MassHealth Medicare Advantage Enrollment Form 2024
This file is the 2024 MassHealth Medicare Advantage Enrollment Form provided by Commonwealth Care Alliance. It includes essential instructions and details for eligible participants. Ensure to complete this form accurately to join a Medicare Advantage plan.
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How do I fill this out?
To fill out the form, gather your personal information including your MassHealth and Medicare numbers. Carefully read each section and provide the required details accurately. Make sure to sign and date the form before submission.
How to fill out the MassHealth Medicare Advantage Enrollment Form 2024?
1
Gather necessary personal information such as your MassHealth Number and Medicare Number.
2
Carefully read the instructions provided on the form.
3
Fill in all required fields in Section 1.
4
Complete optional fields in Section 2 if desired.
5
Sign and submit the completed form to the designated address.
Who needs the MassHealth Medicare Advantage Enrollment Form 2024?
1
Individuals aged 65 or older who have MassHealth Standard benefits and wish to enroll in CCA Health SCO Program.
2
New Medicare recipients seeking guidance on enrollment options.
3
Residents of Massachusetts looking for Medicare Advantage plans with no premium.
4
Individuals eligible for MassHealth who need assistance navigating health care enrollment.
5
Those wishing to change or switch their current Medicare Advantage plans.
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What are the instructions for submitting this form?
To submit this form, send it to Commonwealth Care Alliance at 30 Winter Street, Boston, MA 02108. You can also fax the completed form to the provided fax number on the form. For additional information or submissions, contact CCA by calling 855-210-1790.
What are the important dates for this form in 2024 and 2025?
The important dates for the 2024 MassHealth Medicare Advantage Enrollment are from October 15 to December 7, with the deadline for submission being December 7. Ensure your enrollment forms are submitted by this date to start coverage on January 1, 2024.
What is the purpose of this form?
The purpose of the MassHealth Medicare Advantage Enrollment Form is to provide a comprehensive application process for individuals seeking to enroll in a Medicare Advantage plan. It ensures that all necessary information is collected to determine eligibility for specific healthcare programs. By completing this form accurately, individuals can gain access to essential medical services under the MassHealth program.
Tell me about this form and its components and fields line-by-line.
- 1. Last Name: Your family name as registered with Medicare.
- 2. First Name: Your given name as registered with Medicare.
- 3. Birth Date: Your date of birth formatted as MM/DD/YYYY.
- 4. Sex: Your gender designation selected from Male or Female.
- 5. Permanent Address: Your residential address where you receive mail.
- 6. Mailing Address: Your P.O. Box or alternate mailing address.
- 7. MassHealth Number: Your 12-digit MassHealth identification number.
- 8. Medicare Number: Your Medicare identification number from your card.
What happens if I fail to submit this form?
Failing to submit this form may result in a delay or denial of your healthcare coverage. It is vital to adhere to the specified deadlines to ensure timely enrollment in necessary programs. Additionally, missing information could compromise the processing of your application.
- Delayed Coverage: Failure to submit by the deadline may delay your enrollment in Medicare Advantage.
- Loss of Benefits: Not submitting on time could lead to a lapse in healthcare benefits.
- Inaccurate Information: Incomplete forms may cause processing errors, impacting your eligibility.
How do I know when to use this form?
- 1. Open Enrollment Period: You can enroll between October 15 and December 7 each year.
- 2. New Medicare Beneficiaries: Use it within 3 months of first receiving Medicare.
- 3. Special Situations: You may be allowed to enroll due to specific qualifying events.
Frequently Asked Questions
What is the purpose of this form?
This form is for individuals applying for the MassHealth Medicare Advantage plan.
How can I edit this PDF?
You can edit this PDF directly within PrintFriendly’s PDF editor.
How do I submit the completed form?
Send the completed form to Commonwealth Care Alliance at the address provided in the form.
Who can fill out this form?
Individuals aged 65 or older with MassHealth Standard benefits qualify.
What documents do I need for this application?
You will need your MassHealth Number and Medicare Number.
Can I print the form after editing?
Yes, you can print the edited form directly from PrintFriendly.
What is the contact number for assistance?
For help, call CCA at 855-210-1790.
What happens if I make a mistake on the form?
You can edit the form again before submission.
Is there a deadline for submitting this form?
Yes, submissions must be completed by December 7 for fall open enrollment.
Do I need a signature to submit the form?
Yes, your signature is required for valid submission.
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