One Care Logo    One Care Online Enrollment Form

This form can be used to:

1. Sign up for a new One Care Plan OR;
2. Move from the One Care Plan you have now to a different One Care Plan, if available.

Please Note: If you would like to disenroll or opt-out of your One Care Plan, please call the MassHealth Customer Service Center at 1-800-841-2900 or TTY:1-800-497-4648 for assistance.

Step 1: Enter Your Member Information

Please Indicate the best time to reach you.

Step 2: Choose Your One Care Plan

To join One Care or change One Care Plans: Select the plan you would like to join from the drop-down below. For more information on One Care Plan options,Click Here

Step 3: Tell Us If You Have Other Health Care Coverage

Some people have other health insurance or drug coverage through private insurance, TRICARE, employers, unions, Veterans Affairs, or the State Pharmaceutical Assistance Program.
Do you have other health coverage besides MassHealth and Medicare?
Yes No
Name Of Your Plan Individual ID Number Group Number
Plan 1
Plan 2

Step 4: Please Review this Important Information

Please review this important information prior to submitting the form.

When you sign this form, it means that you understand the following:

* One Care Plans have a contract with the federal government and with Massachusetts.
* The health services I get with my new plan may be different than the services I had before.
* I must keep Medicare Part A, Part B and MassHealth.
* I can be in only one Medicare Plan at a time.
* By joining a One Care Plan I will end my enrollment in another Medicare health or presciption drug plan.
* I must tell Medicare and MassHealth about any prescription drug coverage that I have or may get in the future.
* If I move, I need to tell MassHealth.
* As a member of a One Care Plan, I have the right to appeal if I don’t agree with my One Care Plan’s decisions about payment or services.
* The One Care Plans do not usually cover people while they’re out of the country.

* On the date my One Care Plan coverage begins, I will have access to my current doctors for 90 days.

Beyond 90 days, I must get my health care from my One Care Plan's providers and pharmacies, except for emergency or urgently needed care, out of area dialysis, or if I get my One Care Plan's approval to see other providers in some circumstances.

My One Care Plan will help me find new providers if I need them.

* If I need to see a doctor or other provider who is not in my One Care Plan, I may need prior authorization or I may have to pay out-of-pocket for the services I get.
* I understand that if a sales agent employed by the One Care Plan helps me enroll, the One Care Plan may pay that person.
* By joining a One Care Plan, I know that the One Care Plan may share my information with Medicare and MassHealth and other plans as necessary for treatment, payment, and health care operations.
* I understand that prescription drugs are covered, but not always the same ones I’m already taking. I understand that I’ll have access to my current drugs for at least 30 days, until I can switch to a different drug.
* I know that my One Care Plan may share my information, including my prescription drug information, with Medicare and MassHealth.

They may release it for research and other purposes, as allowed by federal or state statutes and regulations.

* The information on this form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I’ll be disenrolled from my One Care Plan.
* My signature (or my authorized representative’s signature) on this form means that I’ve read and understood this form.

If an authorized representative signs, the person’s signature means that he or she is authorized under state law to complete this enrollment,
and documentation of this authority is available upon request from Medicare and/or MassHealth.

* Estate Recovery Awareness: MassHealth is required by federal law to recover money from the estates of certain MassHealth members who are age 55 years or older, and who are any age and are receiving long-term care in a nursing home or other medical institution. For more information about MassHealth estate recovery, please visit

By selecting this check box, I attest that I've read and understood this form.

Step 5: Sign and Submit the Form

Please Indicate Your relationship to the MassHealth One Care enrollee.

Authorized Representative

Submit Cancel