Tip for Plan-specific (CMS model template)

You must have Medicare Part A and Part B to enroll in a Medicare Advantage plan

Tip for Plan-specific (CMS model template)

Compare plans carefully — networks, formularies, and out-of-pocket costs vary significantly

Tip for Plan-specific (CMS model template)

Check that your doctors and preferred hospitals are in the plan's network

Medicaremoderate

Medicare Advantage Enrollment

Plan-specific (CMS model template) · CMS

Model enrollment form for Medicare Advantage or Part D prescription drug plans. Plans customize the CMS template but must include all required elements.

Form Details

Total fields: 40
Auto-fillable: 30 (75%)
Time without BeneFill: 30 minutes
Time with BeneFill: 8 minutes
Time saved: 22 minutes
Filled by: patient
Frequency: annual

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Where to Submit This Form

🌐

Medicare.gov Plan Finder (recommended)

https://www.medicare.gov/plan-compare/

Compare and enroll in Medicare Advantage plans online.

📬

Mail the completed enrollment form to the plan

Each MA plan provides its own enrollment form.

🏢

Through a licensed Medicare insurance agent or at a plan enrollment event

Filing Deadline

Initial Enrollment Period: 3 months before to 3 months after your 65th birthday. Annual Enrollment: Oct 15 - Dec 7. Open Enrollment: Jan 1 - Mar 31 (switch MA plans only).

Required Attachments

📎 Medicare Part A and Part B card or number
📎 Completed plan enrollment form with personal information
📎 Current prescription drug list (for plan comparison)

Processing Time

Plans must process enrollment within 14 days. CMS confirms enrollment and sends materials before coverage start date.

What Happens Next

You will receive a plan membership card and Evidence of Coverage document. Coverage typically starts the first of the month after enrollment is processed.

Tips for This Form

✓ You must have Medicare Part A and Part B to enroll in a Medicare Advantage plan
✓ Compare plans carefully — networks, formularies, and out-of-pocket costs vary significantly
✓ Check that your doctors and preferred hospitals are in the plan's network
✓ Review the plan's formulary to ensure your medications are covered at a reasonable tier

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Medicare Advantage Disenrollment

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Request to disenroll from a Medicare Advantage or Part D plan and return to Original Medicare. Available during applicable enrollment periods.

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the CMS or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.