Online Enrollment

Mass General Brigham Health Plan 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)

BROKERS: Please do not submit enrollments using this form. If unsure how to submit enrollments, please check with your FMO or email healthplanmedicarebrokers@mgb.org

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 marked required. Items that are not marked as required 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), 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.

What happens next?

Once you submit this online application, you will receive a letter from Mass General Brigham Health Plan notifying you of the outcome of your request within 7-10 business days. If approved, you will join the plan and will become an active member on your effective date.

How do I get help with this form?

Call Mass General Brigham Health Plan at 855-486-3097 (TTY: 711).
Or, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.
En español: Llame a Mass General Brigham Health Plan al 855-486-3097 (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.

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.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1378. The time required to complete this information is estimated to average 20 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. IMPORTANT Do not send this form or any items with your personal information (such as claims, payments, medical records, etc.) to the PRA Reports Clearance Office. Any items we get that aren’t about how to improve this form or its collection burden (outlined in OMB 0938-1378) will be destroyed. It will not be kept, reviewed, or forwarded to the plan. See “What happens next?” on this page to send your completed form to the plan.

IMPORTANT—Read and sign below:

I must keep both Hospital (Part A) and Medical (Part B) to stay in Mass General Brigham Health Plan.
By joining this Medicare Advantage plan, I acknowledge that Mass General Brigham Health Plan will share my information with Medicare, who may use it to track my enrollment, to make payments, and for other purposes allowed by Federal law that authorize the collection of this information (see Privacy Act Statement below). Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan.
I understand that I can be enrolled in only one MA plan at a time—and that enrollment in this plan will automatically end my enrollment in another MA plan (exceptions apply for MA PFFS, MA MSA plans).
I understand that when my Mass General Brigham Health Plan coverage begins, I must get all of my medical and prescription drug benefits from Mass General Brigham Health Plan. Benefits and services provided by Mass General Brigham Health Plan and contained in my Mass General Brigham Health Plan “Evidence of Coverage” document (also known as a member contract or subscriber agreement) will be covered. Neither Medicare nor Mass General Brigham Health Plan will pay for benefits or services that are not covered.
The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan.
I understand that my signature (or the signature of the person legally authorized to act on my behalf) on this application means that I have read and understand the contents of this application. If signed by an authorized representative (as described above), this signature certifies that:
1) This person is authorized under State law to complete this enrollment, and
2) Documentation of this authority is available upon request by Medicare.

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Medicare Advantage Online Enrollment

Mass General Brigham Health Plan Online Enrollment

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Medicare Advantage Online Enrollment

Mass General Brigham Health Plan Online Enrollment

Welcome,

Your plan options

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IMPORTANT—Read and sign below:

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