Important Medicare Forms

Form SSA-44
Medicare Income Related Monthly Adjustment Form – This form is to reduce the amount you are charged for your Medicare Part B and Part D (in some cases) monthly premiums in the event your income has changed from the income they used two years ago. (Medicare Part B and Part D standard monthly premiums for 2021 are based on your adjusted gross income from 2019).

*Example: If in 2019 you earned $200,000 but in 2021 you’re retired and you now earn less than $88,000, you can appeal the Part B monthly premium amount they are charging you with Form SSA-44. *See the Medicare Income-Related Monthly Adjustment Amount chart (IRMAA)

CMS 40 B
The CMS 40B form is for people with Medicare who have Part A but not Part B.
Below is when you would use the form CMS 40B:

• If you are still in your Initial Enrollment Period (IEP) (the 7 months surrounding your 65th birthday hasn’t expired yet) and when you recently enrolled in Medicare you refused or did not sign up for Part B but now want Part B.

• If you want to sign up for Part B during the General Enrollment Period (GEP) from January 1 – March 31 each year.

• If you refused Part B during your Initial Enrollment Period (IEP) because you had group health plan coverage through your or your spouse’s current employment. You may sign up for Medicare Part B during your 8-month Special Enrollment Period (SEP).

CMS L564
In order to apply for Medicare during a Special Enrollment Period (SEP), because you didn’t sign up during your Initial Enrollment Period (IEP), you must have or had group health plan coverage within the last 8 months through your or your spouse’s current employment. This form is used for proof of group health care coverage based on current employment. This information is needed to process your Medicare enrollment application with your local Social Security office. The employer that provides the group health plan coverage completes the information about your health care coverage and dates of employment.