This introductory letter informs the beneficiary that the beneficiary:

• •

  has automatic entitlement to HI and enrolled in SMI;

• •

  must pay a monthly premium for SMI;

• •

  should read the enclosed booklet carefully to learn about the important decisions that needs consideration during the IEP; and

• •

  can stop Marketplace coverage once the Medicare coverage begins, if they have such coverage.

For an exhibit of the domestic IEP package cover letter, see HI 00805.126A.

This booklet provides an overview of the Medicare program and outlines the four main decisions new Medicare beneficiaries need to make during their IEP:

1. 1. 

   keeping SMI coverage;

2. 2. 

   choosing Medicare coverage (Original Medicare or Medicare Advantage);

3. 3. 

   enrolling in Medicare Part D (prescription drug coverage); and

4. 4. 

   enrolling in a Medigap policy, if applicable.

With regard to SMI coverage, the booklet explains items to consider when deciding to keep or refuse SMI coverage, the special enrollment period (SEP) eligibility requirements and ramifications for refusing Part B. It also provides instructions on how to refuse SMI.

Beneficiaries learn about enrollment periods for Medicare Advantage, Part D and Medigap and about assistance programs to help low income beneficiaries such as Supplemental Security Income (SSI), Medicare Savings Programs, Medicaid and the Part D Low Income Subsidy (LIS).

Form CMS-40 (Medicare card) is the beneficiary’s official Medicare card reflecting the HI and SMI entitlement dates. Form CMS-1966 (SMI Refusal card) is the SMI refusal form. CMS prints the forms on the same paper. The Medicare card is on the front and the refusal form is on the back.

CMS includes a postage-paid envelope for the individual to use to send their SMI refusal to SSA.

Beneficiaries that we automatically enroll in SMI have the opportunity to refuse the coverage as outlined in HI 00805.055B. In the domestic IEP package, beneficiaries use Form CMS-1966 (which is on the back of the Medicare card) to refuse SMI. The instructions tell beneficiaries to check the appropriate box on the form, sign and return the form along with the Medicare card, to SSA in the envelope provided. The booklet explains that the beneficiary must return the refusal to SSA prior to the effective date of SMI coverage shown on the Medicare card.

The booklet tells beneficiaries that if they refuse SMI, they may only enroll later during the general enrollment period (GEP) or SEP. The booklet includes a complete explanation of the enrollment periods, including the SEP eligibility requirements, when enrollment may occur and the premium surcharge.

The booklet specifies that the beneficiary must keep SMI in order to be eligible for TRICARE and CHAMPVA coverage.

This introductory letter informs the beneficiary that the beneficiary:

• •

  has automatic entitlement to HI and may enroll in SMI;

• •

  can only enroll in SMI during GEP or SEP, if the beneficiary doesn’t enroll during the IEP;

• •

  must pay a monthly premium for SMI and may have a premium surcharge for enrolling in SMI later;

• •

  should read the enclosed pamphlet carefully to learn about Medicare coverage options that need consideration during the IEP; and

• •

  can stop Marketplace coverage once the Medicare coverage begins, if they have such coverage.

This pamphlet provides an overview of the Medicare program. It includes information on the services and items covered under Medicare, the availability of Medicare Advantage, Medicare Part D and Medigap coverage and the availability of assistance programs to help low income beneficiaries.

The cover letter tells beneficiaries to enroll in SMI by:

• •

  downloading Form CMS-40B (Application for Medicare Part B (Medical Insurance)) from Medicare’s website to complete and return to their local field office (FO),

• •

  contacting their local FO, or

• •

  calling the Teleservice Center (TSC).

The booklet tells beneficiaries that if they refuse SMI, they may only enroll later during the GEP or SEP. The cover letter includes a complete explanation of the enrollment periods, including the SEP eligibility requirements, when enrollment may occur and the premium surcharge.

The cover letter specifies that the beneficiary must keep SMI in order to be eligible for TRICARE and CHAMPVA coverage.

This introductory letter informs the beneficiary that the beneficiary:

• •

  has automatic entitlement to HI and may enroll in SMI;

• •

  can only enroll in SMI during the GEP or a SEP, if the beneficiary doesn’t enroll during the IEP;

• •

  must pay a monthly premium for SMI and may have a premium surcharge for enrolling in SMI later; and

• •

  should read the enclosed pamphlet to learn about Medicare.

The letter also explains that Medicare generally does not cover medical care received outside the U.S. or its territories.

This pamphlet provides an overview of the Medicare program. It includes:

• •

  information on the services and items covered under Medicare;

• •

  enrollment criteria for Medicare Advantage, Medicare Part D and Medigap coverage; and

• •

  the availability of obtaining more information on Medicare's website or from a U.S. Consular office.

CMS includes Form CMS-1739 (Request for Application for Enrollment in Medicare Part B (medical insurance)) for beneficiaries to request a Form CMS-40B. For additional information regarding the use of this form, see HI 00805.075B.5. and HI 00805.120B.

CMS includes a return reply envelope for the beneficiary to use to send their completed Form CMS-1739 to the Office of International Operations (OIO). Postage is not pre-paid.

Beneficiaries can enroll in SMI by:

• •

  downloading Form CMS-40B from Medicare’s website to complete and return to OIO, or

• •

  returning the signed Form CMS-1739 to OIO.

For information on the processing of Form CMS-1739, see HI 00805.120B.

For subsequent enrollment in SMI, see HI 00805.125C.2.b. of this section.

For information regarding TRICARE and CHAMPVA beneficiaries, see HI 00805.125C.2.c. of this section.