The 2025 Annual Enrollment Period runs October 15 through December 7. You can change your plan during this time. You can only change your plan outside of the Annual Enrollment Period if you have a Special Enrollment Period.
Change your plan by clicking the "Start New Form" button at the bottom of this page to fill out an online enrollment form.
By completing this process, you’ll be submitting an actual change to your plan. If you need help with this form, call 866-623-1855.
You can also fill out our Change Form and mail it to us at,
Network Health Insurance Corporation
Attn: Medicare Advantage Plans
1570 Midway Pl.
Menasha, WI, 54952
Find benefit and cost information in our 2025 Medicare Advantage Summary of Benefits documents below. And, see our Star Rating Information (Every year, Medicare evaluates plans based on a 5-star rating system.) See Network Health Prime (MSA) Star Rating.
2025 Northeast Medicare Advantage PPO Plans Summary of Benefits
2025 Southeast Medicare Advantage PPO Plans Summary of Benefits
2025 Network Health Cares PPO D-SNP Summary of Benefits
2025 Network Health Prime MSA Summary of Benefits
Medicare beneficiaries may also enroll in Network Health Medicare Advantage Plans through the CMS Medicare Online Enrollment Center located at Medicare.gov.
ENROLLMENT REQUEST FORM TO ENROLL IN A MEDICARE ADVANTAGE PLAN
Who can use this form?
People with Medicare who want to join a Medicare Advantage Plan
To join a plan, you must:
Important: To join a Medicare Advantage plan, you must also have both:
When do I use this form?
You can join a plan:
Visit Medicare.gov to learn more about when you can sign up for a plan.
What do I need to complete this form?
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:
What happens next?
Send your completed and signed form to:
Network Health
Attn: Medicare Enrollment
1570 Midway Pl.,
Menasha, WI 54952
Once we process your request to join, we’ll contact you.
How do I get help with this form?
Call Network Health Medicare Advantage Plans at 800-983-7587. TTY users can call 800-947-3529. Or, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.
En español: Llame a Network Health Medicare Advantage Plan al 800-983-7587 (TTY 800-947-3529) 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: 6/30/2026
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.
PRIVACY ACT STATEMENT The Centers for Medicare & Medicaid Services (CMS) collects information from Medicare plans to track beneficiary enrollment in Medicare Advantage (MA) Plans, improve care, and for the payment of Medicare benefits. Sections 1851 and 1860D-1 of the Social Security Act and 42 CFR §§ 422.50 and 422.60 authorize the collection of this information. CMS may use, disclose and exchange enrollment data from Medicare beneficiaries as specified in the System of Records Notice (SORN) “Medicare Advantage Prescription Drug (MARx)”, System No. 09-70-0588. Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan.