Take the following actions to process an SEP request:
Offer the beneficiary the option to have the Form CMS-40B (Application for Medicare
Part B (Medical Insurance)) and Form CMS-L564 (Request for Employment Information)
mailed to them or to visit Medicare.gov to get the forms by clicking on the tab “Forms, Help & Resources” and selecting “Get
Medicare Forms.” This tab is located on the top of the screen at the far right. (Medicare.gov/forms-help-and-resources/forms/medicare-forms.html) This is where the beneficiary can find the forms for completion. For information
on Form CMS-40B, see HI 00805.075 and for Form CMS-L564, see HI 00805.295.
If the beneficiary wants the forms mailed:
send the forms and provide a FO return envelope; and
Mark the top of the enrollment form with “SEP Enrollment.” If the beneficiary files
while still covered under the GHP or LGHP, or during the first month after coverage
or employment based on current employment status ends, make sure the Remarks section
of the form CMS-40B includes the statement, “I want Part B (and Part A, if applicable)
coverage to begin (MM/YY).”
Explain to the beneficiary that he or she should mail or take the completed form to
their local FO for processing.
For evidence requirements for GHP or LGHP coverage, see HI 00805.295.
Example of TSC processing an SEP request for
Mr. Martin, age 68, filed for Part A of Medicare when he attained age 65. He refused
SMI because he was working and covered under his employer’s group health plan. Mr.
Martin decides to retire effective June 30, 2013. He wants SMI coverage effective
July 2013. When Mr. Martin contacts the TSC about enrolling in SMI in April 2013,
the TSC tells him that he may file an enrollment request in advance, (i.e. during
April 2013, May 2013 or June 2013) and request SMI coverage effective July 2013. Mr.
Martin may also wait until July 2013 to file the enrollment application for SMI coverage
effective July 2013.
Mr. Martin asks to have the forms mailed to him. The TSC sends the Forms CMS-40B and
CMS-L564 to Mr. Martin to complete and return to the FO. Since Mr. Martin has requested
that the coverage begin July 2013, the form CMS-40B contains the statement, “I want
Part B coverage to begin July 2013.”
If Mr. Martin wants coverage to begin August 2013, he may file an application for
SMI as early as May 2013.