Medicare Part B Online Application - COVID-related

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

APPLICATION FOR ENROLLMENT IN MEDICARE PART B (MEDICAL INSURANCE)
UNDER A SPECIAL ENROLLMENT PERIOD
WHO CAN USE THIS APPLICATION?

WHAT HAPPENS NEXT?

People with Medicare who have Part A but not Part B AND
qualify for a Special Enrollment Period (SEP)
In order to apply for Medicare in an SEP, you must have or had
group health plan (GHP) coverage within the last 8 months
through your or your spouse’s current employment.

Complete and then sign the form digitally. To provide your digital
signature, you will need to provide an email address. You will
receive an email from echosign@echosign.com asking you to
confirm your digital signature. Your signature is not complete and
your application will not be processed until you complete the
instructions in your email. If you have questions, call Social Security
at 1-800-772-1213. TTY users should call 1-800-325-0778.

NOTE: If you do not have Part A, do not complete this form. If
you do not qualify for an SEP, do not complete this form. Contact
Social Security if you want to apply for Medicare for the first time.

HOW DO YOU GET HELP WITH THIS APPLICATION?
WHEN DO YOU USE THIS APPLICATION?

• Phone: Call Social Security at 1-800-772-1213. TTY users should
call 1-800-325-0778.

Use this form:
• If you live in the US and Puerto Rico. You may sign up for Part B
using this form.

• En español: Llame a SSA gratis al 1-800-772-1213 y oprima el 2 si
desea el servicio en español y espere a que le atienda un agente.

• If you refused Part B during your Initial Enrollment Period (IEP)
because you had GHP coverage through your or your spouse’s
current employment. You may sign up during your 8-month SEP.

WHAT INFORMATION DO YOU NEED TO
COMPLETE THIS APPLICATION?
You will need:
• Your Medicare Number
• Your current address and phone number
• Documentation verifying your GHP coverage through your or
your spouse’s current employment
• A valid email address

REMINDERS
If you sign up for Part B, you must pay premiums for every month
you have the coverage.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

SPECIAL MESSAGE FOR INDIVIDUALS APPLYING FOR PART B UNDER A SPECIAL
ENROLLMENT PERIOD
This form is your application for Medicare Part B (Medical
Insurance). You can use this form to sign up for Part B if you’re
eligible for an SEP and you’re covered under a GHP based on
current employment.
Do not use this form if you are applying for Medicare Part B under
your Initial Enrollment Period (IEP) or during the General
Enrollment Period (GEP).

INITIAL ENROLLMENT PERIOD
Your IEP is the first chance you have to sign up for Part B. It lasts
for 7 months. It begins 3 months before the month you reach 65,
and it ends 3 months after you reach 65. If you have Medicare due
to disability, your IEP begins 3 months before the 25th month of
getting Social Security Disability benefits, and it ends 3 months
after the 25th month of getting Social Security Disability benefits.
To have Part B coverage start the month you’re 65 (or the 25th
month of disability insurance benefits); you must sign up in the
first 3 months of your IEP. If you sign up in any of the remaining 4
months, your Part B coverage will start later. Do not use this
application to enroll under your IEP.

GENERAL ENROLLMENT PERIOD
If you don’t sign up for Part B during your IEP, you can sign up
during the GEP. The GEP runs from January 1 through March 31 of
each year. If you sign up during a GEP, your Part B coverage begins
July 1 of that year. You may have to pay a late enrollment penalty
for as long as you have Part B. 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 sign up. You may have to pay this late enrollment
penalty as long as you have Part B coverage. Do not use this
application to enroll under your GEP.

SPECIAL ENROLLMENT PERIOD
If you don’t sign up for Part B during your IEP, you can sign up
without a late enrollment penalty during an SEP. If you think you
may be eligible for an SEP, use this online application or contact
Social Security at 1-800-772-1213. TTY users should call
1-800-325-0778. You can use a SEP when your IEP has ended.

WORKING AGED
You have an SEP if you’re covered under a GHP based on current
employment. To use this SEP, you must:
• Be 65 or older and currently employed
or
• Be the spouse of an employed person, and covered under your
spouse’s employer GHP based on his/her current employment
You can sign up for Part B anytime while you have a GHP coverage
based on current employment or during the 8 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 first full month that you no longer
have this coverage, your Part B coverage will begin the first day of
the month you sign up. You can also choose to have your coverage
begin with any of the following 3 months. If you sign up during
any of the remaining 7 months of your SEP, your Part B coverage
will begin the month after you sign up. NOTE: COBRA
(Consolidated Omnibus Budget Reconciliation Act) coverage,
retiree health plans, VA coverage, and individual health coverage
(like through the Health Insurance Marketplace) aren't considered
coverage based on current employment.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

APPLICATION FOR ENROLLMENT IN MEDICARE PART B (MEDICAL INSURANCE)
SECTION A: Applicant Info
1. Your Medicare Number

2. Do you wish to sign up for Medicare Part B (Medical Insurance)?

YES

3. Your Name (Last Name, First Name, Middle Name)

4. Mailing Address (Number and Street, P.O. Box, or Route)

5. City

State

Zip Code

6. Phone Number (including area code)

7.. Remark (For Example - Desired Coverage Start Date)

SECTION B: Employment Information
1. Employer’s Name

2. Employer’s Address

City

State

Zip Code

3. Applicant’s Name

4. Applicant’s Social Security Number

5. Employee’s Name

6. Employee’s Social Security Number

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 is xxxx-xxxx. The time required to complete this information
collection 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 comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, MD 21244-1850.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

SECTION C: For Employer Group Health Plans ONLY
Complete this information to the best of your ability.
1. Are or were you covered under an employer group health plan?

Yes

✔

No

2. If yes, provide date coverage began. (mm/yyyy)

3. Has the coverage ended?

Yes

No

4. If yes, provide date coverage ended. (mm/yyyy)

5. When did you or your spouse work for the company?
To: (mm/yyyy)
From: (mm/yyyy)

SECTION D: Employment Verification
INSTRUCTIONS
Attach documentation that verifies your group health plan coverage within the last 8 months through your or your spouse's current
employment. Please see instructions for acceptable types of verifying documents. Please note that submitting incorrect or incomplete
documentation may delay processing of your application and/or cause the application to be rejected.
Only attach PNG, JPG, JPEG, GIF, BMP, PDF, DOC, DOCX, WP, TXT, RTF, HTM, or HTML file types. Attachments are limited to 5 MB and 25 Pages

1. Verifying Documents

Click to attach a file.

2. Signature

Click to attach a file.

3. Date Signed

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 is xxxx-xxxx. The time required to complete this information
collection 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 comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, MD 21244-1850.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STEP BY STEP INSTRUCTIONS FOR FILLING OUT THIS APPLICATION
SECTION A: APPLICANT INFO
1. Your Medicare Number:
Enter your Medicare number.
2. Do you wish to sign up for Medicare Part B (Medical
Insurance)?
Mark “YES” in this field if you want to sign up for Medicare
Part B which provides you with medical insurance under
Medicare. You can only sign up using this form if you already
have Medicare Part A (Hospital Insurance). If your answer to
this question is “no” then you don’t need to fill out this
application. This application is to sign up to get medical
insurance under Medicare. If you don’t have Part A and want
to sign up, please contact Social Security at 1-800-772-1213. TTY
users should call 1-800-325-0778.
3. Name:
Enter your name as you did when you applied for Social
Security or Medicare. List last name, first name and middle
name in that order. If you don’t have a middle name, leave it
blank.
4. Mailing Address:
Enter your full mailing address including the number and street
name, P.O. Box, or route in this field.
5. City, State, and ZIP code:
Enter the city name, state and ZIP code for the mailing address.
6. Phone Number:
Enter your 10-digit phone number, including area code.
7. Remarks:
Provide any remarks or comments on the form to clarify
information about your enrollment application.

SECTION B: EMPLOYMENT INFORMATION
The person applying for Medicare completes all of Section B.
1. Employer’s name: Enter the name of your employer.
2. Employer’s address: Enter your employer’s address.
3. Applicant’s Name: Enter your name here.
4. Applicant’s Social Security Number: Enter your Social
Security Number here.
5. Employee’s Name: If you get GHP coverage based on your
employment, Enter your name here. If you get GHP coverage
through another person, like a spouse or family member, Enter
their name.
6. Employee’s Social Security Number: If you get GHP
coverage based on your employment, Enter your Social Security
Number here. If you get GHP coverage through another
person, like a spouse or family member, enter their Social
Security Number.

SECTION C: FOR EMPLOYER GROUP HEALTH
PLANS ONLY
1. Are (or were) you covered under an employer group
health plan? Please check yes or no if you were covered under
your group health plan offered by your company. You (the
applicant) may be the employee or another person related to
the employee, such as a spouse. If the employer doesn’t offer a
group health plan, please check No. A group health plan is any
plan of one or more employers to provide health benefits or
medical care (directly or otherwise) to current or former
employees, the employer, or their families.
2. If yes, give the date the coverage began. Write the month
and year the date the applicant’s coverage began in your group
health plan.
3. Has the coverage ended? Check yes or no if the group health
plan coverage for the applicant has ended.
4. If yes, give the date the coverage ended. Enter the month
and year the group health plan coverage ended for the
applicant.
5. When did the employee work for the company? Enter the
start and end dates of the employment for the employee to
which the applicant is related. It may be the applicant or
another person related to the employee, such as a spouse. Enter
the month and year of the start of the employment in the
“From” box. Enter the month and year of end of the
employment in the “To” box. If the employee is still employed,
enter the month and year of the current date. Current
employment is active working status. It is not disability or
retirement.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STEP BY STEP INSTRUCTIONS FOR FILLING OUT THIS APPLICATION
SECTION D: EMPLOYMENT INFORMATION
1. In order to process your application in an SEP, you will need to
submit documentation verifying that you have or had GHP
coverage within the last 8 months through your or your spouse’s
current employment.
Acceptable verifying documentation includes:
• A letter, fax, or email from your coverage provider (the
employer, the GHP). This written notification must be signed
by (or come from) the company’s or GHP’s official, and
include: The official’s title, the official’s phone number and/or
other contact information and, the date;
• Income tax returns that show health insurance premiums paid;
• W-2s reflecting pre-tax medical contributions;
• Pay stubs that reflect health insurance premium deductions;
• Health insurance cards with a policy effective date;
• Explanations of benefits paid by the GHP or LGHP; and
• Statements or receipts that reflect payment of health
insurance premiums.
2. Digital Signature:
Digitally sign and date the form. To provide your digital
signature, you will need to provide an email address. You will
receive an email from echosign@echosign.com asking you to
confirm your digital signature. Your signature is not complete and
your application will not be processed until you complete the
instructions in your email. If you have questions, call Social
Security at 1-800-772-1213. TTY users should call 1-800-325-0778.
3. Date Signed:
Enter the date that you signed the application.