APPLICATION FOR ENROLLMENT IN MEDICARE PART B (MEDICAL INSURANCE)

Transcript

1 Form Approved DEPARTMENT OF HEALTH AND HUMAN SERVICES OMB No. 0938-1230 CENTERS FOR MEDICARE & MEDICAID SERVICES Expires: 02/20 APPLICATION FOR ENROLLMENT IN MEDICARE PART B (MEDICAL INSURANCE) WHAT HAPPENS NEXT? WHO CAN USE THIS APPLICATION? People with Medicare who have Part A but not Part B Send your completed and signed application to your local Social Security office. If you sign up in a SEP, include the If you do NOTE: complete this form. not have Part A, do not CMS-L564 with your Part B application. If you have questions, Contact Social Security if you want to apply for Medicare for TTY users should call . 1-800-772-1213 call Social Security at the first time. 1-800-325-0778. WHEN DO YOU USE THIS APPLICATION? HOW DO YOU GET HELP WITH THIS Use this form: APPLICATION? Initial Enrollment Period (IEP) and live in • If you’re in your Phone: . 1-800-772-1213 Call Social Security at • TTY users Puerto Rico . You must sign up for Part B using this form. should call 1-800-325-0778. refused Part B or did not sign up and IEP • If you’re in your y oprima • En español: Llame a SSA gratis al 1-800-772-1213 when you applied for Medicare, but now want Part B. el 2 si desea el servicio en español y espere a que le • If you want to sign up for Part B during the General atienda un agente. Enrollment Period (GEP) from January 1 – March 31 • In person: Your local Social Security office. For an office each year. near you check www.ssa.gov . • If you refused Part B during your IEP because you had group health plan (GHP) coverage through your or your spouse’s current employment. You may sign up during REMINDERS your 8-month Special Enrollment Period (SEP). • If you sign up for Part B, you must pay premiums for • If you have Medicare due to disability and refused Part every month you have the coverage. B during your IEP because you had group health plan If you sign up after your IEP, you may have to pay a late • coverage through your, your spouse or family member’s enrollment penalty (LEP) of 10% for each full 12-month current employment. period you don’t have Part B but were eligible to sign up. You may sign up during your 8-month SEP. • NOTE: Your IEP lasts for 7 months. It begins 3 months before your 65th birthday (or 25th month of disability) and ends 3 months after you reach 65 (or 3 months after the 25th month of disability). WHAT INFORMATION DO YOU NEED TO COMPLETE THIS APPLICATION? You will need: • Your Medicare Number Your current address and phone number • • Form CMS-L564 ”Request for Employment Information” if you’re signing up in a SEP . completed by your employer p rint, Braille, or a udio. You also have the You have the right to get Medicare information in an accessible format, like l arge to a complaint if you feel you’ve been discriminated against. Visit right https://www.medicare.gov/about-us/accessibility- file nondiscrimination-notice, or call 1-800-MEDICARE (1-800-633-4227) for more information. TTY users can call 1-877-486-2048. 1 CMS-40B (04/1 9 )

2 Form Approved DEPARTMENT OF HEALTH AND HUMAN SERVICES OMB No. 0938-1230 CENTERS FOR MEDICARE & MEDICAID SERVICES Expires: 02/20 APPLICATION FOR ENROLLMENT IN MEDICARE PART B (MEDICAL INSURANCE) 1. Your Medicare Number YES 2. Do you wish to sign up for Medicare Part B (Medical Insurance)? 3. Your Name (Last Name, First Name, Middle Name) 4. Mailing Address (Number and Street, P.O. Box, or Route) Zip Code 5. City State 6. Phone Number (including area code) ( ) – 8. Date Signed 7. Written Signature (DO NOT PRINT) SIGN HERE / / IF THIS APPLICATION HAS BEEN SIGNED BY MARK (X), A WITNESS WHO KNOWS THE APPLICANT MUST SUPPLY THE INFORMATION REQUESTED BELOW. 10. Date Signed 9. Signature of Witness / / 11. Address of Witness 12. Remarks According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1230. The time required to complete this information is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. CMS-40B (04/1 9 ) 2

3 Form Approved OMB No. 0938-1230 Expires: 02/20 SPECIAL MESSAGE FOR INDIVIDUAL APPLYING FOR PART B This form is your application for Medicare Part B (Medical Special Enrollment Period Insurance). You can use this form to sign up for Part B: If you don’t sign up for Part B during your IEP, you can During your Initial Enrollment Period (IEP) when you’re • sign up without a late enrollment penalty during a Special first eligible for Medicare Enrollment Period (SEP). If you think that you may be eligible for a SEP, please contact Social Security at 1-800-772-1213. • During the General Enrollment Period (GEP) from TTY users should call 1-800-325-0778 You can use a SEP when January 1 through March 31 of each year your IEP has ended. The most common SEPs apply to the • If you’re eligible for a Special Enrollment Period (SEP), working aged, disabled, and international volunteers. like if you’re covered under a group health plan (GHP) based on current employment. Working Aged/Disabled You have a SEP if you’re covered under a group health plan Initial Enrollment Period (GHP) based on current employment. To use this SEP, you Your IEP is the first chance you have to sign up for Part B. must: It lasts for 7 months. It begins 3 months before the month Be 65 or older and currently employed • you reach 65, and it ends 3 months after you reach 65. If you • Be the spouse of an employed person, and covered under have Medicare due to disability, your IEP begins 3 months your spouse’s employer GHP based on his/her current before the 25th month of getting Social Security Disability employment benefits, and it ends 3 months after the 25th month of Be under 65 and disabled, and covered under a GHP • getting Social Security Disability benefits. To have Part B based on your own or your spouse’s current employment coverage start the month you’re 65 (or the 25th month of disability insurance benefits); you must sign up in the first 3 You can sign up for Part B anytime while you have a GHP months of your IEP. If you sign up in any of the remaining 4 coverage based on current employment or during the 8 months, your Part B coverage will start later. months after either the coverage ends or the employment ends, whichever happens first. If you sign up while you have GHP coverage based on current employment, or, during the General Enrollment Period first full month that you no longer have this coverage, your If you don’t sign up for Part B during your IEP, you can sign Part B coverage will begin the first day of the month you up during the GEP. The GEP runs from January 1 through sign up. You can also choose to have your coverage begin March 31 of each year. If you sign up during a GEP, your with any of the following 3 months. If you sign up during Part B coverage begins July 1 of that year. You may have to any of the remaining 7 months of your SEP, your Part B pay a late enrollment penalty if you sign up during the GEP. coverage will begin the month after you sign up. The cost of your Part B premium will go up 10% for each 12-month period that you could have had Part B but didn’t NOTE: COBRA coverage or a retiree health plan is not sign up. You may have to pay this late enrollment penalty as considered group health plan coverage based on current long as you have Part B coverage. employment. International Volunteers You have a SEP if you were volunteering outside of the United States for at least 12 months for a tax-exempt organization and had health insurance (through the organization) that provided coverage for the duration of the volunteer service. PRIVACY ACT STATEMENT: Social Security is authorized to collect your information under sections 1836, 1840, and 1872 of the Social Security Act, as amended (42 U.S.C. 1395o, 1395s, and 1395ii) for your enrollment in Medicare Part B. Social Security and the Centers for Medicare & Medicaid Services (CMS) need your information to determine if you’re entitled to Part B. While you don’t have to give your information, failure to give all or part of the information requested on this form could delay your application for enrollment. Social Security and CMS will use your information to enroll you in Part B. Your information may be also be used to administer Social Security or CMS programs or other programs that coordinate with Social Security or CMS to: 1)Determine your rights to Social Security benefits and/or Medicare coverage. 2)Comply with Federal laws requiring Social Security and CMS records (like to the Government Accountability Office and the VeteransAdministration) 3)Assist with research and audit activities necessary to protect integrity and improve Social Security and CMS programs (like to the Bureau ofthe Census and contractors of Social Security and CMS).We may verify your information using computer matches that help administer Social Security and CMS programs in accordance with theComputer Matching and Privacy Protection Act of 1988 (P.L. 100-503). 9 ) CMS-40B (04/1 3

4 Form Approved OMB No. 0938-1230 Expires: 02/20 STEP BY STEP INSTRUCTIONS FOR FILLING OUT THIS APPLICATION 6. Phone Number: 1. Your Medicare Number: Write your 10-digit phone number, including area code. Write your Medicare number. 7. Written Signature: Do you wish to sign up for Medicare Part B (Medical 2. Sign your name in this section in the same way Insurance)? you would sign it for any other official document. Mark “YES” in this field if you want to sign up for Do not print. Medicare Part B which provides you with medical insurance under Medicare. You can only sign up using If you’re unable to sign, you may mark an “X” in this this form if you already have Medicare Part A (Hospital field. In this case, you will need a witness and the Insurance). If your answer to this question is “no” witness must complete questions 11, 12 and 13. then you don’t need to fill out this application. This application is to sign up to get medical insurance under 8. Date Signed: Medicare. Write the date that you signed the application. If you don’t have Part A and want to sign up, please 9. Signature of Witness: contact Social Security at 1-800-772-1213. TTY users In the case that question 9 is signed by an “X” instead should call 1-800-325-0778. of a written signature, a witness signature is needed in question 11 showing that the person who signs the 3. Name: application is the person represented on the application. Write your name as you did when you applied for Social Security or Medicare. List last name, first name and 10. Date Signed: middle name in that order. If you don’t have a middle If a witness signs this application, the witness must name, leave it blank. provide the date of the signature. 4. Mailing Address: 11. Address of Witness: Write your full mailing address including the number If a witness signs this application, provide the witness’s and street name, P.O. Box, or route in this field. address. City, State, and ZIP code: 5. 12. Remarks: Write the city name, state and ZIP code for the mailing Provide any remarks or comments on the form to clarify address. information about your enrollment application. IMPORTANT INFORMATION: Review the scenario below to determine if you need to include additional information or forms with your application. If you’re signing up for Part B using a Special Enrollment Period (SEP) because you were covered under a group health plan based on current employment, in addition to this application, you will also need to have your employer fill out and return the “Request for Employment Information” form ( CMS-L564/CMS-R-297 ) with your application. The purpose of this form is to provide documentation to Social Security that proves that you have been continuously covered by a group health plan based on current employment, with no more than 8 consecutive months of not having coverage. If your employer went out of business or refuses to complete the form, please contact Social Security about other information you may be able to provide to process your SEP enrollment request. Send the application (and the “Request for Employment Information,” if applicable) to your local Social Security Office. Find your local office at www.ssa.gov . INSTRUCTIONS: ) 4 CMS-40B (04/1 9

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