yates<\/option><option value=\"Onondaga\">Onondaga<\/option><\/select><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<p><label for=\"mailing-zip-code\">C\u00f3digo postal*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mailing-zip-code\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"mailing-zip-code\" autocomplete=\"off\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mailing-zip-code\"><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"cf7mls-btns \"><button type=\"button\" class=\"cf7mls_back action-button\" name=\"cf7mls_back\" id=\"cf7mls-back-btn-cf7mls_step-7\">Atr\u00e1s<\/button><button type=\"button\" class=\"cf7mls_next cf7mls_btn action-button\" name=\"cf7mls_next\" id=\"cf7mls-next-btn-cf7mls_step-7\">Continuar<img decoding=\"async\" src=\"https:\/\/elderplan0.wpengine.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" alt=\"Step Loading\" data-lazy-src=\"https:\/\/elderplan0.wpengine.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" style=\"display: none;\"><\/button><\/div><p><\/p><\/fieldset><fieldset class=\"fieldset-cf7mls\">\n\n<div class=\"form-layout\">\n\t<div class=\"screen-reader-response\">\n\t\t<p role=\"status\" aria-live=\"polite\">\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"form-sidebar\">\n\t\t<div data-id=\"group-extra-help\" data-orig_data_id=\"group-extra-help\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><br>\n<span>Usted se est\u00e1 inscribiendo en el plan<\/span> <span>Elderplan Extra Help(HMO-POS)<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div data-id=\"group-plan-flex\" data-orig_data_id=\"group-plan-flex\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><br>\n<span>Usted se est\u00e1 inscribiendo en el plan<\/span> <span>Elderplan Flex(HMO-POS) Plan<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div data-id=\"group-plan-medicaid\" data-orig_data_id=\"group-plan-medicaid\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><br>\n<span>Usted se est\u00e1 inscribiendo en el plan<\/span> <span>Elderplan For Medicaid Beneficiaries (HMO-POS D-SNP) Plan<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div class=\"form-tracker\">\n\t\t\t<div class=\"step completed\">\n\t\t\t\t<p><i class=\"fa-solid fa-check\"><\/i> Elegibilidad\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step in-progress\">\n\t\t\t\t<p><i class=\"fa-solid fa-user\"><\/i> Informaci\u00f3n personal\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step\">\n\t\t\t\t<p><i class=\"fa-solid fa-file-lines\"><\/i> Inscripci\u00f3n\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step\">\n\t\t\t\t<p><i class=\"fa-solid fa-magnifying-glass\"><\/i> Confirmaci\u00f3n\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"percentage\">\n\t\t\t<p><strong>50%<\/strong> completado\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"form-content\">\n\t\t<h2 class=\"font-32\">\u00bfC\u00f3mo podemos comunicarnos con usted?\n\t\t<\/h2>\n\t\t<p class=\"small-cf7 mb-12 text-centered\">Todos los campos marcados con un * son obligatorios y se deben completar.\n\t\t<\/p>\n\t\t<div class=\"mb-24\">\n\t\t<\/div>\n\t\t<div class=\"box\">\n\t\t\t<p class=\"mb-12\">\u00bfCu\u00e1l es su n\u00famero de tel\u00e9fono?\n\t\t\t<\/p>\n\t\t\t<p><label for=\"home-phone\">Tel\u00e9fono particular*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"home-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" id=\"home-phone\" autocomplete=\"off\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"home-phone\"><\/span>\n\t\t\t<\/p>\n\t\t\t<p class=\"small-cf7 input-help mb-24\">Este es un n\u00famero de 10 d\u00edgitos.\n\t\t\t<\/p>\n\t\t\t<p><label for=\"cell-phone\">Tel\u00e9fono celular<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cell-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" id=\"cell-phone\" autocomplete=\"off\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"cell-phone\"><\/span>\n\t\t\t<\/p>\n\t\t\t<p class=\"small-cf7 input-help mb-24\">Este es un n\u00famero de 10 d\u00edgitos.\n\t\t\t<\/p>\n\t\t\t<div data-id=\"group-sms-opt-in\" data-orig_data_id=\"group-sms-opt-in\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t\t<p class=\"mb-12\">Suscr\u00edbase para recibir las siguientes notificaciones por mensaje de texto:\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>Informaci\u00f3n del plan de salud*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"health-plan-information\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"health-plan-information\" value=\"S\u00ed\"><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"health-plan-information\" value=\"No\" checked><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t<\/div>\n\t\t\t\t<p><label>Informaci\u00f3n de bienestar:*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"wellness-information\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"wellness-information\" value=\"S\u00ed\"><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"wellness-information\" value=\"No\" checked><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t<\/div>\n\t\t\t\t<p><label>Incentivos y encuestas:*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"incentives-and-surveys\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"incentives-and-surveys\" value=\"S\u00ed\"><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"incentives-and-surveys\" value=\"No\" checked><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<div data-id=\"group-if-email\" data-orig_data_id=\"group-if-email\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t\t<p><label for=\"email\">\u00bfCu\u00e1l es su direcci\u00f3n de correo electr\u00f3nico?*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" id=\"email\" autocomplete=\"off\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"email\"><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t<\/div>\n\t\t\t\t<p class=\"small-cf7\">Dependiendo de sus preferencias de correo electr\u00f3nico, utilizamos esta informaci\u00f3n para enviarle actualizaciones sobre los detalles del plan y avisos importantes para mantenerlo bien informado. Tambi\u00e9n le enviaremos un registro de esta inscripci\u00f3n mediante un n\u00famero de confirmaci\u00f3n.\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-no-email\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"checkbox-no-email[]\" value=\"No tengo una direcci\u00f3n de correo electr\u00f3nico.\"><span class=\"wpcf7-list-item-label\">No tengo una direcci\u00f3n de correo electr\u00f3nico.<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"mb-24\">\n\t\t\t<\/div>\n\t\t\t<div data-id=\"group-if-email\" data-orig_data_id=\"group-if-email\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t\t<p class=\"mb-12\"><strong>\u00bfCu\u00e1l es su m\u00e9todo preferido para recibir avisos sobre su plan o los materiales del plan?<\/strong>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>Seleccione su preferencia*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-contact-preference\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-contact-preference\" value=\"Correo\" checked><span class=\"wpcf7-list-item-label\">Correo<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-contact-preference\" value=\"Correo electr\u00f3nico\"><span class=\"wpcf7-list-item-label\">Correo electr\u00f3nico<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t<\/div>\n\t\t\t\t<p><label>Quiero recibir los siguientes materiales por correo electr\u00f3nico (email). Seleccione uno o m\u00e1s.<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-email-materials\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-email-materials[]\" value=\"Aviso anual de cambios (ANOC)\"><span class=\"wpcf7-list-item-label\">Aviso anual de cambios (ANOC)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-email-materials[]\" value=\"Informaci\u00f3n de bienestar\"><span class=\"wpcf7-list-item-label\">Informaci\u00f3n de bienestar<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-email-materials[]\" value=\"Folletos y volantes de beneficios\"><span class=\"wpcf7-list-item-label\">Folletos y volantes de beneficios<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"mb-24\">\n\t\t\t<\/div>\n\t\t\t<p><label>\u00bfRecibe alg\u00fan beneficio para veteranos?*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"veterans-benefits-question\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"veterans-benefits-question\" value=\"S\u00ed\"><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"veterans-benefits-question\" value=\"No\" checked><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<div data-id=\"group-benefits-yes\" data-orig_data_id=\"group-benefits-yes\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t<\/div>\n\t\t\t\t<p><label>\u00bfCu\u00e1l es el nombre de su hospital o cl\u00ednica para veteranos? *<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"vh-or-clinic\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"vh-or-clinic\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"vh-or-clinic\"><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t<\/div>\n\t\t\t\t<p><label>\u00bfLe gustar\u00eda hablar con alguien sobre los beneficios para veteranos que podr\u00eda recibir?*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"more-veterans-benefits-info\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"more-veterans-benefits-info\" value=\"S\u00ed\"><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"more-veterans-benefits-info\" value=\"No\" checked><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"cf7mls-btns \"><button type=\"button\" class=\"cf7mls_back action-button\" name=\"cf7mls_back\" id=\"cf7mls-back-btn-cf7mls_step-8\">Atr\u00e1s<\/button><button type=\"button\" class=\"cf7mls_next cf7mls_btn action-button\" name=\"cf7mls_next\" id=\"cf7mls-next-btn-cf7mls_step-8\">Continuar<img decoding=\"async\" src=\"https:\/\/elderplan0.wpengine.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" alt=\"Step Loading\" data-lazy-src=\"https:\/\/elderplan0.wpengine.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" style=\"display: none;\"><\/button><\/div><p><\/p><\/fieldset><fieldset class=\"fieldset-cf7mls\">\n\n<div class=\"form-layout\">\n\t<div class=\"screen-reader-response\">\n\t\t<p role=\"status\" aria-live=\"polite\">\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"form-sidebar\">\n\t\t<div data-id=\"group-extra-help\" data-orig_data_id=\"group-extra-help\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><br>\n<span>Usted se est\u00e1 inscribiendo en el plan<\/span> <span>Elderplan Extra Help(HMO-POS)<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div data-id=\"group-plan-flex\" data-orig_data_id=\"group-plan-flex\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><br>\n<span>Usted se est\u00e1 inscribiendo en el plan<\/span><span>Elderplan Flex(HMO-POS) Plan<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div data-id=\"group-plan-medicaid\" data-orig_data_id=\"group-plan-medicaid\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><br>\n<span>Usted se est\u00e1 inscribiendo en el plan<\/span><span>Elderplan For Medicaid Beneficiaries (HMO-POS D-SNP) Plan<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div class=\"form-tracker\">\n\t\t\t<div class=\"step completed\">\n\t\t\t\t<p><i class=\"fa-solid fa-check\"><\/i> Elegibilidad\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step in-progress\">\n\t\t\t\t<p><i class=\"fa-solid fa-user\"><\/i> Informaci\u00f3n personal\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step\">\n\t\t\t\t<p><i class=\"fa-solid fa-file-lines\"><\/i> Inscripci\u00f3n\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step\">\n\t\t\t\t<p><i class=\"fa-solid fa-magnifying-glass\"><\/i> Confirmaci\u00f3n\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"percentage\">\n\t\t\t<p><strong>55%<\/strong> completado\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"form-content\">\n\t\t<h2 class=\"font-32\">Cu\u00e9ntenos un poco m\u00e1s sobre usted\n\t\t<\/h2>\n\t\t<p class=\"small-cf7 mb-12 text-centered\">Todos los campos marcados con un * son obligatorios y se deben completar.\n\t\t<\/p>\n\t\t<details class=\"secondary\">\n\t\t\t<summary><span>\u00bfPor qu\u00e9 necesita esta informaci\u00f3n?<\/span><span>Ocultar<\/span>\n\t\t\t<\/summary>\n\t\t\t<div class=\"details-content\">\n\t\t\t\t<p>Elderplan se compromete a identificar y cerrar las brechas en la atenci\u00f3n. Nuestro objetivo es garantizar que cada persona tenga una oportunidad justa y equitativa de tener una salud \u00f3ptima, independientemente de su raza, origen \u00e9tnico, discapacidad, orientaci\u00f3n sexual, identidad de g\u00e9nero, nivel socioecon\u00f3mico, geograf\u00eda, idioma preferido o cualquier otro factor que influya en el acceso a la atenci\u00f3n y resultados de salud. Responder estas preguntas es opcional y no afectar\u00e1 su elegibilidad de ninguna manera. Los recopilamos \u00fanicamente para brindarle una mejor cobertura de atenci\u00f3n de una manera que sea \u00fatil y significativa para usted.\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/details>\n\t\t<div class=\"mb-24\">\n\t\t<\/div>\n\t\t<div class=\"box\">\n\t\t\t<p class=\"font-24 mb-12\">Idioma preferido\n\t\t\t<\/p>\n\t\t\t<p><label>Seleccione una opci\u00f3n si prefiere hablar en otro idioma que no sea ingl\u00e9s:*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"preferred-language-gate\"><select class=\"wpcf7-form-control wpcf7-select\" id=\"preferred-language-gate\" aria-invalid=\"false\" name=\"preferred-language-gate\"><option value=\"I prefer to speak in English\">I prefer to speak in English<\/option><option value=\"Espa\u00f1ol\">Espa\u00f1ol<\/option><option value=\"Chino\">Chino<\/option><option value=\"Otro \u2013 especifique\">Otro \u2013 especifique<\/option><\/select><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"mb-24\">\n\t\t\t<\/div>\n\t\t\t<div data-id=\"group-speak-english\" data-orig_data_id=\"group-speak-english\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t\t<p><label>\u00bfHabla ingl\u00e9s?<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"speak_english_radio\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"speak_english_radio\" value=\"Si\"><span class=\"wpcf7-list-item-label\">Si<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"speak_english_radio\" value=\"No\" checked><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<div data-id=\"group-preferred-language\" data-orig_data_id=\"group-preferred-language\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t\t<div class=\"group-green-box-lt mb-24\">\n\t\t\t\t\t<p><label>Si respondi\u00f3 \u201cOtro\u201d, \u00bfqu\u00e9 idioma prefiere?*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"preferred-language\"><select class=\"wpcf7-form-control wpcf7-select\" id=\"preferred-language\" aria-invalid=\"false\" name=\"preferred-language\"><option value=\"Espa\u00f1ol\">Espa\u00f1ol<\/option><option value=\"Chino\">Chino<\/option><option value=\"Mandar\u00edn (China)\">Mandar\u00edn (China)<\/option><option value=\"Canton\u00e9s (China)\">Canton\u00e9s (China)<\/option><option value=\"Alban\u00e9s\">Alban\u00e9s<\/option><option value=\"Am\u00e1rico\">Am\u00e1rico<\/option><option value=\"\u00c1rabe\">\u00c1rabe<\/option><option value=\"Armenio\">Armenio<\/option><option value=\"Ashanti\">Ashanti<\/option><option value=\"Bengal\u00ed\">Bengal\u00ed<\/option><option value=\"Bosnio\">Bosnio<\/option><option value=\"B\u00falgaro\">B\u00falgaro<\/option><option value=\"Birmano\">Birmano<\/option><option value=\"Criollo\">Criollo<\/option><option value=\"Croata\">Croata<\/option><option value=\"Dan\u00e9s\">Dan\u00e9s<\/option><option value=\"Holand\u00e9s\">Holand\u00e9s<\/option><option value=\"Estonio\">Estonio<\/option><option value=\"Ew\u00e9\">Ew\u00e9<\/option><option value=\"Farsi\">Farsi<\/option><option value=\"Filipino\">Filipino<\/option><option value=\"Franc\u00e9s\">Franc\u00e9s<\/option><option value=\"Fujian\u00e9s\">Fujian\u00e9s<\/option><option value=\"Fuzhou\">Fuzhou<\/option><option value=\"Georgiano\">Georgiano<\/option><option value=\"Alem\u00e1n\">Alem\u00e1n<\/option><option value=\"Griego\">Griego<\/option><option value=\"Gujarati\">Gujarati<\/option><option value=\"Haddad\">Haddad<\/option><option value=\"Haitiano\">Haitiano<\/option><option value=\"Hausa\">Hausa<\/option><option value=\"Hebreo\">Hebreo<\/option><option value=\"Hindi\">Hindi<\/option><option value=\"H\u00fangaro\">H\u00fangaro<\/option><option value=\"Igbo\">Igbo<\/option><option value=\"Indio\">Indio<\/option><option value=\"Italiano\">Italiano<\/option><option value=\"Japon\u00e9s\">Japon\u00e9s<\/option><option value=\"Kachchi\">Kachchi<\/option><option value=\"Canar\u00e9s\">Canar\u00e9s<\/option><option value=\"Coreano\">Coreano<\/option><option value=\"Let\u00f3n\">Let\u00f3n<\/option><option value=\"Macedonio\">Macedonio<\/option><option value=\"Malayalam\">Malayalam<\/option><option value=\"Marat\u00ed\">Marat\u00ed<\/option><option value=\"Nepal\u00ed\">Nepal\u00ed<\/option><option value=\"Noruego\">Noruego<\/option><option value=\"Pakistan\u00ed\">Pakistan\u00ed<\/option><option value=\"Polaco\">Polaco<\/option><option value=\"Portugu\u00e9s\">Portugu\u00e9s<\/option><option value=\"Punyab\u00ed\">Punyab\u00ed<\/option><option value=\"Rhade\">Rhade<\/option><option value=\"Rumano\">Rumano<\/option><option value=\"Ruso\">Ruso<\/option><option value=\"Senegal\u00e9s\">Senegal\u00e9s<\/option><option value=\"Shangh\u00e1i\">Shangh\u00e1i<\/option><option value=\"Sichuan\u00e9s\">Sichuan\u00e9s<\/option><option value=\"Lengua de se\u00f1as\">Lengua de se\u00f1as<\/option><option value=\"Sinhala\">Sinhala<\/option><option value=\"Esloveno\">Esloveno<\/option><option value=\"Somal\u00ed\">Somal\u00ed<\/option><option value=\"Suajili\">Suajili<\/option><option value=\"Sueco\">Sueco<\/option><option value=\"Sirio\">Sirio<\/option><option value=\"Tagalo\">Tagalo<\/option><option value=\"Taishan\u00e9s\">Taishan\u00e9s<\/option><option value=\"Taiwan\u00e9s\">Taiwan\u00e9s<\/option><option value=\"Tamil\">Tamil<\/option><option value=\"Tegul\u00fa\">Tegul\u00fa<\/option><option value=\"Tailand\u00e9s\">Tailand\u00e9s<\/option><option value=\"Tigri\u00f1a (norte de Etiop\u00eda)\">Tigri\u00f1a (norte de Etiop\u00eda)<\/option><option value=\"Turco\">Turco<\/option><option value=\"Ucraniano\">Ucraniano<\/option><option value=\"Urdu\">Urdu<\/option><option value=\"Uzbeko\">Uzbeko<\/option><option value=\"Vietnamita\">Vietnamita<\/option><option value=\"Yiddish\">Yiddish<\/option><option value=\"Yoruba\">Yoruba<\/option><\/select><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<div class=\"mb-24\">\n\t\t\t<\/div>\n\t\t\t<p><label>Seleccione una opci\u00f3n si desea que le enviemos informaci\u00f3n en un idioma distinto al ingl\u00e9s.*<\/label><br>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"preferred-language-information\"><select class=\"wpcf7-form-control wpcf7-select\" id=\"preferred-language-information\" aria-invalid=\"false\" name=\"preferred-language-information\"><option value=\"I prefer information in English\">I prefer information in English<\/option><option value=\"Espa\u00f1ol\">Espa\u00f1ol<\/option><option value=\"Chino\">Chino<\/option><option value=\"Otro \u2013 especifique\">Otro \u2013 especifique<\/option><\/select><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"mb-24\">\n\t\t\t<\/div>\n\t\t\t<div data-id=\"group-other-information\" data-orig_data_id=\"group-other-information\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"preferred-language-information-other\"><select class=\"wpcf7-form-control wpcf7-select\" id=\"preferred-language-information-other\" aria-invalid=\"false\" name=\"preferred-language-information-other\"><option value=\"Espa\u00f1ol\">Espa\u00f1ol<\/option><option value=\"Chino\">Chino<\/option><option value=\"Mandar\u00edn (China)\">Mandar\u00edn (China)<\/option><option value=\"Canton\u00e9s (China)\">Canton\u00e9s (China)<\/option><option value=\"Alban\u00e9s\">Alban\u00e9s<\/option><option value=\"Am\u00e1rico\">Am\u00e1rico<\/option><option value=\"\u00c1rabe\">\u00c1rabe<\/option><option value=\"Armenio\">Armenio<\/option><option value=\"Ashanti\">Ashanti<\/option><option value=\"Bengal\u00ed\">Bengal\u00ed<\/option><option value=\"Bosnio\">Bosnio<\/option><option value=\"B\u00falgaro\">B\u00falgaro<\/option><option value=\"Birmano\">Birmano<\/option><option value=\"Criollo\">Criollo<\/option><option value=\"Croata\">Croata<\/option><option value=\"Dan\u00e9s\">Dan\u00e9s<\/option><option value=\"Holand\u00e9s\">Holand\u00e9s<\/option><option value=\"Estonio\">Estonio<\/option><option value=\"Ew\u00e9\">Ew\u00e9<\/option><option value=\"Farsi\">Farsi<\/option><option value=\"Filipino\">Filipino<\/option><option value=\"Franc\u00e9s\">Franc\u00e9s<\/option><option value=\"Fujian\u00e9s\">Fujian\u00e9s<\/option><option value=\"Fuzhou\">Fuzhou<\/option><option value=\"Georgiano\">Georgiano<\/option><option value=\"Alem\u00e1n\">Alem\u00e1n<\/option><option value=\"Griego\">Griego<\/option><option value=\"Gujarati\">Gujarati<\/option><option value=\"Haddad\">Haddad<\/option><option value=\"Haitiano\">Haitiano<\/option><option value=\"Hausa\">Hausa<\/option><option value=\"Hebreo\">Hebreo<\/option><option value=\"Hindi\">Hindi<\/option><option value=\"H\u00fangaro\">H\u00fangaro<\/option><option value=\"Igbo\">Igbo<\/option><option value=\"Indio\">Indio<\/option><option value=\"Italiano\">Italiano<\/option><option value=\"Japon\u00e9s\">Japon\u00e9s<\/option><option value=\"Kachchi\">Kachchi<\/option><option value=\"Canar\u00e9s\">Canar\u00e9s<\/option><option value=\"Coreano\">Coreano<\/option><option value=\"Let\u00f3n\">Let\u00f3n<\/option><option value=\"Macedonio\">Macedonio<\/option><option value=\"Malayalam\">Malayalam<\/option><option value=\"Marat\u00ed\">Marat\u00ed<\/option><option value=\"Nepal\u00ed\">Nepal\u00ed<\/option><option value=\"Noruego\">Noruego<\/option><option value=\"Pakistan\u00ed\">Pakistan\u00ed<\/option><option value=\"Polaco\">Polaco<\/option><option value=\"Portugu\u00e9s\">Portugu\u00e9s<\/option><option value=\"Punyab\u00ed\">Punyab\u00ed<\/option><option value=\"Rhade\">Rhade<\/option><option value=\"Rumano\">Rumano<\/option><option value=\"Ruso\">Ruso<\/option><option value=\"Senegal\u00e9s\">Senegal\u00e9s<\/option><option value=\"Shangh\u00e1i\">Shangh\u00e1i<\/option><option value=\"Sichuan\u00e9s\">Sichuan\u00e9s<\/option><option value=\"Lengua de se\u00f1as\">Lengua de se\u00f1as<\/option><option value=\"Sinhala\">Sinhala<\/option><option value=\"Esloveno\">Esloveno<\/option><option value=\"Somal\u00ed\">Somal\u00ed<\/option><option value=\"Suajili\">Suajili<\/option><option value=\"Sueco\">Sueco<\/option><option value=\"Sirio\">Sirio<\/option><option value=\"Tagalo\">Tagalo<\/option><option value=\"Taishan\u00e9s\">Taishan\u00e9s<\/option><option value=\"Taiwan\u00e9s\">Taiwan\u00e9s<\/option><option value=\"Tamil\">Tamil<\/option><option value=\"Tegul\u00fa\">Tegul\u00fa<\/option><option value=\"Tailand\u00e9s\">Tailand\u00e9s<\/option><option value=\"Tigri\u00f1a (norte de Etiop\u00eda)\">Tigri\u00f1a (norte de Etiop\u00eda)<\/option><option value=\"Turco\">Turco<\/option><option value=\"Ucraniano\">Ucraniano<\/option><option value=\"Urdu\">Urdu<\/option><option value=\"Uzbeko\">Uzbeko<\/option><option value=\"Vietnamita\">Vietnamita<\/option><option value=\"Yiddish\">Yiddish<\/option><option value=\"Yoruba\">Yoruba<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"mb-24\">\n\t\t\t<\/div>\n\t\t\t<p><label>\u00bfPrefiere la informaci\u00f3n del plan en un formato accesible?<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"accessible-format\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"accessible-format\" value=\"Braille\"><span class=\"wpcf7-list-item-label\">Braille<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"accessible-format\" value=\"Tama\u00f1o de letra grande\"><span class=\"wpcf7-list-item-label\">Tama\u00f1o de letra grande<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"accessible-format\" value=\"CD de audio\"><span class=\"wpcf7-list-item-label\">CD de audio<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"accessible-format\" value=\"No, gracias\" checked><span class=\"wpcf7-list-item-label\">No, gracias<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"mb-24\">\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"cf7mls-btns \"><button type=\"button\" class=\"cf7mls_back action-button\" name=\"cf7mls_back\" id=\"cf7mls-back-btn-cf7mls_step-9\">Atr\u00e1s<\/button><button type=\"button\" class=\"cf7mls_next cf7mls_btn action-button\" name=\"cf7mls_next\" id=\"cf7mls-next-btn-cf7mls_step-9\">Continuar<img decoding=\"async\" src=\"https:\/\/elderplan0.wpengine.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" alt=\"Step Loading\" data-lazy-src=\"https:\/\/elderplan0.wpengine.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" style=\"display: none;\"><\/button><\/div><p><\/p><\/fieldset><fieldset class=\"fieldset-cf7mls\">\n\n<div class=\"form-layout\">\n\t<div class=\"screen-reader-response\">\n\t\t<p role=\"status\" aria-live=\"polite\">\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"form-sidebar\">\n\t\t<div data-id=\"group-extra-help\" data-orig_data_id=\"group-extra-help\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><br>\n<span>Usted se est\u00e1 inscribiendo en el plan<\/span> <span>Elderplan Extra Help(HMO-POS)<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div data-id=\"group-plan-flex\" data-orig_data_id=\"group-plan-flex\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><br>\n<span>Usted se est\u00e1 inscribiendo en el plan<\/span> <span>Elderplan Flex(HMO-POS) Plan<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div data-id=\"group-plan-medicaid\" data-orig_data_id=\"group-plan-medicaid\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><br>\n<span>Usted se est\u00e1 inscribiendo en el plan<\/span> <span>Elderplan For Medicaid Beneficiaries (HMO-POS D-SNP) Plan<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div class=\"form-tracker\">\n\t\t\t<div class=\"step completed\">\n\t\t\t\t<p><i class=\"fa-solid fa-check\"><\/i> Elegibilidad\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step in-progress\">\n\t\t\t\t<p><i class=\"fa-solid fa-user\"><\/i> Informaci\u00f3n personal\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step\">\n\t\t\t\t<p><i class=\"fa-solid fa-file-lines\"><\/i> Inscripci\u00f3n\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step\">\n\t\t\t\t<p><i class=\"fa-solid fa-magnifying-glass\"><\/i> Confirmaci\u00f3n\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"percentage\">\n\t\t\t<p><strong>65%<\/strong> completado\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"form-content\">\n\t\t<h2 class=\"font-32\">\u00bfD\u00f3nde recibe atenci\u00f3n actualmente?\n\t\t<\/h2>\n\t\t<p class=\"small-cf7 mb-12 text-centered\">Todos los campos marcados con un * son obligatorios y se deben completar.\n\t\t<\/p>\n\t\t<div class=\"mb-24\">\n\t\t<\/div>\n\t\t<div class=\"box\">\n\t\t\t<h3 class=\"font-24 mb-24\">Cu\u00e9ntenos sobre su m\u00e9dico y cl\u00ednica actuales.\n\t\t\t<\/h3>\n\t\t\t<p><br>\n<label>Nombre del m\u00e9dico de atenci\u00f3n primaria (PCP)<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"text-primary-care\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-primary-care\"><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"mb-12\">\n\t\t\t<\/div>\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-primary-care-additional-1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-primary-care-additional-1\"><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"mb-12\">\n\t\t\t<\/div>\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-primary-care-additional-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-primary-care-additional-2\"><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"mb-24\">\n\t\t\t<\/div>\n\t\t\t<div class=\"mb-24\">\n\t\t\t<\/div>\n\t\t\t<p><br>\n<label>Name of Clinic<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"text-clinic\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-clinic\"><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"mb-12\">\n\t\t\t<\/div>\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-clinic-additional-1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-clinic-additional-1\"><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"mb-12\">\n\t\t\t<\/div>\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-clinic-additional-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-clinic-additional-2\"><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"mb-24\">\n\t\t\t<\/div>\n\t\t\t<div class=\"mb-24\">\n\t\t\t<\/div>\n\t\t\t<p><br>\n<label>Health Center<\/label><br>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-health-center\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-health-center\"><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"mb-12\">\n\t\t\t<\/div>\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-health-center-additional-1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-health-center-additional-1\"><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"mb-12\">\n\t\t\t<\/div>\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-health-center-additional-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-health-center-additional-2\"><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"mb-24\">\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"cf7mls-btns \"><button type=\"button\" class=\"cf7mls_back action-button\" name=\"cf7mls_back\" id=\"cf7mls-back-btn-cf7mls_step-10\">Atr\u00e1s<\/button><button type=\"button\" class=\"cf7mls_next cf7mls_btn action-button\" name=\"cf7mls_next\" id=\"cf7mls-next-btn-cf7mls_step-10\">Continuar<img decoding=\"async\" src=\"https:\/\/elderplan0.wpengine.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" alt=\"Step Loading\" data-lazy-src=\"https:\/\/elderplan0.wpengine.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" style=\"display: none;\"><\/button><\/div><p><\/p><\/fieldset><fieldset class=\"fieldset-cf7mls\">\n\n<div class=\"form-layout\">\n\t<div class=\"screen-reader-response\">\n\t\t<p role=\"status\" aria-live=\"polite\">\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"form-sidebar\">\n\t\t<div data-id=\"group-extra-help\" data-orig_data_id=\"group-extra-help\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><br>\n<span>Usted se est\u00e1 inscribiendo en el plan<\/span> <span>Elderplan Extra Help(HMO-POS)<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div data-id=\"group-plan-flex\" data-orig_data_id=\"group-plan-flex\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><br>\n<span>Usted se est\u00e1 inscribiendo en el plan<\/span><span>Elderplan Flex(HMO-POS) Plan<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div data-id=\"group-plan-medicaid\" data-orig_data_id=\"group-plan-medicaid\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><br>\n<span>Usted se est\u00e1 inscribiendo en el plan<\/span><span>Elderplan For Medicaid Beneficiaries (HMO-POS D-SNP) Plan<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div class=\"form-tracker\">\n\t\t\t<div class=\"step completed\">\n\t\t\t\t<p><i class=\"fa-solid fa-check\"><\/i> Elegibilidad\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step completed\">\n\t\t\t\t<p><i class=\"fa-solid fa-user\"><\/i> Informaci\u00f3n personal\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step in-progress\">\n\t\t\t\t<p><i class=\"fa-solid fa-file-lines\"><\/i> Inscripci\u00f3n\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step\">\n\t\t\t\t<p><i class=\"fa-solid fa-magnifying-glass\"><\/i> Confirmaci\u00f3n\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"percentage\">\n\t\t\t<p><strong>80%<\/strong> completado\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"form-content\">\n\t\t<div data-id=\"group-plan-flex\" data-orig_data_id=\"group-plan-flex\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7 font-24 mb-24 text-centered\">Usted se est\u00e1 inscribiendo en el plan Elderplan Flex(HMO-POS)\n\t\t\t<\/h3>\n\t\t\t<h2 class=\"font-32 text-left-align mb-8\">Beneficios adicionales\n\t\t\t<\/h2>\n\t\t\t<h3 class=\"font-24 mb-8\">Su plan tiene beneficios adicionales.\n\t\t\t<\/h3>\n\t\t\t<div class=\"box\">\n\t\t\t\t<p><label>Seleccione beneficios adicionales<\/label>\n\t\t\t\t<\/p>\n\t\t\t\t<p>Seleccione una opci\u00f3n*\n\t\t\t\t<\/p>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-extra-benefits\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-extra-benefits\" value=\"Producto de venta libre (OTC)\"><span class=\"wpcf7-list-item-label\">Producto de venta libre (OTC)<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-extra-benefits\" value=\"Transporte\"><span class=\"wpcf7-list-item-label\">Transporte<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"flex-payment-message\">\n\t\t\t\t<p>Es posible que tenga costos adicionales asociados con su plan, como una multa por inscripci\u00f3n tard\u00eda en la Parte D.\n\t\t\t\t<\/p>\n\t\t\t\t<p>If you have to pay a Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA), you must pay this extra amount in addition to your plan premium.\n\t\t\t\t<\/p>\n\t\t\t\t<p>DON\u2019T pay Elderplan the Part D-IRMAA.\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div data-id=\"group-extra-help\" data-orig_data_id=\"group-extra-help\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h2 class=\"font-50 text-left-align mb-24\">C\u00f3mo pagar su plan\n\t\t\t<\/h2>\n\t\t\t<div class=\"premium-wrap\">\n\t\t\t\t<div class=\"premium-col\">\n\t\t\t\t\t<h3>Prima mensual\n\t\t\t\t\t<\/h3>\n\t\t\t\t\t<p>$58.80\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<div class=\"premium-message\">\n\t\t\t\t<p>El monto final de la prima se confirmar\u00e1 en el momento de la inscripci\u00f3n efectiva.\n\t\t\t\t<\/p>\n\t\t\t\t<p>Adem\u00e1s de cualquier prima, tambi\u00e9n puede incurrir en costos adicionales, como los siguientes:\n\t\t\t\t<\/p>\n\t\t\t\t<ul>\n\t\t\t\t\t<li>\n\t\t\t\t\t\t<p>Prima mensual\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/li>\n\t\t\t\t\t<li>\n\t\t\t\t\t\t<p>Multa por inscripci\u00f3n tard\u00eda en la Parte D\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/li>\n\t\t\t\t<\/ul>\n\t\t\t\t<p>Si tiene que pagar un monto de ajuste mensual relacionado con el ingreso de la Parte D (IRMAA de la Parte D), deber\u00e1 pagar este monto adicional adem\u00e1s de la prima de su plan.\n\t\t\t\t<\/p>\n\t\t\t\t<p>NO le pague a Elderplan el IRMAA de la Parte D.\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div data-id=\"group-plan-medicaid\" data-orig_data_id=\"group-plan-medicaid\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h2 class=\"font-50 text-left-align mb-24\">Su plan tiene una prima.\n\t\t\t<\/h2>\n\t\t\t<div class=\"premium-wrap\">\n\t\t\t\t<div class=\"premium-col\">\n\t\t\t\t\t<h3>Prima mensual\n\t\t\t\t\t<\/h3>\n\t\t\t\t\t<p>$22.70\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<div class=\"premium-message\">\n\t\t\t\t<p>The final premium amount will be confirmed upon effective enrollment.\n\t\t\t\t<\/p>\n\t\t\t\t<p>In addition to any premium, you may also incur additional costs such as\n\t\t\t\t<\/p>\n\t\t\t\t<ul>\n\t\t\t\t\t<li>\n\t\t\t\t\t\t<p>Prima mensual\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/li>\n\t\t\t\t\t<li>\n\t\t\t\t\t\t<p>Part D Late Enrollment Penalty\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/li>\n\t\t\t\t<\/ul>\n\t\t\t\t<p>If you have to pay a Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA), you must pay this extra amount in addition to your plan premium.\n\t\t\t\t<\/p>\n\t\t\t\t<p>DON\u2019T pay Elderplan the Part D-IRMAA.\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div data-id=\"group-not-flex\" data-orig_data_id=\"group-not-flex\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h2 class=\"font-32 text-left-align mb-8\"><br>\n<strong>Confirme la informaci\u00f3n de pago<\/strong>\n\t\t\t<\/h2>\n\t\t\t<p class=\"font-24 mb-8\">H\u00e1ganos saber a continuaci\u00f3n c\u00f3mo le gustar\u00eda pagar su prima o cualquier costo adicional asociado con su inscripci\u00f3n, tal como se describe anteriormente:\n\t\t\t<\/p>\n\t\t\t<p class=\"small-cf7 mb-24\">Todos los campos marcados con un * son obligatorios y se deben completar.\n\t\t\t<\/p>\n\t\t\t<div class=\"box\">\n\t\t\t\t<p><label>Opciones de pago<\/label>\n\t\t\t\t<\/p>\n\t\t\t\t<p class=\"mb-16\">Seleccione una opci\u00f3n de pago*\n\t\t\t\t<\/p>\n\t\t\t\t<div class=\"stacked-radios mb-12\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"payment-options\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"payment-options\" value=\"Recibir una factura\"><span class=\"wpcf7-list-item-label\">Recibir una factura<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"payment-options\" value=\"Transferencia electr\u00f3nica de fondos (EFT) de su cuenta bancaria todos los meses\"><span class=\"wpcf7-list-item-label\">Transferencia electr\u00f3nica de fondos (EFT) de su cuenta bancaria todos los meses<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"payment-options\" value=\"Tarjeta de cr\u00e9dito\"><span class=\"wpcf7-list-item-label\">Tarjeta de cr\u00e9dito<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"payment-options\" value=\"Deducci\u00f3n autom\u00e1tica de su cheque de beneficios mensual del Seguro Social o de la Junta de Jubilaci\u00f3n para Ferroviarios (RRB)\"><span class=\"wpcf7-list-item-label\">Deducci\u00f3n autom\u00e1tica de su cheque de beneficios mensual del Seguro Social o de la Junta de Jubilaci\u00f3n para Ferroviarios (RRB)<\/span><\/span><\/span><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div data-id=\"group-eft\" data-orig_data_id=\"group-eft\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t\t\t<div class=\"group-green-box-lt\">\n\t\t\t\t\t\t<p><label for=\"eft-account-holder\">Nombre del titular de la cuenta como aparece en la tarjeta*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"eft-account-holder\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"eft-account-holder\" autocomplete=\"off\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"eft-account-holder\"><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<p><label for=\"eft-routing-number\">N\u00famero de enrutamiento del banco*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"eft-routing-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"eft-routing-number\" autocomplete=\"off\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"eft-routing-number\"><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<p><label for=\"eft-account-number\">N\u00famero de cuenta*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"eft-account-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"eft-account-number\" autocomplete=\"off\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"eft-account-number\"><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<p><label>Tipo de cuenta*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"eft-account-type\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"eft-account-type\" value=\"De cheques\" checked><span class=\"wpcf7-list-item-label\">De cheques<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"eft-account-type\" value=\"De ahorros\"><span class=\"wpcf7-list-item-label\">De ahorros<\/span><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div data-id=\"group-credit-card\" data-orig_data_id=\"group-credit-card\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t\t\t<div class=\"group-green-box-lt\">\n\t\t\t\t\t\t<p><label>Type of card*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"credit-card-type\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"credit-card-type\" value=\"Visa\" checked><span class=\"wpcf7-list-item-label\">Visa<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"credit-card-type\" value=\"Mastercard\"><span class=\"wpcf7-list-item-label\">Mastercard<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"credit-card-type\" value=\"Otra\"><span class=\"wpcf7-list-item-label\">Otra<\/span><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<p><label for=\"credit-card-account-holder\">Nombre del titular de la cuenta como aparece en la tarjeta*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"credit-card-account-holder\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"credit-card-account-holder\" autocomplete=\"off\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"credit-card-account-holder\"><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<p><label for=\"credit-card-account-number\">N\u00famero de cuenta*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"credit-card-account-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"credit-card-account-number\" autocomplete=\"off\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"credit-card-account-number\"><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<div class=\"mb-24\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<p><label for=\"credit-card-expiration-date\">Fecha de vencimiento*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"credit-card-expiration-date\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"credit-card-expiration-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"credit-card-expiration-date\"><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<p class=\"small-cf7 input-help mb-24\">Utilice el formato MM\/YY. Por ejemplo, 09\/24.\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div data-id=\"group-automatic-deduction\" data-orig_data_id=\"group-automatic-deduction\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t\t\t<div class=\"group-green-box-lt\">\n\t\t\t\t\t\t<div class=\"stacked-radios\">\n\t\t\t\t\t\t\t<p><label>Obtengo beneficios mensuales de*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"monthly-benefits-from\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"monthly-benefits-from\" value=\"Seguro Social\" checked><span class=\"wpcf7-list-item-label\">Seguro Social<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"monthly-benefits-from\" value=\"Junta de Jubilaci\u00f3n para Ferroviarios (RRB)\"><span class=\"wpcf7-list-item-label\">Junta de Jubilaci\u00f3n para Ferroviarios (RRB)<\/span><\/span><\/span><\/span>\n\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"cf7mls-btns \"><button type=\"button\" class=\"cf7mls_back action-button\" name=\"cf7mls_back\" id=\"cf7mls-back-btn-cf7mls_step-11\">Atr\u00e1s<\/button><button type=\"button\" class=\"cf7mls_next cf7mls_btn action-button\" name=\"cf7mls_next\" id=\"cf7mls-next-btn-cf7mls_step-11\">Continuar<img decoding=\"async\" src=\"https:\/\/elderplan0.wpengine.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" alt=\"Step Loading\" data-lazy-src=\"https:\/\/elderplan0.wpengine.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" style=\"display: none;\"><\/button><\/div><p><\/p><\/fieldset><fieldset class=\"fieldset-cf7mls\">\n\n<div class=\"form-layout\">\n\t<div class=\"screen-reader-response\">\n\t\t<p role=\"status\" aria-live=\"polite\">\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"form-sidebar\">\n\t\t<div data-id=\"group-extra-help\" data-orig_data_id=\"group-extra-help\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><br>\n<span>Usted se est\u00e1 inscribiendo en el plan<\/span><span>Elderplan Extra Help(HMO-POS)<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div data-id=\"group-plan-flex\" data-orig_data_id=\"group-plan-flex\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><br>\n<span>Usted se est\u00e1 inscribiendo en el plan<\/span><span>Elderplan Flex(HMO-POS) Plan<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div data-id=\"group-plan-medicaid\" data-orig_data_id=\"group-plan-medicaid\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><br>\n<span>Usted se est\u00e1 inscribiendo en el plan<\/span><span>Elderplan For Medicaid Beneficiaries (HMO-POS D-SNP) Plan<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div class=\"form-tracker\">\n\t\t\t<div class=\"step completed\">\n\t\t\t\t<p><i class=\"fa-solid fa-check\"><\/i> Elegibilidad\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step completed\">\n\t\t\t\t<p><i class=\"fa-solid fa-user\"><\/i> Informaci\u00f3n personal\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step in-progress\">\n\t\t\t\t<p><i class=\"fa-solid fa-file-lines\"><\/i> Inscripci\u00f3n\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step\">\n\t\t\t\t<p><i class=\"fa-solid fa-magnifying-glass\"><\/i> Confirmaci\u00f3n\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"percentage\">\n\t\t\t<p><strong>90%<\/strong> completado\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"form-content\">\n\t\t<h2 class=\"font-32\">Acuerdo y firma\n\t\t<\/h2>\n\t\t<p class=\"small-cf7 text-centered mb-32\">Todos los campos marcados con un * son obligatorios y se deben completar.\n\t\t<\/p>\n\t\t<div class=\"mb-24\">\n\t\t<\/div>\n\t\t<div class=\"box\">\n\t\t\t<p class=\"font-22 mb-16\">Al hacer clic en el bot\u00f3n \u201cAceptar\u201d a continuaci\u00f3n, acepto y entiendo que:\n\t\t\t<\/p>\n\t\t\t<ul class=\"mb-24\">\n\t\t\t\t<li class=\"flexed-li\">\n\t\t\t\t\t<p>Me estoy inscribiendo en El plan\n\t\t\t\t\t<\/p>\n\t\t\t\t\t<div data-id=\"group-extra-help\" data-orig_data_id=\"group-extra-help\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t\t\t\t<p><strong>Elderplan Extra Help(HMO-POS)<\/strong>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div data-id=\"group-plan-flex\" data-orig_data_id=\"group-plan-flex\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t\t\t\t<p><strong>Elderplan Flex(HMO-POS)<\/strong>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div data-id=\"group-plan-medicaid\" data-orig_data_id=\"group-plan-medicaid\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t\t\t\t<p><strong>Medicaid Beneficiaries (HMO-POS D-SNP)<\/strong>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/li>\n\t\t\t\t<li>\n\t\t\t\t\t<p>Para permanecer en Elderplan, debo mantener el seguro hospitalario (Parte A) y el seguro m\u00e9dico (Parte B).\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/li>\n\t\t\t\t<li>\n\t\t\t\t\t<p>Al inscribirme en este plan Medicare Advantage (MA), reconozco que Elderplan compartir\u00e1 mi informaci\u00f3n con Medicare, que podr\u00e1 usarla para realizar un seguimiento de mi inscripci\u00f3n, hacer pagos, y para otros fines permitidos por la ley federal que autoriza la recopilaci\u00f3n de esta informaci\u00f3n (consulte la Declaraci\u00f3n de Ley de Privacidad abajo).\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/li>\n\t\t\t\t<li>\n\t\t\t\t\t<p>Comprendo que puedo estar inscrito en un solo plan de MA a la vez, y que la inscripci\u00f3n en este plan cancelar\u00e1 autom\u00e1ticamente mi inscripci\u00f3n en otro plan de MA (se aplican excepciones para el plan privado de pago por servicio [PFFS] de MA o el plan de cuenta de ahorro para gastos m\u00e9dicos [MSA] de MA).\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/li>\n\t\t\t\t<li>\n\t\t\t\t\t<p>Comprendo que, cuando comience mi cobertura de Elderplan, debo recibir todos los beneficios de atenci\u00f3n m\u00e9dica y de medicamentos con receta de parte de Elderplan. Estar\u00e1n cubiertos los beneficios y servicios proporcionados por Elderplan e incluidos en el documento \u201cEvidencia de cobertura\u201d de Elderplan (tambi\u00e9n conocido como contrato del miembro o acuerdo del suscriptor). Ni Medicare ni Elderplan pagar\u00e1n beneficios o servicios que no est\u00e9n cubiertos.\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/li>\n\t\t\t\t<li>\n\t\t\t\t\t<p>A mi leal saber y entender, la informaci\u00f3n contenida en este formulario de inscripci\u00f3n es correcta. Comprendo que, si proporciono intencionalmente informaci\u00f3n falsa en este formulario, se cancelar\u00e1 mi inscripci\u00f3n en el plan.\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/li>\n\t\t\t\t<li>\n\t\t\t\t\t<p>Comprendo que mi firma (o la firma de la persona legalmente autorizada para actuar en mi nombre) en esta solicitud implica que he le\u00eddo y comprendo el contenido de esta solicitud. Si un representante autorizado (tal como se describi\u00f3 anteriormente) firma la solicitud, esta firma certifica lo siguiente:\n\t\t\t\t\t<\/p>\n\t\t\t\t\t<ol>\n\t\t\t\t\t\t<li>\n\t\t\t\t\t\t\t<p>Esta persona est\u00e1 autorizada por la ley estatal para completar esta inscripci\u00f3n.\n\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t<li>\n\t\t\t\t\t\t\t<p>La documentaci\u00f3n de esta autorizaci\u00f3n est\u00e1 disponible a solicitud de Medicare.\n\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t<\/li>\n\t\t\t\t\t<\/ol>\n\t\t\t\t<\/li>\n\t\t\t\t<li>\n\t\t\t\t\t<p>Su respuesta a este formulario es voluntaria. Sin embargo, si no responde, su inscripci\u00f3n en el plan puede verse afectada.\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/li>\n\t\t\t<\/ul>\n\t\t\t<p><label>\u00bfHa le\u00eddo y est\u00e1 de acuerdo con el acuerdo de inscripci\u00f3n?<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"acceptance-941\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"acceptance-941\" value=\"1\" aria-invalid=\"false\"><span class=\"wpcf7-list-item-label\">De acuerdo<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"mb-8\">\n\t\t\t<\/div>\n\t\t\t<p>Si firmo como representante autorizado, significa que tengo el derecho legal de firmar seg\u00fan la ley estatal.\n\t\t\t<\/p>\n\t\t\t<p class=\"font-24\">Firma electr\u00f3nica\n\t\t\t<\/p>\n\t\t\t<div class=\"mb-12\">\n\t\t\t<\/div>\n\t\t\t<p class=\"font-22\">Escriba su nombre como firma electr\u00f3nica.\n\t\t\t<\/p>\n\t\t\t<div class=\"mb-8\">\n\t\t\t<\/div>\n\t\t\t<p><label>Nombre completo*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"text-esignature\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" id=\"text-esignature\" autocomplete=\"off\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-esignature\"><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"mb-24\">\n\t\t\t<\/div>\n\t\t\t<p><label for=\"date-esignature\">Fecha de hoy*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"date-esignature\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" id=\"date-esignature\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-esignature\"><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"cf7mls-btns \"><button type=\"button\" class=\"cf7mls_back action-button\" name=\"cf7mls_back\" id=\"cf7mls-back-btn-cf7mls_step-12\">Atr\u00e1s<\/button><button type=\"button\" class=\"cf7mls_next cf7mls_btn action-button\" name=\"cf7mls_next\" id=\"cf7mls-next-btn-cf7mls_step-12\">Continuar<img decoding=\"async\" src=\"https:\/\/elderplan0.wpengine.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" alt=\"Step Loading\" data-lazy-src=\"https:\/\/elderplan0.wpengine.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" style=\"display: none;\"><\/button><\/div><p><\/p><\/fieldset><fieldset class=\"fieldset-cf7mls\">\n\n<div class=\"form-layout\">\n\t<div class=\"screen-reader-response\">\n\t\t<p role=\"status\" aria-live=\"polite\">\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"form-sidebar\">\n\t\t<div data-id=\"group-extra-help\" data-orig_data_id=\"group-extra-help\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><span>Usted se est\u00e1 inscribiendo en el plan<\/span> <span>Elderplan Extra Help(HMO-POS)<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div data-id=\"group-plan-flex\" data-orig_data_id=\"group-plan-flex\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><span>Usted se est\u00e1 inscribiendo en el plan<\/span><span>Elderplan Flex(HMO-POS) Plan<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div data-id=\"group-plan-medicaid\" data-orig_data_id=\"group-plan-medicaid\" class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<h3 class=\"selected-plan-cf7\"><span>Usted se est\u00e1 inscribiendo en el plan<\/span><span>Elderplan For Medicaid Beneficiaries (HMO-POS D-SNP) Plan<\/span>\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div class=\"form-tracker\">\n\t\t\t<div class=\"step completed\">\n\t\t\t\t<p><i class=\"fa-solid fa-check\"><\/i> Elegibilidad\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step completed\">\n\t\t\t\t<p><i class=\"fa-solid fa-user\"><\/i> Informaci\u00f3n personal\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step completed\">\n\t\t\t\t<p><i class=\"fa-solid fa-file-lines\"><\/i> Inscripci\u00f3n\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"step in-progress\">\n\t\t\t\t<p><i class=\"fa-solid fa-magnifying-glass\"><\/i> Confirmaci\u00f3n\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"percentage\">\n\t\t\t<p><strong>95%<\/strong> completado\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"form-content\">\n\t\t<h2 class=\"font-50 mb-32 text-left-align\">Resumen\n\t\t<\/h2>\n\t\t<div class=\"mb-24\">\n\t\t<\/div>\n\t\t<div class=\"box\">\n\t\t\t<p class=\"font-18 mb-12\">Revise su solicitud antes de enviarla.\n\t\t\t<\/p>\n\t\t\t<p class=\"content-width mb-12\">Cuando haga clic en \u201cEnviar solicitud\u201d a continuaci\u00f3n, proporcione su firma electr\u00f3nica (o la firma electr\u00f3nica de su representante autorizado). Si un representante autorizado (tal como se describi\u00f3 anteriormente) firma la solicitud, esta firma electr\u00f3nica certifica lo siguiente:\n\t\t\t<\/p>\n\t\t\t<ol class=\"content-width\">\n\t\t\t\t<li>\n\t\t\t\t\t<p>Esta persona est\u00e1 autorizada seg\u00fan las leyes del estado donde vive para completar esta inscripci\u00f3n\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/li>\n\t\t\t\t<li>\n\t\t\t\t\t<p>La documentaci\u00f3n de esta autorizaci\u00f3n est\u00e1 disponible a solicitud de Medicare.\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/li>\n\t\t\t<\/ol>\n\t\t\t<div class=\"mb-24\">\n\t\t\t<\/div>\n\t\t\t<p class=\"mb-12\">Significa que ha le\u00eddo y comprendido la informaci\u00f3n de este formulario.\n\t\t\t<\/p>\n\t\t\t<p class=\"mb-12\">Tenga en cuenta que una vez que env\u00ede su solicitud, ya no podr\u00e1 hacer modificaciones en l\u00ednea.\n\t\t\t<\/p>\n\t\t\t<p class=\"mb-12\">Al enviar su solicitud de inscripci\u00f3n, usted:\n\t\t\t<\/p>\n\t\t\t<ul>\n\t\t\t\t<li>\n\t\t\t\t\t<p>Proporciona su firma electr\u00f3nica\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/li>\n\t\t\t\t<li>\n\t\t\t\t\t<p>Env\u00eda de su solicitud de inscripci\u00f3n de manera electr\u00f3nica\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/li>\n\t\t\t\t<li>\n\t\t\t\t\t<p>Acepta la contrataci\u00f3n en l\u00ednea a trav\u00e9s de Internet\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/li>\n\t\t\t\t<li>\n\t\t\t\t\t<p>Acepta recibir futuras comunicaciones nuestras en l\u00ednea a trav\u00e9s de Internet, incluido el correo electr\u00f3nico\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/li>\n\t\t\t\t<li>\n\t\t\t\t\t<p>Desea comprar un producto de Elderplan\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/li>\n\t\t\t\t<li>\n\t\t\t\t\t<p>Reconoce y est\u00e1 de acuerdo con las declaraciones anteriores\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/li>\n\t\t\t<\/ul>\n\t\t\t<div class=\"mb-24\">\n\t\t\t<\/div>\n\t\t\t<p class=\"font-bold content-width\">No ser\u00e1 inscrito hasta que se revise y acepte su solicitud.\n\t\t\t<\/p>\n\t\t\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Enviar solicitud\">\n\t\t\t<\/p>\n\t\t\t<p><a class=\"print-button-cf7\" id=\"print-enrollment-form-spanish\" href=\"#\">Imprimir una copia de mi solicitud<\/a>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"cf7mls-btns cf7mls-btns-last-step\"><button type=\"button\" class=\"cf7mls_back action-button\" name=\"cf7mls_back\" id=\"cf7mls-back-btn-cf7mls_step-13\">Atr\u00e1s<\/button><button type=\"button\" style=\"display: none;\" class=\"cf7mls_next cf7mls_btn action-button\" name=\"cf7mls_next\" id=\"cf7mls-next-btn-cf7mls_step-13\"><img decoding=\"async\" src=\"https:\/\/elderplan0.wpengine.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" alt=\"Step Loading\" data-lazy-src=\"https:\/\/elderplan0.wpengine.com\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" style=\"display: none;\"><\/button>\n<\/div><input type=\"hidden\" class=\"wpcf7-pum\" value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}'><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n\n<\/fieldset><\/div>\n\n<\/form><\/div>","protected":false},"excerpt":{"rendered":"{:en} Welcome to Online Enrollment! Let\u2019s get you to the right spot Elderplan For Medicaid Beneficiaries (HMO-POS D-SNP)$22.70 per monthSELECT THIS PLAN View Plan Materials Summary of Benefits \u2013 Elderplan [...]","protected":false},"author":21,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-37252","page","type-page","status-publish","hentry"],"translation":{"provider":"WPGlobus","version":"3.0.0","language":"es","enabled_languages":["en","es","zh"],"languages":{"en":{"title":true,"content":true,"excerpt":false},"es":{"title":true,"content":true,"excerpt":false},"zh":{"title":true,"content":true,"excerpt":false}}},"acf":[],"jetpack_sharing_enabled":true,"publishpress_future_action":{"enabled":false,"date":"2026-04-11 19:25:47","action":"change-status","newStatus":"draft","terms":[],"taxonomy":"category","extraData":[]},"publishpress_future_workflow_manual_trigger":{"enabledWorkflows":[]},"_links":{"self":[{"href":"https:\/\/elderplan0.wpengine.com\/es\/wp-json\/wp\/v2\/pages\/37252","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/elderplan0.wpengine.com\/es\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/elderplan0.wpengine.com\/es\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/elderplan0.wpengine.com\/es\/wp-json\/wp\/v2\/users\/21"}],"replies":[{"embeddable":true,"href":"https:\/\/elderplan0.wpengine.com\/es\/wp-json\/wp\/v2\/comments?post=37252"}],"version-history":[{"count":0,"href":"https:\/\/elderplan0.wpengine.com\/es\/wp-json\/wp\/v2\/pages\/37252\/revisions"}],"wp:attachment":[{"href":"https:\/\/elderplan0.wpengine.com\/es\/wp-json\/wp\/v2\/media?parent=37252"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}