OMB No. 0938-1378
Expires 7/31/2023

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What is the election period you are enrolling in? And when would you like coverage to start?


Please select your election period.
Please select an effective start month.
mm/dd/yyyy


Typically, you may enroll in a Medicare Advantage plan only during the Annual Enrollment Period (AEP) from Oct. 15 – Dec. 7 of each year. However, some exceptions may allow you to enroll in a Medicare Advantage plan outside of the AEP. Please read the following statements carefully, and check the box next to the one that applies to you.


Please click the Click for more info next to the statements below for additional information about any of the criteria listed. By checking any of the following boxes below you are certifying that, to the best of your knowledge, you are eligible for an Enrollment Period. If we later determine that this information is incorrect, you may be disenrolled.


I am new to Medicare. Click for more info
I am enrolled in a Medicare Advantage Plan and want to make a change during the Medicare Advantage Open Enrollment Period (MA OEP). Click for more info
I currently have a Medicare plan and want to enroll under the 5-Star SEP in this Medicare Advantage plan with a 5-Star Rating during the same year as my enrollment. I can use this SEP only one time a year. Effective dates are the 1st of the month from Jan.1-Dec.1, during the year of the plan’s 5-Star Rating designation. Click for more info
I recently moved outside of the service area for my current plan or I recently moved and this plan is a new option for me. I moved on: Click for more info
I recently was released from Incarceration. I was released on: Click for more info
I recently returned to the United States after living permanently outside of the U.S. I returned to the U.S. on: Click for more info
I recently obtained lawful presence status in the United States. I got this status on: Click for more info
I recently had a change in my Medicaid (newly got Medicaid, had a change in level of Medicaid assistance, or lost Medicaid) on: Click for more info
I recently had a change in my Extra Help paying for Medicare prescription drug coverage (newly got Extra Help, had a change in the level of Extra Help, or lost Extra Help) on: Click for more info
I have both Medicare and Medicaid (or my state helps pay for my Medicare premiums) or I get Extra Help paying for my Medicare prescription drug coverage, but I haven’t had a change. Click for more info
I am moving into, live in, or recently moved out of a Long-Term Care Facility (for example, a nursing home or long term care facility). I moved/will move into/out of the facility on: Click for more info
I recently left a PACE program on: Click for more info
I recently involuntarily lost my creditable prescription drug coverage (coverage as good as Medicare’s). I lost my drug coverage on: Click for more info
I am leaving employer or union coverage on: Click for more info
I belong to a pharmacy assistance program provided by my state. Click for more info
My plan is ending its contract with Medicare, or Medicare is ending its contract with my plan. Click for more info
I was enrolled in a plan by Medicare (or my state) and I want to choose a different plan. My enrollment in that plan started on: Click for more info
I was enrolled in a Special Needs Plan (SNP) but I lost the special needs qualification required to be in that plan. I was disenrolled from the SNP on: Click for more info
I was affected by a weather-related emergency of major disaster (as declared by the Federal Emergency Management Agency (FEMA). One of the other statements here applied to me, but I was unable to make my enrollment because of the natural disaster. Click for more info


ATTENTION: You are enrolling in a 2022 plan. Your enrollment effective dates are as follows:
Election Period Effective Date of Coverage
Annual Election Period (AEP) (October 15 – December 7) January 1 of the following year
New to Medicare (Initial Coverage Election Period - ICEP) – If you’re new to Medicare, you can join during the period that starts three months before the month you get Medicare, and ends three months after you get Medicare. If you enroll during the first 3 months before the month you get Medicare—your effective date is the 1st day of the month you get Medicare.
If you enroll during or after the month you get Medicare, your effective date will be the 1st of the month following the month you enrolled in your Medicare plan.
Open Enrollment Period (OEP) (January 1 – March 31) – An MA-PD enrollee may use the OEP to switch to: (1) another MA-PD plan; (2) and MA-only plan; or (3) Original Medicare with or without a PDP.
An MA-only enrollee may use the OEP to switch to - (1) another MA-only plan; (2) an MA-PD plan; or (3) Original Medicare with or without a PDP.
Varies, generally the 1st of the following month
Open Enrollment Period for Institutionalized Individuals (OEPI) – The OEPI is continuous for institutionalized individuals. For purposes of enrollment under the OEPI election period, an institutionalized individual is defined as an individual who moves into, resides in, or moves out of an institution. The OEPI ends two months after the month the individual moves out of the institution. Varies, generally the 1st of the following month
Special Election Period (SEP) Varies, generally the 1st of the following month



Effective Date: 01/01/2022
H5262_21 124_C CMS ACCEPTED 07/29/2021
GH00569UW (0721)