Medicare Application

The 2015 online form

Overview

You will be automatically enrolled in Medicare by applying for Social Security Retirement before age 65. If not, you must apply for Medicare yourself during the initial enrollment period of three months before to four months after the month you turn 65. (You might want to read the last sentence, and this entire post, more slowly.)

Medicare recommends and some employers require that you sign up for the premium-free hospital insurance (Part A) during this initial period. If you aren’t continuing employer group coverage for doctor insurance (Part B), you should also sign up to pay the monthly Part B premium at this time, to avoid a permanent penalty surcharge later.

You can’t sign up for private Medicare insurance (Medigap, Part C Medicare Advantage, or a Part D drug plan) until you’re approved for original Medicare Parts A and B.

You can submit your application up to 3 months before the month you turn 65. Application options are online (recommended by Social Security), phone (1-800-772-1213 or TTY 1-800-325-0778), or in-person at your local office (appointments are recommended). Apply online at your my Social Security account.

Application Details

These are the online questions for the Medicare application, last retrieved on 2/1/19. The entries are either free text or drop-down menu selections (e.g., Yes/No). Some questions may vary, depending on your earlier answers. Comments or editing added for the Wiki are shown in italics.

One of the unexpected details of both Medicare and Social Security is the individual nature of the insurance. For those with decades of family employer insurance, there is no family or joint coverage.

Applicant Identification
Name:
Social Security number:
Date of Birth:
Gender:
Blind:
Disabled: 

Applicant’s Contact Information

Contact Information
Mailing Address:
Reside at this address:
Phone:
Best time to call:
Email Address:
Confirm Address: 

Language preferences
Preferred language for speaking:
Preferred language for reading: 

Birth and Citizenship Information
Place Of Birth:
U.S. Citizen:
Type of Citizenship: 

Medicare Election
Wish to apply for Medicare ONLY, but not for monthly retirement cash benefits at this tine:
Already enrolled in Medicare under a Social Security Number other than own: 

Re-entry Number The Re-entry Number is:
(The Re-entry cannot be edited.) 

Other Benefits

Health Insurance Information
Want to enroll in Medicare Part B:
Medicaid (state health insurance): 

Group Health Plan Information
Covered under a Group Plan: 

Social Security defines a “Group Health Plan (GHP)” as health insurance based on the current employment of the beneficiary or the beneficiary’s spouse.

Remarks
These are your remarks: 

This is a place to provide any additional information to clarify earlier entries.

After completing the form, you have the option of submitting it, or saving it and returning later with your Re-entry Number.

Electronic Signature Agreement

Congratulations, you are just about ready to complete your application for Medicare insurance. Please read and accept the following statement to finish the application. If you are helping someone apply, then the person filing for benefits must read and accept this agreement by checking the box themselves. 

I apply for all insurance benefits for which I may be eligible under Part A (and Part B, if applicable) of Title XVIII (Health Insurance for the Aged and Disabled) of the Social Security Act as presently amended. 

I understand and agree that my application will be signed electronically when I select the check box below. I also understand that my electronic signature means that I intend to file for Medicare insurance and have provided the Social Security Administration with accurate information. 

I understand that I must apply separately to get monthly Social Security benefits. 

If applying for Medicare before Social Security Retirement.

I declare under penalty of perjury that I have examined all the information on this application and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false or misleading statement about a material fact in this electronic application. or causes someone else to do so, commits a crime and may be sent to prison or face other penalties, or both. 

I agree With the Electronic Signature Agreement above. 

You no longer be able to Change this information you continue.
When you select “Submit Know” below. you will be sending this completed information electronically to Social Security Administration. Please make sure that everything is correct. 

Application Approval

There’s a wealth of information about Medicare online, but here’s something I couldn’t find: a schedule for my application approval. 

Medicare Application Timeline

Time	Events
—	Submit online Medicare application.
1-2 weeks	Medicare Award email. The email does not have your Medicare number, but that can be read at the Benefit Verification Letter link of your my Social Security account. The Medicare number permits (1) application(s) for private Medigap supplement, Medicare Advantage plan, and/or Drug (Part D) insurance, (2) registration for a MyMedicare.gov account, and (3) mailing of the Authorization Agreement for Preauthorized Payments form (SF-5510) for automatic ACH Part B premium payments if desired.
6-7 weeks	Medicare Notice of Award letter.
7-8 weeks	Medicare card.
2 months	A first Medicare Part B bill for 3 months.
3 months	Medicare coverage starts. The 6-month open enrollment period for private supplemental insurance (Medigap, Medicare Advantage or other Part C plans, and drugs) starts the month you’re 65 and enrolled in Medicare Part B.
5 months	Approved Preauthorized Payments notice.
5 months 1 week	First monthly ACH payment is made. A monthly Social Security paper statement noting “This is not a bill” is sent before each ACH payment.