Online Enrollment

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 Section 1.
The items in Section 2 are optional - you can't be denied coverage because you don't fill them out.

Individuals experiencing homelessness

If you want to join a plan but have no permanent residence, a Post Office Box, an address of a shelter or clinic, or the address where you receive mail (e.g., social security checks) may be considered your permanent residence address.

Reminders:

If you want to join a plan during fall open enrollment (October 15-December 7), the plan must get your completed form by December 7.
Your plan 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.

How do I get help with this form?
Call PrimeTime Health Plan at 1-800-577-5084.
TTY users can call 711.

Or, call Medicare at 1-800-MEDICARE
(l-800-633-4227). TTY users can call 1-877-486-2048.

En español: Llame a PrimeTime Health Plan al
1-800-577-5084 / TTY 711 o a Medicare
gratis al 1-800-633-4227 y oprima el 8 para asistencia
en español y un representante estará disponible para asistirle.

2025 Online Enrollment