Enrollment Form and Instructions

Enrollment Form:

Individual Enrollment Forms - Use this form to enroll in the HNE Medicare Advantage Plan for the first time.

• 2016 Massachusetts Individual Enrollment Form
• 2016 Connecticut Individual Enrollment Form

Eligibility Requirements

You may be eligible to enroll in an HNE Medicare Advantage Plan if you are enrolling during a valid election period and:

• You are entitled to Medicare Part A and are enrolled in Medicare Part B
• You live in our service area
• You do not have End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant), with limited exceptions, such as if you develop ESRD when you are already a member of a plan that we offer, or you were a member of a different plan that was terminated. If you had ESRD but no longer require regular dialysis or have had a successful kidney transplant, you would not be considered to have ESRD any longer. In this case, you should send us a doctor’s note or records showing that the ESRD status has changed and you may be eligible for enrollment.

Eligible individuals may enroll in an HNE Medicare Advantage Plan only at certain times of the year. To obtain more information on enrollment periods, please click on here for Key Enrollment Dates, or call Member Services at one of the numbers listed below.

Once you are enrolled in an HNE Medicare Advantage Plan, you must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third-party.

Enrollment Instructions:

Click for detailed Enrollment Instructions. If you would like a printed copy of the enrollment form or instructions or to request an alternative format, please call Member Services at one of the numbers listed below.

Interpreter Services Are Available:

IMPORTANT REMINDER: We have free interpreter services to answer any questions you may have about our health or drug plan.

Click for Multi-Language Interpreter Services.

Enroll On-line:

You may enroll in an HNE Medicare Advantage Plan on-line simply by clicking: Enroll Now

Medicare beneficiaries may also enroll in HNE Medicare Advantage through the CMS Online Enrollment Center located at http://www.medicare.gov

H8578_2016_049 Approved
The information on this page was last updated on 2/18/2016