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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. The employer that provides the group health plan coverage completes the information about your health care coverage and dates of employment.
To apply for Medicare in a Special Enrollment Period, you must have or had group health plan coverage within the last 8 months through your or your spouse’s current employment. People with disabilities must have large group health plan coverage based on your, your spouse’s or a family member’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.
You may use this form if you received a notice that your monthly Medicare Part B (medical insurance) or prescription drug coverage premiums include an income-related monthly adjustment amount (IRMAA) and you experienced a life-changing event (like retirement) that may reduce your IRMAA.