TN 26 (11-14)

A. Forms used to enroll in Supplementary Medical Insurance (SMI)

For beneficiaries who are not eligible for automatic enrollment or wish to reenroll after termination of SMI, use the following forms:

• CMS-4040 (Request for Enrollment in Supplementary Medical Insurance);

• CMS-40B (Application for Enrollment in Medicare Part B (Medical Insurance));

• CMS-L40D (Application for Medicare Part B); and

• CMS-1739 (Request for Application for Enrollment in Medicare Part B (Medical Insurance)).

For information on automatic enrollment, see HI 00805.110.

A beneficiary may enroll for SMI when applying for Hospital Insurance (HI) coverage or when applying for Social Security monthly benefits.

See details:

• HI 00801.022 Application Requirement and Effective Date for Hospital Insurance for Insured Beneficiaries;

• HI 00801.052 Application Requirement and Effective Date for Hospital Insurance for Deemed Insured Beneficiaries; and

• HI 00801.138 Application for Premium HI.

B. When to use SMI enrollment forms

Beneficiaries may only enroll in SMI during the specified enrollment periods as outlined in See HI 00805.010. Use the appropriate SMI enrollment form based on the beneficiary’s circumstance.

1. CMS-4040

Beneficiaries not eligible for Social Security monthly benefits or premium-free HI use Form CMS-4040 to enroll in SMI only.

NOTE: Beneficiaries applying for both SMI and Premium-HI use Form CMS-18F (Application for Hospital Insurance Entitlement). For information on the application for Premium-HI, see HI 00801.138.

2. CMS-40B

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;

• 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;

• 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.

Beneficiaries not eligible for premium-free HI use Form CMS-4040 to enroll in SMI only.

3. CMS-L40D

Only beneficiaries who receive the general enrollment period (GEP) mailing from CMS can use Form CMS-L40D to enroll in SMI during the GEP. CMS mails Form CMS-L40D to individuals that refused, withdrew, or terminated SMI during the prior year. The beneficiary completes the Form CMS-L40D and sends it to CMS. At the end of the GEP, CMS sends the received forms to the Wilkes-Barre Data Operations Center for processing. For information on GEP enrollment processing, see WB 00601.001.

Field offices do not process the Form CMS-L40D.

4. CMS-40F (Application for medical insurance)

This form is obsolete. We no longer use it for SMI enrollment. Beneficiaries living outside the U.S. use form CMS-40B to enroll in SMI.

5. CMS-1739 (Request for application for enrollment in Medicare Part B (medical insurance)

CMS mails Form CMS-1739 in the IEP package to beneficiaries living outside the United States. The beneficiary returns it to request a SMI enrollment form. Form CMS-1739 protects the filing date for SMI enrollment.

C. References:

• HI 00801.022 Application Requirement and Effective Date for Hospital Insurance for Insured Beneficiaries

• HI 00801.052 Application Requirement and Effective Date for Hospital Insurance for Deemed Insured Beneficiaries

• HI 00801.138 Application for Premium HI

• HI 00805.010 Rules on Enrollment Periods

• HI 00805.110 SMI Enrollment Process

• SM 00706.265 Exhibits for Form CMS-40B

• WB 00601.001 Medical Insurance Form CMS-L40D – Background