AA-23 (XX-XX) Prop Application for Medicare - Medical Insurance (Part B)

Proposed

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

PROPOSED FORM
OMB NO. 3220-XXXX

Application for Enrollment in Medicare Medical Insurance (Part B) [GEP
1.

SEP

IEP

]

RRB Claim Number

2a. Name and Address

2b. If this is a change of address, check box
2c. Daytime Telephone Number
(

3.

)

Do you want to enroll for Medical Insurance (Part B) under Medicare?
Yes

No – Go to item 5a

4a. Complete this item only if you are filing in a
Special Enrollment Period.

4b. Complete this section only if you are filing in a
General Enrollment Period (GEP).

I want my Part B coverage to begin on the first
day of:
Month:
Year:

I was covered under a Group Health Plan (GHP)
based on active employment prior to filing for
Medicare Part B. (Months covered by active GHP
will not be counted towards any penalty rate that
may be assessed.)

NOTE: If you enroll during the last 7 months of
a Special Enrollment Period, your Part B
coverage will be effective the first day of the
month after the month in which you enroll.

Yes – Attach proof of coverage (required
for premium surcharge relief).
No
NOTE: If no proof of Group Health Plan coverage is
provided, a penalty may be assessed.

5a. Signature (Do not print)

5b. Date Signed
Month

6.

Day

Year

If this application is signed by mark ("X") in Item 5a, a witness who knows the person signing must
complete 6a - 6d below:
6a. Signature of Witness

6b. Date Signed
Month

6c. Address (Number and Street, City, State, and ZIP Code)

Remarks

8.

For RRB Use Only

Month

Officially Filed
Day

Year

Year

6d. Daytime Telephone Number of Witness
(

7.

Day

)

Field Office Number:
By:

Form AA-23 (XX-XX)

ATTESTATION

I understand that anyone who, knowingly and willfully — (1) falsifies, conceals, or covers up by any
trick, scheme, or device a material fact; or (2) makes any materially false, fictitious, or fraudulent
statements or representations, or makes or uses any materially false writing or document knowing
the same to contain any materially false, fictitious, or fraudulent statement or entry, in connection with
the delivery of or payment for health care benefits, items, or services, shall be fined or imprisoned not
more than 5 years, or both.
Signature (Do not print)
Date Signed
Month

Day

Year

Message for Individuals Applying for Medical Insurance under Medicare
This form is your application for Medicare medical insurance (Part B). The application can be used to apply for
Part B coverage during your initial enrollment period (IEP), during any general enrollment period (GEP), or
during a special enrollment period (SEP).
Your IEP lasts 7 months. It begins 3 months before you reach age 65 (or 3 months before the 25th month you
are entitled to railroad retirement benefits based on a total and permanent disability) and ends 3 months after
you reach age 65 (or 3 months after the 25th month you are entitled to disability benefits). To have your Part B
coverage begin the month you are age 65 (or the 25th month you are entitled to disability 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 coverage will begin the
1st day of the month after you sign up for Part B.
If you do not file during your IEP or you terminate your Part B coverage, you may file during any GEP, which is
the first 3 months of every year. If you sign up in a GEP, your Part B coverage will begin the 1st day of the month
after you sign up for Part B. However, if you delay enrolling until a GEP, your premium may be subject to a
penalty increase. For each 12-month period you could have had Part B coverage but did not, your monthly
premium will be increased 10 percent.
If you are age 65 or older, or you are a disabled beneficiary eligible for Medicare, and currently working, or are
the spouse of a person who is currently working, and you are covered under a group health plan (GHP), you
may be eligible to enroll during a special enrollment period (SEP). If you are a disabled beneficiary eligible for
Medicare and are covered under a large group health plan (LGHP) based on your own current employment or
the current employment of any family member, you also may be eligible to enroll during a special enrollment
period. If you are eligible, you can enroll while you have GHP or LGHP coverage based on the current
employment, or if you do not enroll for Part B while you are covered under the GHP or LGHP, you can enroll
during the special enrollment period that ends 8 months after employment is terminated or, if earlier, after your
GHP or LGHP coverage ends. If you are eligible for a SEP, your Part B coverage can begin sooner than if you
delay enrolling until the next GEP. Also, you may be eligible for a reduction in the premium surcharge or penalty
that usually applies to people who delay their enrollment in Medicare medical insurance. If you are covered
under a GHP or LGHP, or recently lost GHP or LGHP coverage based on current employment and think you are
eligible for a SEP or a reduction in your monthly premium, contact any RRB field office.
If you missed enrolling in Part B because of a natural disaster, other exceptional circumstances, incarceration, or
loss of Medicaid coverage you may also be eligible for a SEP. For more information, visit www.medicare.gov or
call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

Form AA-23 (XX-XX) Page 2

I Important Notices
Paperwork Reduction Act and Privacy Act Notices
This notice is given under the Paperwork Reduction Act of
1995 and the Privacy Act of 1974. The Privacy Act requires
that the Railroad Retirement Board (RRB) tell you the
following whenever we ask you for information.
1) The law which allows us to ask for the information;
2) whether that law requires you to give us that information
and what, if anything, might happen to you if you do not give
it to us;
3) the reason why the information is requested; and
4) the persons, organizations, and agencies to which we
may release the information without your permission.
The RRB is authorized to collect the information on this form
under sections 7(b) and 7(d) of the Railroad Retirement Act
and sections 226, 1836 and 1840 of the Social Security Act,
as amended. The information on this form is needed to
enable the RRB to determine your eligibility to monthly
benefits and entitlement to hospital and/or medical
insurance coverage. While you do not have to furnish the
information requested on this form, no hospital or medical
insurance can be provided until an application has been
received. Failure to provide all or part of the information
requested could prevent an accurate and timely decision on
your claim and could result in the loss of hospital or medical
insurance.
Although the information you furnish on this form is almost
never used for any other purpose than stated above, there is
a possibility that for the administration of the Railroad
Retirement, Social Security, and the Centers for Medicare &
Medicaid Services programs, information may be disclosed
to another person or to another government agency as
follows:
1) Beneficiary identification, enrollment status and premium
deductions information may be released to the Social
Security Administration and the Centers for Medicare &
Medicaid Services to correlate action with the administration
of Title ll and Title XVlIl (MEDICARE) of the Social Security
Act.
2) Beneficiary identification may be disclosed to third party
contacts to determine if incapacity of the beneficiary or
potential beneficiary to understand or use benefits exists,
and to determine the suitability of a proposed representative
payee.
3) Jurisdictional clearance, premium rate, coverage election,
paid-thru date, and amounts of payments in arrears may be
released to the Social Security Administration and the
Centers for Medicare & Medicaid Services to assist in
administering Title XVlll of the Social Security Act.

4) The last address information may be disclosed to
the Department of Health and Human Services in
conjunction with the Parent Locator Service.
5) Beneficiary identification, entitlement data and rate
information may be referred to the Department of State and
embassy officials to aid in the development of applications,
supporting evidence and the continued eligibility of
beneficiaries and potential beneficiaries living abroad.
6) Records may be released to the Government
Accountability Office for auditing purposes and for
collection of debts arising from overpayments under Title
XVlll of the Social Security Act, as amended.
7) Disclosure may be made to a congressional office from
the record of an individual in response to an inquiry from
the congressional office made at the request of that
individual.
8) Pursuant to a request from an employer covered by the
Railroad Retirement Act or the Railroad Unemployment
Insurance Act, information regarding the RRB’s
determination of Medicare entitlement, entitlement data and
present address may be released to the requesting
employer for the purposes of determining entitlement to
and rates of supplemental benefits payable under private
employer welfare benefit plans.
We estimate this form takes an average of 5 minutes per
response to complete, including the time for reviewing the
instructions, getting the needed data, and reviewing the
completed form. Federal agencies may not conduct or
sponsor, and respondents are not required to respond to, a
collection of information unless it displays a valid OMB
number. If you wish, send comments regarding the
accuracy of our estimate or any other aspect of this form,
including suggestions for reducing completion time, to
ATTN: Information Collections Officer in Bureau of
Information Services, Railroad Retirement Board, 844
North Rush Street, Chicago, Illinois 60611-1275.
Computer Matching and Privacy Protection Act Notice
The Computer Matching and Privacy Protection Act of 1988
requires the Railroad Retirement Board (RRB) to advise
you that information you have provided may be used,
without your consent, in automated matching programs.
These matching programs are a computer comparison of
RRB records with records kept by other Federal, state, or
local governmental agencies. Information from these
matching programs can be used to establish or verify a
person’s eligibility for Federally funded or administered
benefit programs and for repayment of payments or
delinquent debts under these programs.
Form AA-23 (XX-XX) Page 3