Form Cms-40b - Application For Enrollment In Medicare - Part B (Medical Insurance) Page 3
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4Form Approved
OMB No. 0938-1230
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 large
getting Social Security Disability benefits. To have Part B
group health plan (LGHP) based on your or your spouse’s
coverage start the month you’re 65 (or the 25th month of
current employment, or the current employment of any
disability insurance benefits); you must sign up in the first 3
family member
months of your IEP. If you sign up in any of the remaining 4
months, your Part B coverage will start later.
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
General Enrollment Period
ends, whichever happens first. If you sign up while you have
If you don’t sign up for Part B during your IEP, you can sign
GHP coverage based on current employment, or, during the
up during the GEP. The GEP runs from January 1 through
first full month that you no longer have this coverage, your
March 31 of each year. If you sign up during a GEP, your
Part B coverage will begin the first day of the month you
Part B coverage begins July 1 of that year. You may have to
sign up. You can also choose to have your coverage begin
pay a late enrollment penalty if you sign up during the GEP.
with any of the following 3 months. If you sign up during
The cost of your Part B premium will go up 10% for each
any of the remaining 7 months of your SEP, your Part B
12-month period that you could have had Part B but didn’t
coverage will begin the month after you sign up.
sign up. You may have to pay this late enrollment penalty as
long as you have Part B coverage.
NOTE: COBRA coverage or a retiree health plan is not
considered group health plan coverage based on current
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 Notice: The Social Security Administration (SSA) is authorized to collect the information under sections 1836, 1840 and 1872 of
the Social Security Act, as amended (42 U.S.C. 1395o, 1395s, and 1395ii). This information is needed for SSA and the Centers for Medicare &
Medicaid Services (CMS) to determine if you are entitled to Supplementary Medical Insurance (Part B). Completing this form is voluntary, but
you will not be enrolled in Part B if you do not provide all of the required information. The information you give can be shared for “routine
uses” published in the Federal Register. Because there are too many to list here, SSA can give you more information about this if you ask. The
information you give on this form may be verified by way of computer match (Pub. Law 100-503).
CMS-40B (04/17)
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