60 Day Crosswalk

Type of Change

Current Location

30 day package

Reason for Change

60-day package
APPLICATION FOR ENROLLMENT IN
MEDICARE PART C (MEDICARE ADVANTAGE
PLAN) or PART D (MEDICARE PRESCRIPTION
DRUG PLAN)

EXHIBIT 1: MODEL INDIVIDUAL
ENROLLMENT REQUEST FORM TO ENROLL
IN A MEDICARE ADVANTAGE PLAN (PART C)
OR MEDICARE PRESCRIPTION DRUG PLAN
(PART D)

Rev

Revised the title so that this page is included as Cover page, page 1 - top
part of the exhibit in the enrollment guidance,
especially as plans might include it in their
paper applications.

Who can use this form?
People with Medicare who want to join a
Medicare Advantage Plan or Medicare
Prescription Drug Plan

Rev

Rev

For legibility, all headers were made sentence Throughout document
case.
Changed "application" to "form" which is more Cover page, page 1
user-friendly.

Rev

Revised for clarity

Cover page, page 1

Important: To join a Medicare Advantage
Plan, you must also have both:
• Medicare Part A (Hospital Insurance)
• Medicare Part B (Medical Insurance)

Add

Flagged the special rule for MA enrollment
since anyone with Medicare can join a Part D
plan.

Cover page, page 1

Headers

WHO CAN USE THIS APPLICATION?
• (For MA eligibility) Individuals entitled to
Medicare Part A and enrolled in Part B
• (For Part D eligibility) Individuals entitled to
Medicare Part A and/or enrolled in Part B
In addition, individuals must:
• Live in the MA or Part D plan’s service area
• Be U.S. Citizens or be lawfully present
individuals in the United States

Headers

To join a plan, you must:
• Be a United States citizen or be lawfully
present in the U.S.
• Live in the plan’s service area

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesignation.

Type of Change

Current Location

30 day package

Reason for Change

60-day package
WHEN DO YOU USE THIS APPLICATION?
Use this form:
If you are newly eligible for Medicare or
otherwise have a valid election period to
enroll in either a Medicare Advantage plan OR
Prescription Drug Plan.
NOTE:
Your Initial Coverage Election Period (ICEP)
lasts for 7 months. It begins 3 months before
the month you are newly eligible for Medicare
(generally, your 65th birthday or 25th month
of disability) and ends 3 months after the
month you are newly eligible for Medicare

When do I use this form?
You can join a plan:
• Between October 15–December 7 each year
(for coverage starting January1)
• Within 3 months of first getting Medicare
• In certain situations where you’re allowed to
join or switch plans
Visit Medicare.gov to learn more about when
you can sign up for a plan.

Rev

Simplified collection request due to comments
received from PRA package and consumer
testing.

What do I need to complete this form?
• Your Medicare Number (the number on your
red, white, and blue Medicare card)
• Your permanent address and phone number
Note: You must complete all items on page 1.
The items on page 2 are optional — you can’t
be denied coverage because you don’t fill them
out.

Rev

Replaced header. Added (the number on your Cover page, page 1
red, white, and blue Medicare card) at
commenters requests. Included details of
what's required to process the enrollment as
well as clarify that a response to optional items
had no effect on enrollment eligibility.

WHAT INFORMATION DO YOU NEED TO
COMPLETE THIS APPLICATION?
You will need:
• Your Medicare Number
• Your current address and phone number

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesignation.

Cover page, page 1

Current Location

Type of Change
Add

Included for informational purposes to help
individuals understand the required and
optional fields within the form.

Cover page, page 1

Del

Removed plan requirements to keep form
beneficiary-focused.

Cover page, page 1

Rev

Clarified per public comments that the request Cover page, page 1
must be received by December 7. Added SSA
and RRB as other payment options for plan
premium deductions.

WHAT’S INCLUDED WITH THE
ENROLLMENT FORM?
We have mandatory addenda (to be part of the
application), which are optional for the
beneficiary to complete; and optional addenda
which are optional for the plan to include and
the beneficiary to complete.
THINGS TO REMEMBER?
• If you’re signing up during open enrollment
you can send your form anytime from October
15 but no later than December 7.
• You (or your authorized representative)
must fill out a separate form for each person
enrolling in the plan.
• Your plan will bill you. You can choose to
sign up to have your premium payments
deducted from your bank account.

Reason for Change

30 day package

60-day package

Note: You must complete all items in Section
1. The items in Section 2 are optional — you
can’t be denied coverage because you don’t fill
them out.

Reminders:
• If you want to join a plan during fall open
enrollment (October 15–December 7), the
plan must get your completed form by
December 7.
• Your plan will send you a bill for the plan’s
premium. You can choose to sign up to have
your premium payments deducted from your
bank account or your monthly Social Security
(or Railroad Retirement Board) benefit.

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesignation.

Current Location

Reason for Change

Type of Change

HOW DO YOU GET HELP WITH THIS
APPLICATION?
Phone: Call MEDICARE at 1-800-633-4227.
TTY users should call 1-877-486-2048.
En español: Llame a Medicare gratis al 1-800633-4227 y oprima el 2 para asistencia en
español y unrepresentante estará disponible
para asistirle.

30 day package

60-day package
WHAT HAPPENS NEXT?
Send your completed and signed application
to the Medicare Advantage or Prescription
Drug plan. If you have questions, call
MEDICARE at 1-800-633-4227. TTY users
should call 1-877-486-2048. You may call 24
hours a day 7 days per week.

What happens next?
Send your completed and signed form to:

Once they process your request to join, they’ll
contact you.

Rev

Provides greater clarity. Revised to add plan
specific information.

Cover page, page 1

Rev

Updated to include plan contact information.
Updated Spanish translation.

Cover page, page 1

How do I get help with this form?
Call at . TTY
users can call < phone number >.
Or, call Medicare at 1-800-MEDICARE
(1-800- 633-4227). TTY users can call
1-877-486-2048.
En español: Llame a al o a Medicare gratis al
1-800-633-4227 y oprima el 2 para asistencia
en español y un representante estará
disponible para asistirle.

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesignation.

Type of Change
Rev

Updated PRA form number and beneficiary
burden to reflect decreased time to
complete/submit an application.

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesignation.

Current Location

30 day package
According to the Paperwork Reduction Act of
1995, no persons are required to respond to a
collection of information unless it displays a
valid OMB control number. The valid OMB
control number for this information collection
is 0938-NEW. The time required to complete
this information is estimated to average 20
minutes per response, including the time to
review instructions, search existing data
resources, gather the data needed, and
complete and review the information
collection. If you have any comments
concerning the accuracy of the time
estimate(s) or suggestions for improving this
form, please write to: CMS, 7500 Security
Boulevard, Attn: PRA Reports Clearance
Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850.

Reason for Change

60-day package
According to the Paperwork Reduction Act of
1995, no persons are required to respond to a
collection of information unless it displays a
valid OMB control number. The valid OMB
control number for this information collection
is 0938-NEW. The time required to complete
this information is estimated to average 30
minutes per response, including the time to
review instructions, search existing data
resources, gather the data needed, and
complete and review the information
collection. If you have any comments
concerning the accuracy of the time
estimate(s) or suggestions for improving this
form, please write to: CMS, 7500 Security
Boulevard, Attn: PRA Reports Clearance
Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850.

PRA Disclosure: Footer
on page 1 of the
document

Type of Change

Current Location

30 day package

Reason for Change

60-day package
****CMS Disclosure****
Please do not send applications, claims,
payments, medical records or any documents
containing sensitive information to the PRA
Reports Clearance Office. Please note that any
correspondence not pertaining to the
information collection burden approved under
the associated OMB control number listed on
this form will not be reviewed, forwarded, or
retained. If you have questions or concerns
regarding where to submit your documents,
please contact [Deme Umo, 410-786-8854]

IMPORTANT
Do not send this form or any items with your
personal information (such as claims,
payments, medical records, etc.) to the PRA
Reports Clearance Office. Any items we get
that aren’t about how to improve this form or
its collection burden (outlined in PMB 0939XXXX) will be destroyed. It will not be kept,
reviewed, or forwarded to the plan. See “What
happens next?” on this page to send your
completed form to the plan.

Rev

Plain language edits to the CMS disclosure
section to inform beneficiaries not to send the
completed form to CMS.

To Enroll in , Please Provide the
Following Information:

Section 1 – All fields on this page are
required (unless marked optional)

Rev

Revised header to clarify the data fields on page Top of page 2
2 were required

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesignation.

CMS Disclosure: Footer
on page 1 of the
document

Current Location

Reason for Change

Type of Change

30 day package

60-day package
Name of Plan You are Enrolling In:

Select the plan you want to join:
• Product ABC – $XX per month
• Product XYZ – $XX per month

Rev

Accepted comments to Include check boxes to
eliminate beneficiary confusion.

Top of page 2

LAST name:
FIRST Name:

FIRST name:
LAST Name:

Rev

Changed order to list First then last name

Page 2

Optional: Middle Initial

Add

Included to help plans accurately identify an
enrollee

Page 2

Sex: Male

Rev

Important change: CMS isnt asking for their
gender identity - we're asking for their sex at
birth.

Page 2

Rev

Allow the beneficiary the option to list the best Page 2
number they can be reached.

Rev

PO Box written per USPS styling.

Gender: Male

Female

Home Phone Number:

Female

Phone Number:

Permanent Residence Street Address (P.O. Box Permanent street  address (Don’t enter a PO
is not allowed):
Box) :

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesignation.

Page 2

 [Optional: County:]:

[Optional field: E-mail Address:
__________________________________]

Current Location

Reason for Change

Type of Change

30 day package

60-day package
[Optional field: County:]

Rev

Replaced "Optional field" throughout the form
to "Optional"

Page 2 and 3

Rev

Moved to the last page of the Enrollment form

Page 3

Please Provide Your Medicare Insurance
Information

Your Medicare information:

Rev

Revised header

Page 2

Please read and answer these important
questions:

Answer these important questions:

Rev

Page 2

IMPORTANT: Read and sign below:

IMPORTANT: Read and sign below:
1st bullet now reads:
• [MA plans insert: I must keep both Part A
and Part B to stay in .]

Rev

Consumer testing indicated invididuals didn't
fully understand the ask, so we provided
examples of other prescription drug coverge.
We also revised the header

IMPORTANT: Read and sign below:

IMPORTANT: Read and sign below:
2nd bullet now reads:
• [Part D plans insert: I must keep Part A or
Part B to stay in .]

Add

Required to include on any enrollment
mechasism: the requirement to keep both Part
A and Part B to stay in MA.

Page 2

Included the requirement to keep Part A or Part Page 2
B to stay in a Part D plan.

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesignation.

Type of Change

IMPORTANT: Read and sign below:
3rd bullet:
By joining this Medicare Advantage Plan or
Medicare Prescription Drug Plan, I
acknowledge that will release
my information to Medicare, who may use it to
track beneficiary enrollment, payment and
other purposes applicable to Federal statutes
that authorize the collection of this
information (see Privacy Act Statement
below).

Rev

Revised to meet the requirement in § 422.60(c) Page 2
and 423.32(b)(1) for that acknowledgement
which states: 422.60(c) The election must be
completed by the MA eligible individual (or the
individual who will soon become eligible to
elect an MA plan) and include authorization for
disclosure and exchange of necessary
information between the U.S. Department of
Health and Human Services and its designees
and the MA organization. It also includes a note
to see the Privacy Act statement on the last
page of the enrollment form.

IMPORTANT: Read and sign below:
4th bullet now reads:
Your response to this form is voluntary.
However, failure to respond may affect
enrollment in the plan.

Add

The Privacy Act requires that whenever an
Page 2
individual is asked to supply information about
himself, herself, or a family member, that the
individual be completely informed about the
use to be made of the information; which
information is mandatory and which is
voluntary; and the cost or forfeiture that might
be experienced in terms of money, time, lost
opportunity or other measure of value if all or
some of the information is not supplied.

IMPORTANT: Read and sign below:

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesignation.

Current Location

30 day package

Reason for Change

60-day package
IMPORTANT: Read and sign below:
2nd bullet:
• Release of information: By joining this
Medicare Advantage Plan or Medicare
Prescription Drug Plan, I acknowledge that the
plan will release my information to Medicare
and other plans as is necessary for treatment,
payment, and health care operations. I also
acknowledge that will release
my information, including my prescription
drug event data, to Medicare, who may release
it for research and other purposes which
follow all applicable Federal statutes and
regulations.

30 day package

Type of Change

Current Location

Reason for Change

60-day package
IMPORTANT: Read and sign below:
7th bullet:
• [MA plans insert: I understand that when my
coverage begins, I must get all of
my medical and prescription drug benefits
from . Benefits and services
authorized by and contained in
my “Evidence of Coverage”
document (also known as a member contract
or subscriber agreement) will be covered.
Without authorization, neither Medicare nor
will pay for benefits or services.]

IMPORTANT: Read and sign below:
7th bullet:
• [MA plans insert: I understand that when my
coverage begins, I must get all of
my medical and prescription drug benefits
from . Benefits and services
provided by and contained in
my “Evidence of Coverage”
document (also known as a member contract
or subscriber agreement) will be covered.
Neither Medicare nor will pay
for benefits or services not covered.]

Rev

Removed bold text as this information is no
more important than the other text. Also,
updated language and removed "authorized"
and "authorization" language.

Page 2

Section 2 – All fields on this page are
optional

Rev

Removed plan requirements to simplify
collection instrument.

Top of page 3

Please tell us a little more about yourself.
Answering these questions is your choice.
You can’t be denied coverage because you
don’t fill them out. Any information you
share will only be used to help us understand
who joins plans for the purpose of reducing
inequalities in certain groups.

Rev

Replaced language. Rather than have the plan
instructions that the plan is required to ask
them but its optional for the bene to answer,
adjusted language so it just speaks to the
beneficiary.

Page 3

[Optional fields: Can you please tell us a little
more about yourself. Answering these
questions is voluntary and will not be used to
process your enrollment. Information
provided will only be used to help understand
program participation for the purpose of
reducing inequalities in certain groups.]

These changes and formatting should provide
enough emphasis and reminders that the info
on this page is optional for the bene to
complete.

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesignation.

Do you or your spouse work?

0 Yes 0 No

Current Location

Reason for Change

Type of Change

Please provide language or accessible format
preference:
Preferred spoken language _____________
Preferred written language _____________
Accessible format preference (e.g., Braille,
audio tape, or large print) ______________
Please contact at if you need information in an
accessible format or language other than what
is listed above. Our office hours are . TTY users
should call

30 day package

60-day package
• I decline to provide this information

• I choose not to answer.

Rev

Provides greater clarity.

Page 3

Select one if you want us to send you
information in a language other than English.
[• Plans insert the langugages required in your
service area.]

Rev

Separated from accessible format preference.

Page 3

Select one if you want us to send you
information in an accessible format.
• Braille
• Large print
• Audio CD
Please contact at if you need information in an
accessible format other than what’s listed
above. Our office hours are . TTY users can call

Rev

Provides clarity.

Page 3

Do you work? Yes No
Does your spouse work?

Rev

Separated language.

Page 3

Yes No

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesignation.

[Optional field: Electronic Delivery of Plan
Specific Materials: Choose one
• I opt/choose to receive all plan specific
• I opt/choose to receive only the following
plan related materials electronically: {plans
may list those types or categories of materials
that are available for electronic delivery}
Plans may also include information needed to
sign up for portals or other mechanisms to
receive materials electronically.]

I want to get the following materials via email.
Select one or more.
• [Plans may list those types or categories of
materials that are available for electronic
delivery]
E-mail address:

Current Location

Reason for Change

Type of Change

30 day package

60-day package

[Optional field: Please choose the name of a List your Primary Care Phsyician (PCP),
clinic, or health center:
Primary Care Physician (PCP), clinic or
health center: ]

Rev

Removed bold and Optional Field.

Page 3

Rev

Updated for plans to include only those
materials available for electronic delivery

Page 3

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesignation.

Type of Change
Rev

Provides greater clarity. Replaced bold text to
those most important to the beneficiary.

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesignation.

Current Location

30 day package
Paying your plan premiums
[Plans
with premiums insert: You can pay your
monthly plan premium [MA-PD plans with
premiums insert: (including any late
enrollment penalty that you currently have or
may owe)] by mail each month . You
can also choose to pay your premium by
having it automatically taken out of your
Social Security or Railroad Retirement
Board (RRB) benefit each month.]
[MA-PD
and PDPs with premiums insert: If you have
to pay a Part D-Income Related Monthly
Adjustment Amount (Part D-IRMAA), you
must pay this extra amount in addition to
your plan premium. The amount is usually
taken out of your Social Security benefit, or
you may get a bill from Medicare (or the RRB).
DON’T pay [insert appropriate plan and/or
organization name] the Part D-IRMAA.]

Reason for Change

60-day package
[Optional field: Paying Your Plan Premiums:
MA-only, MA-PD plans and Part D plans with
premiums insert: You can pay your monthly
plan premium [MA-PD plans with premiums
insert: (including any late enrollment
penalty that you currently have or may
owe)] by mail each month . You can also choose to pay
your premium by automatic deduction
from your Social Security or Railroad
Retirement Board (RRB) benefit check
each month.]
[MAPD and PDPs with premiums insert: If you are
assessed a Part D-Income Related Monthly
Adjustment Amount (Part D-IRMAA), you
will be responsible for paying this extra
amount in addition to your plan premium.
You will either have the amount withheld
from your Social Security benefit check or
be billed directly by Medicare or RRB. DO
NOT pay [insert appropriate plan and/or
organization name] the Part D-IRMAA ]

Page 3

Added to meet HIPAA Privacy Rule
requirements which, at a minimum, includes
the authority, purpose, routine uses and
disclosure.

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesignation.

Current Location

Type of Change
Add

Reason for Change

30 day package

60-day package

Privacy Act Statement:
The Centers for Medicare & Medicaid Services
(CMS) collects information from Medicare
plans to track beneficiary enrollment in
Medicare Advantage (MA) or Prescription
Drug Plans (PDP), improve care, and for the
payment of Medicare benefits. Sections 1851
and 1860D-1 of the Social Security Act and 42
CFR §§ 422.50, 422.60, 423.30 and 423.32
authorize the collection of this information.
CMS may use, disclose and exchange
enrollment data from Medicare beneficiaries
as specified in the System of Records Notice
(SORN) “Medicare Advantage Prescription
Drug (MARx)”, System No. 09-70-0588. Your
response to this form is voluntary. However,

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