You can enroll by phone, online or through the mail.
You can also visit Medicare.gov, the official U.S. government site for Medicare.
You are completing a 2021 Online Enrollment Request to Golden State Medicare Health Plan.
Online Enrollment (Step 1 of 6)
Who can use this online enrollment 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 online enrollment form?
You can join a plan:
- Between October 15–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 Medicare.gov to learn more about when you can sign up for a plan.
What do I need to complete this online enrollment 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 online enrollment 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.
Online Enrollment (Step 2 of 6)
Section 1 – All fields on this page are required (unless marked optional)
Online Enrollment (Step 3 of 6)
Online Enrollment (Step 4 of 6)
IMPORTANT: Read and sign below:
- I must keep both Hospital (Part A) and Medical (Part B) to stay in Golden State Medicare Health Plan.
- By joining this Medicare Advantage Plan, I acknowledge that Golden State Medicare Health Plan will share my information with Medicare, who may use it to track my enrollment, to make payments, and for other purposes allowed by Federal law that authorize the collection of this information (see Privacy Act Statement below).
- Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan.
- The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan.
- I understand that people with Medicare are generally not covered under Medicare while out of the country, except for limited coverage near the U.S. border.
- I understand that when my Golden State Medicare Health Plan coverage begins, I must get all of my medical and prescription drug benefits from Golden State Medicare Health Plan. Benefits and services provided by Golden State Medicare Health Plan and contained in my Golden State Medicare Health Plan “Evidence of Coverage” document (also known as a member contract or subscriber agreement) will be covered. Neither Medicare nor Golden State Medicare Health Plan will pay for benefits or services that are not covered.
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I understand that my signature (or the signature of the person legally authorized to act on my behalf) on this application means that I have read and understand the contents of this application. If signed by an authorized representative (as described above), this signature certifies that:
- This person is authorized under State law to complete this enrollment, and
- Documentation of this authority is available upon request by Medicare.
If you are the authorized representative, you must check above and provide the following information:
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.
Online Enrollment (Step 5 of 6)
Section 2 – All fields on this page are optional
Online Enrollment (Step 6 of 6)
Attestation Of Eligibility For An Enrollment Period
Please read the following statements carefully and check the box if the statement applies to you. By checking any of the following boxes 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.
Thank you for enrolling in Golden State Medicare Health Plan !
at (877) 541-4111 (TTY: 711) 8:00 AM to 8:00 PM
7 days a week from October 1 - March 31, and Monday - Friday from April 1 - September 30.
We were unable to enroll now.
For questions or assistance completing the enrollment form, please call Golden State Medicare Health Plan Member Services, toll-free at 1-877-541-4111 (TTY: 711) 8 AM to 8 PM, 7 days a week from October 1 - March 31, and Monday - Friday from April 1 - September 30.
Or, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.
Medicare beneficiaries may also enroll in Golden State Medicare Health Plan through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.
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