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Eligibility Information & Enrollment Instructions

To be eligible for Medicare Advantage, you must be entitled to Medicare benefits under Part A or enrolled in Part B and reside in New Jersey.

Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center.

The Centers for Medicare & Medicaid Services (CMS) created the Best Available Evidence (BAE) policy to address incorrect low subsidy/extra help cost sharing data in the electronic data systems of CMS. Horizon will comply with the BAE policy when situations arise that result in incorrect low income subsidy/cost sharing data at the point of sale. This policy requires Horizon to update our internal systems to reflect the correct cost sharing subsidy for the beneficiary when presented with evidence that the information showing the beneficiary to be ineligible is not correct.

More information on the CMS BAE policy can be found at

Enrollment Instructions

  1. If you prefer not to enroll online, download and print the Enrollment Form in the Enrollment Form section for your preferred plan. Please complete the form, writing as clearly as you can. The most common errors are from hard–to–read handwriting. Carefully print your answers in the boxes provided.
  2. Have this important information available:
    • Your Medicare card.
    • Your Medicaid program number, if you have one.
    • Your health insurance card(s) for any other insurance you carry besides Medicare and/or Medicaid. You can only enroll in one plan. Please be sure to clearly indicate which plan you wish to enroll in at the top of the form.
  3. Clearly and accurately provide all of the requested personal information. Make sure your birthday matches what is on file with Medicare and Social Security. If it does not match, your form will be denied. Make sure you accurately copy the information from your Medicare card.
  4. Clearly mark how you want to pay for your plan. If you forget to fill in one of the boxes in this section, Horizon BCBSNJ will send you a bill every month. Also, be sure to read the information that is titled "Paying Your Plan Premium" as this contains useful information about how to get help paying for your plan should you need it.
  5. In the section titled "Attestation of Eligibility for an Enrollment Period," please read the options and fill in the box that describes your situation. This section is significant. Horizon BCBSNJ determines which enrollment period is appropriate by the information and answers you provide in this section.
  6. Do not enter any information in "Agent Use Only" section.
  7. Please double– and triple–check that what you write on the form is correct and written clearly. It saves time in the long run. Do not forget to sign and date your enrollment form before mailing it back.

Mail the form to:
Horizon Blue Cross Blue Shield of New Jersey
PO Box 10138
Newark, New Jersey 07101-9633

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