Enroll Now

The Medicare annual enrollment period runs from October 15 through December 7. Start the online enrollment process below. By completing this process, you will submit an actual enrollment application. To enroll with the help of a licensed representative please call 866-627-4164 or email [email protected] You may also print and fill out an Enrollment Form. Send your completed enrollment application to Network Health, Attn: Medicare Enrollment, 1570 Midway Pl., Menasha, WI, 54952.

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For 2023 Enrollment

2023 Northeast Medicare Advantage PPO Plans
2023 Southeast Medicare Advantage PPO Plans
2023 NetworkPrime (MSA) Individual Enrollment Request Form

For 2022 Enrollment

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:

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 through 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 www.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.

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?
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 800-947-3529). Or, call Medicare at 1-800-MEDICARE (1-800-633-4227) (TTY 1-877-486-2048).

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View the Medicare Advantage Summary of Benefits for benefit and cost information. See our 2023 Star Rating Information for Network Health PPO Medicare Advantage Plans, Network Prime (MSA) and Network Health Medicare Explore (HMO). (Medicare evaluates plans based on a Five-Star rating system. Star Ratings are calculated each year and may change from one year to the next).

Medicare beneficiaries may also enroll in Network Health through the CMS Medicare Online Enrollment Center located at https://www.medicare.gov. Please contact Network Health Medicare Advantage Plans if you need information in another language or format.

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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.

Medicare Plans

Enroll Now

For 2023 Enrollment

For 2022 Enrollment