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Enroll into Central Health Medicare Plan

Where do you live?

Which of the following best describes you?

Which of the following best describes your situation?

When would you like your coverage to start?

Please note that your effective date may depend on your election
By clicking “Next”, you will begin completing an Individual Enrollment Request Form to Enroll in a Medicare Advantage Plan (Part C).

Who can use this form?

People with Medicare who want to join a Medicare Advantage Plan

To join a plan, you must:

  • Be a United States citizen or be lawfully present in the U.S.
  • Live in the plan’s service area

Important: To join a Medicare Advantage Plan, you must also have both:

  • Medicare Part A (Hospital Insurance)
  • Medicare Part B (Medical Insurance)

When do I use this form?

You can join a plan:

  • Between October 15–December 7 each year (for coverage starting January 1)
  • Within 3 months of first getting Medicare
  • In certain situations where you’re allowed to join or switch plans

Visit Medicare.gov to learn more about when you can sign up for a plan.

What do I need to complete this form?

  • Your Medicare Number (the number on your red, white, and blue Medicare card)
  • Your permanent address and phone number

Note: You must complete all items in sections marked “Required.” All other sections are optional – you can’t be denied coverage because you don’t fill them out.

Reminders:

  • If you want to join a plan during fall open enrollment (October 15–December 7), we must get your completed form by December 7.
  • We will send you a bill for the plan’s premium. You can choose to sign up to have your premium payments deducted from your bank account or your monthly Social Security (or Railroad Retirement Board) benefit.

What happens next?

Once we receive your electronic enrollment request, we will contact you.

How do I get help with this form?

Call Central Health Medicare Plan at 1-866-314-2427. TTY users can call 711. Or, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

En español: Llame a Central Health Medicare Plan al 1-866-314-2427. Usuarios TTY: 711.

o a Medicare gratis al 1-800-633-4227 y oprima el 2 para asistencia en español y un representante estará disponible para asistirle


OMB No. 0938-1378
Expires: 7/31/2023


What is OEP?
If you are enrolled in a Medicare Advantage plan as of January 1, 2021, you can make one (1) election during the first three (3) months of the calendar year (January 1 - March 31) to switch MA plans or to disenroll from an MA plan and obtain coverage through Original Medicare. If you are in an MA plan, you can use the MA OEP to add or drop Part D coverage. Newly eligible beneficiaries who enrolled in an Medicare Advantage plan during their Initial Coordinated Election Period (ICEP) can also make one election to switch or drop MA coverage during the first three (3) months they have Medicare Parts A and B.
What is AEP?
The Annual Open Enrollment Period (AEP) is when Medicare beneficiaries can add, change, or drop their Medicare Part D or Medicare Advantage plan coverage for the next year. The AEP starts on October 15th and continues through December 7th of each year with coverage or plan changes taking effect on January 1st of the New Year.
I am new to Medicare
If you are newly eligible for both Medicare Part A and Part B, you can join a Medicare Advantage Plan during the 7-month period, which starts 3 months before the month you are eligible for Medicare Part A and Part B and ends 3 months after your Medicare Part A and Part B becomes effective. This is true if you are eligible for Medicare because of age or disability. If you already have Part A and are now adding Part B, you may enroll in a Medicare Advantage plan during the 3 months prior to the month your Part B coverage begins. If you apply before your Medicare starts, the Medicare Advantage coverage will start on the same day as your Medicare. If you apply after your Medicare starts, your Medicare Advantage coverage will start on the first day of the month after your plan receives the application for enrollment.