Medicare Forms & Documents
View, read and print.
Useful Medicare forms and documents
Read, review, download, and/or print commonly requested Medicare forms and documents below. For example, are you looking for SEP forms 40B and L564 to start your Part B of Medicare? Maybe you’re interested in reading more about Medicare Supplement Plans? If so, review the Guide to Choosing a Medigap Policy 2023. Although wordy, it outlines everything you’ll need to know about Medicare Supplement Plans, your guaranteed-issue rights, and important Medigap plan features, such as, Medigap policies being guaranteed-renewable.
As a reminder, not all of these Medicare forms and documents are required to be used by every Medicare beneficiary. More specifically, they are to be used in specific enrollment scenarios, such as Special Enrollment Periods. The Medicare forms and documents page is intentionally designed to allow you to scroll through each PDF document without needing to download or print them. However, if you prefer, you may download and/or print the materials.
If you need assistance review any of these forms, please contact my office.
Medicare Forms & Documents.
- Guide to Choosing a Medigap Policy (2022)
- Form CMS-40B
- Form CMS-L564
- Part D Credible Coverage Disclosure
- IRMAA Redermination Form SSA-44
- IRMAA Updated Figures for 2021 (Apply to Form SSA-44)
- Sample Part B Billing Statement- See auto draft option for checking/credit card
Guide to Choosing a Medigap Policy (2022)
This is the official CMS guide providing Medicare beneficiaries with information on Medicare Supplement Plans (Medigap). Moreover, the Guide to Choosing a Medigap Policy includes the rules and regulations, rights to guaranteed-issue rights as well as many other topics relating to Medicare Supplement Plans. Indeed, you will find this helpful if you are seeking government issued material to enrollment periods and additional information on Medicare Supplement Plans.
Form CMS-40B
Form 40B is used to enroll a Medicare beneficiary into Part B of Medicare at 65 or if they have delayed enrollment into Medicare while working past their 65th birthday with creditable coverage through an employer group plan. Use along with Form CMS-L564 for your Part B SEP when enrolling in Part B outside your IEP.
40B - Use to Enroll in Part B of Medicare
Use form 40B to complete enrollment into Part B for your Initial Enrollment Period (IEP) if applying in-person at Social Security to start Medicare surrounding your 65th birthday. If enrolling in Medicare online, you will be the online version of this form.
If enrolling using an SEP after leaving an employer plan and over the age of 65 (outside IEP), use form 40B along with form L564 to complete Medicare enrollment into Part B.
Form CMS-L564
Use Form L564 in conjunction with Form CMS-40B to enroll as a Medicare beneficiary into Part B of Medicare using your SEP eligibility with creditable coverage while working past your 65th birthday (outside of IEP if still 65). Accordingly, submit this form to your employer for proof of creditable coverage to start Part B within a 8 month window of you having current employer group plan coverage.
Fax or deliver in-person to your local Social Security office. I recommend that you specify the month you would like to Medicare coverage to begin under remarks of form 40B that needs to accompany this form. When electing to use this specific Special Enrollment Period, the start date is your choice, however, most clients choose the 1st of the month after their group employer health plan coverage ends (no lapse in coverage). Also, Part A will become primary with Part B once the forms are filed and a Medicare effective date is established by Social Security.
L564 - Use to Enroll in Part B of Medicare
Use both form L564 and 40B to complete your Special Enrollment Period (SEP) enrollment into Medicare Part B.
Have your employer fill out the form– confirming your current group plan coverage. This will give you an 8 month window to enroll into Part B using this SEP.
If done properly, you will not have a late enrollment penalty for Part B and/or Part D. You will also have the same guaranteed-issue rights to a Medicare Supplement Plan as you did when you were 65 (no health questions).
Part D Credible Coverage Disclosure
View this disclosure outlines creditable coverage under an employer group plan that allows you to avoid a Part D late enrollment penalty. For example, if you did not enroll in a Part D plan at the age of 65 and were working with coverage through an employer group plan and later transitioned to Medicare, you may need proof from your prior employer or your spouse’s employer.
Your employer must legally provide you with a notice of creditable coverage. Your employer benefits administrator will provide you with the proper documentation to submit to the Part D plan to avoid the Part D penalty. Fax this proof of creditable coverage documentation to the Part D plan insurer, not Medicare or Social Security. If your HR department has not provided you proof of creditable coverage, contact your benefits administrator for the proper forms– it is required by law that employers provide this to you when you exit their employer group plan.
IRMAA Redetermination Form SSA-44
Use form SSA-44 to make a IRMAA redetermination for higher earning individuals and married filling jointly Medicare beneficiaries. Use SSA-44 form if you have had a life changing event or recent change/loss of income. Current IRMAA surcharges are calculated based on income reported two years prior. You may avoid applicable surcharges to your Medicare Part B and Part D enrollment if your MAGI is lower than what is currently applicable to the IRMAA surcharges.
Use the updated 2021 limits shown in a PDF below this document (source-ssa.gov). SSA has not updated limits on their official form as of this post, so I’ve provided them to you below. However, this SSA-44 Form is the most current form provided by SSA.gov and should be used for your IRMAA redetermination (see 2021 limits below). Click on the SSA-44 link above to see if the 2022 IRMAA redetermination form has been updated for 2022.
2022 IRMAA Limits
The following outline the 2022 limits for IRMAA surcharges for higher earning individuals and married filled jointly Medicare beneficiaries. The limits on the current SSA-44 form are showing 2020 figures. Use the current SSA-44 form above, but apply these limits to determine which IRMAA classification you or you and your spouse fall under. Remember these IRMAA limits are applied from IRMAA calculated two years prior.
To be clear, if your MAGI is accurate and you happen to fall within the income brackets set for Part B and D surcharges, there is no avoiding the additional costs if you are to activate either Part B and/or Part D of Medicare. Contact me if you’d like me to review this chart as well as how the IRMAA billing will take place for you.
Sample Part B Billing Statement
This is an example of a Medicare Part B billing statement you may receive as a new Medicare beneficiary who is delaying his/her Social Security benefit at the time he/she starts Medicare. Since this Medicare beneficiary does not have a monthly Social Security benefit check, there is no account for the Part B premium to be withdrawn each month. You will likely see this billed as a quarterly statement ($494.70 standard for 2023 quarterly). However, I have seen statements for anywhere between 2-5 months on the first billing statement.
You have the option to pay quarterly by check or you may set up an auto draft from a checking account or credit card. This alternative monthly payment option will be presented on the first billing statement if this payment method is preferable.
In contrast to someone delaying their Social Security benefit, if you are already receiving your Social Security retirement benefit, you will see your Part B premium automatically drafted from your monthly benefit check ($164.90 – 2023). Contact your local Social Security office for a recent statement if you would like to update your billing options.
