Only beneficiaries who have premium-free HI can use Form CMS-40B. Beneficiaries use
Form CMS-40B when:
-
•
they did not elect to enroll in SMI on the Social Security monthly benefits and Medicare
application;
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•
they did not elect to enroll in SMI on the Medicare-only application;
-
•
they refused SMI based on automatic enrollment into Medicare hospital insurance (HI)
and SMI;
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•
they canceled a SMI enrollment during their initial enrollment period (IEP); or
-
•
their SMI coverage terminated based on voluntary termination or non-payment of premiums;
or they refused, withdrew, or terminated SMI during the prior year.
Beneficiaries not eligible for premium-free HI use Form CMS-4040 to enroll in SMI
only.
NOTE: CMS mails Form 40-B to individuals who receive the general enrollment period (GEP)
mailing. Beneficiaries who receive the GEP mailing can use Form CMS-40B to enroll
in SMI during the GEP. For information on GEP enrollment processing, see WB 00601.001.
Beneficiaries should mail the completed form to: SSA PO Box 67650 Wilkes-Barre, PA
18767-7650