0938-1230. APPLICATION FOR ENROLLMENT IN MEDICARE PART B (
MEDICAL INSURANCE). WHO CAN USE THIS APPLICATION? People with Medicare who have Part A but not Part B. NOTE: If you do not have Part A, do not
complete this form. Contact Social Security if you want to apply for Medicare for
the first time.
What is Medicare? Medicare is a federal health insurance plan for people who
are age 65 or older. People who are disabled or have permanent kidney failure
can get. Medicare at any age. Medicare has four parts—A, B, C, and. D. Part A (
hospital insurance) is free for insured people and helps pay for inpatient hospital
If you don't enroll in Part B when you're first eligible for it, you may have to pay a
late enrollment penalty for as long as you have Part B coverage. Read Signing
up for Medicare on page 8. Medicare Part C (Medicare Advantage plans). If you
receive your Part A and Part B benefits directly from the government, you have …
(If "Yes," answer (b) and (c).) Do not answer question 9 if you are one year past
full retirement age or older; go to question 10. (a) Have you (or has someone on
your behalf) ever filed an application for Social Security, Supplemental Security.
Income, or hospital or medical insurance under Medicare? (c) Enter Social Security …
you have Medicare prescription drug coverage. However, you won't pay a
penalty if you get Extra Help or another eligible prescription drug plan coverage.
NOTE: The Medicare prescription drug plan late enrollment penalty is different
than the Medicare Part B late enrollment penalty. If you don't enroll in Part B
when you're …
You may use this form if you received a notice that your monthly Medicare Part B
(medical insurance) or … you should not fill out this form even if you experienced
a life-changing event. If you filed your taxes as: And your MAGI was: Your Part B
monthly adjustment is: …. improve our efforts for the Medicare program. We may …
keep you from working (even if you have never worked)?. 10. (a) Have you (or
has someone on your behalf) ever filed an application for Social Security benefits
, a period of disability under Social Security, Supplemental Security Income, or
hospital or medical insurance under Medicare? Yes. (If "Yes," answer. (b) and (c))
Re-entry Number. When you have successfully started your application, you will
get a re-entry number that you can use to: • Continue your application later if you
need a break; and. • Check the status of your completed application. How to Apply Online for Medicare Only. SocialSecurity.gov …
You may be able to get help paying your Medicare prescription drug coverage
costs and Medicare Part B (medical insurance) premiums and other expenses.
Some people also get help with their Medicare Part A (hospital insurance) costs.
Extra Help with Medicare Prescription Drug Plan Costs. The Extra Help program
Medicare Part. B premiums for both you and your spouse. for married couples
who live together. MassHealth Buy-In for people who are eligible for Medicare.
What is MassHealth Buy-In? MassHealth Buy-In is a program authorized by
Congress for persons … this refund in the same way as you now get your social security:.
amount (IRMAA) during CALENDAR YEAR 2016 – which means more than the
standard Medicare Part B monthly … enrollment does not qualify as an amount
that is eligible for additional reimbursement.) To claim … Submit a copy of your
and/or your eligible dependent's Social Security Administration (SSA) letter
The Social Security Administration (SSA) is authorized to collect information on
this form under sections 1836, 1840, and 1872 of the Social Security Act, as
amended (42 U.S.C. 1395o,. 1395s, and 1395ii). The information on this form is
needed to enable SSA and the Centers for. Medicare Medicaid Services (CMS)
4. Social Security is the foundation for a secure retirement, but you also will need
other savings and investments. If you want to learn more about how and why to
save, visit www.mymoney.gov. Save for a Secure Future …
If you are under age 65 and not receiving Social Security Disability income, a
disability determination will … Part B Premium. *If you are enrolled with a Medicare HMO, your co-pays will also be paid. If you elect additional coverage
from a Medicare HMO, you will be responsible for any additional premiums and
costs. DE-103 …
Retirees and their covered dependents enrolled in the. State's benefits program
MUST enroll in Medicare Parts A. & B if eligible due to disability, regardless of
their age, in order to receive the maximum coverage available. If Social. Security
denies Medicare coverage, you must provide a copy of the Social Security's
For example, if the Social Security of the wage earner number is 123-45-6789,
then once you apply for retirement benefits; your claim number is 123-45-6789A.
This number will also be used as your Medicare claim number, once you are
eligible for Medicare. Code. Identification. A. Primary claimant (wage earner). B.
Initial Enrollment Period for Medicare Part B (IEP). You have seven months to
enroll in Medicare Part B. It starts three months before your 65th birthday and
ends three months after your 65thbirthday. If you are receiving early Social Security or Social. Security disability benefits you will be automatically enrolled in
. Medicare …
NAMES (List your name first. Include aliases and maiden name). 6. First. M.I..
Last. Date Of Birth. Sex Social Security Number Race/Ethnic. Code. SELF.
SPOUSE. CHILD*. *If under 18 years of age. Attach extra sheet if necessary to list
additional children. B – Black, not of Hispanic origin. W – White, not of Hispanic