Track Change - Application

Form Approved
OMB No. 0938-1428
Expires: 02/25

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

APPLICATION FOR Application for Medicare Part B Immunosuppressive Drug
CoverageENROLLMENT IN PART B IMMUNOSUPPRESSIVE DRUG COVERAGE

WHAT IS PART B IMMUNOSUPPRESSIVE DRUG
COVERAGE (PART B-ID)?
The Part B-ID benefit coverage is only
available to individuals who are entitled to
Medicare based on End-Stage Renal
Disease (ESRD) and are losing Medicare
entitlement 36 months after a kidney
transplant. The benefit is coverage solely
for immunosuppressive drugs under
Medicare Part B.

WHO CAN USE THIS FORM?
Use this form if you or your child/dependent had a kidney
transplant and have lost or will be losing their Medicare
coverage that was based on ESRD 36 months after their
kidney transplant.
NOTE: If you or your child/dependent have other health
coverage, or you or your child/dependent have Medicaid or
State Children’s Health Insurance Program (CHIP) that covers
immunosuppressive drugs, do not complete this form.

If you only have Medicare because of End-Stage Renal
Disease (ESRD), use this form to sign up for Medicare Part B
Immunosuppressive Drug Coverage (Part B-ID) if you have
lost (or will be losing) your Medicare coverage after a kidney
transplant.

•

Part B-ID helps pay for immunosuppressive drugs
beyond 36 months after a kidney transplant.

•

You can only apply for Part B-ID if you don’t have
certain types of other health coverage (like a group
health plan, TRICARE, or Medicaid that covers
immunosuppressive drugs).

•

Part B-ID only covers immunosuppressive drugs and
no other items or services. It isn’t a substitute for
full health coverage.

•

You’ll pay a monthly premium and an annual
deductible for Part B-ID.

Get more information about Part B-ID at
Medicare.gov/basics/end-stage-renal-disease.

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spacing: single

ARE THERE STATUTORY EXCLUSIONS?
Congress has excluded certain individuals from receiving Part
B-ID. If you have certain other coverage, you are not eligible
for this benefit. Excluded coverage includes:
•

Employer Group Health Plan or Individual Health Plan.
(These plans are defined in section 2791 of the Public
Health Service Act).

•

TRICARE for Life (This program is established at 10 USC
1086(d).

•

Medicaid (Title XIX of the Social Security Act) or State
Children’s Health Insurance Program (CHIP) (Title XXI
of the Social Security Act) if such coverage includes
immunosuppressive drugs

•

Being enrolled in the patient enrollment system of the
Department of Veterans Affairs (VA) (38 USC 1705) or
otherwise eligible to receive immunosuppressive drugs
from the VA

NOTE: If you enroll in any excluded health insurance
coverage, you must notify the Social Security Administration
(SSA) within 60 days of obtaining that health insurance
coverage.
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Form Approved
OMB No. 0938-1428
Expires: 02/25

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

APPLICATION FOR Application for Medicare Part B Immunosuppressive Drug
CoverageENROLLMENT IN PART B IMMUNOSUPPRESSIVE DRUG COVERAGE

WHEN DO YOU USE THIS FORM?

When can you sign up for Part B-ID?
You can sign up for Part B-ID anytime.

You should use this form:
•
If you or your child/dependent have lost or will be
losing Medicare coverage that was based on ESRD 36
months after a kidney transplant, and you/they want to
enroll in the Part B-ID benefit for coverage of
immunosuppressive drugs.
•
If you or your child/dependent are not enrolled in
any other health insurance coverage (except Medicaid or
CHIP that does not cover immunosuppressive drugs).
•
If you or your child/dependent do not expect to enroll
in any other health insurance coverage (except Medicaid or
CHIP that does not cover immunosuppressive drugs).
•
You do not currently have Medicare based on being
age 65 or older or based on having a disability.

If you enroll in Part B-ID before your Medicare coverage
ends, your Part B-ID coverage starts the month after
Medicare ends. If you enroll in Part B-ID after your Medicare
ends, Part B-ID will start the month after you enroll.

HOW DO YOU SUBMIT THIS FORM
Submit this form by mail
Mail your completed, signed form to:
Social Security Administration
Office of Central Operations
PO Box 32914

WHEN CAN YOU ENROLL?
Enrollment in Part B-ID can begin two months prior to the
termination of your Medicare based on ESRD or anytime
after ESRD termination. If you enroll prior to the
termination of your Medicare based on ESRD, your Part BID benefit will begin the month after ESRD Medicare
termination. If you enroll in Part B-ID after your ESRD
Medicare termination, Part B-ID will begin the month
following the enrollment.

WHAT INFORMATION DO YOU NEED TO
COMPLETE THIS FORM?
•

Applicant’s Medicare Number or Social Security Number

•

Applicant’s current address and phone number

HOW DO YOU SUBMIT THE FORM?
Complete and sign page 2 of this form and send it to
Social Security Administration Office of Central Operations,
PO Box 32914, Baltimore, Maryland 21298. You can apply for
this benefit by calling 1-877-465-0355.

HOW DO YOU GET HELP WITH THIS FORM?
•

Call Social Security at 1-800-772-1213. TTY users can call
1-800-325-0778.

•

Contact your local field office. Find an office near
you at www.ssa.gov.

•

En español: Llame a SSA gratis al 1-800-772-1213 y
oprima el 7 si desea el servicio en español y espere a
que le atienda un agente.

CMS-10798

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Baltimore, Maryland 21298
You can also apply for Part B-ID by calling 1-877-465-0355. TTY
users can call 1-800-325-0778.
Get help with this form
• Phone: Call Social Security at 1-800-772-1213. TTY users call
1-800-325-0778.
• En Español: Llame a SSA gratis al 1-800-772-1213 y oprima
el 2 si desea el servicio en español y espere a que le atienda
un agente.
• In person: Visit your local Social Security office for inperson help. Find an office near you at SSA.gov/locator.
State Health Insurance Assistance Program (SHIP): Visit
shiphelp.org to get free, personalized, and unbiased health
insurance counseling from your local SHIP.
Get information in another format
You have the right to get Medicare information in an
accessible format, like large print, braille, or
audio. You also have the right to file a complaint if you feel
you’ve been discriminated against. Visit
Medicare.gov/about-us/accessibility-nondiscriminationnotice, or call 1-800-MEDICARE (1-800-633-4227)
for more information. TTY users can call 1-877-486-2048.

2

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bullets or numbering, Tab stops: Not at 0.26"

Form Approved
OMB No. 0938-1428
Expires: 02/25

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Application for Medicare Part B Immunosuppressive Drug CoverageAPPLICATION FOR
ENROLLMENT IN PART B IMMUNOSUPPRESSIVE DRUG COVERAGE
1. Medicare Number/SSNSSN or Medicare Number
2. Your Name (Last Name, First Name, Middle Name, Last Name)

3. Mailing AddressHome Address (NuLeave blank if you don’t have onember and Street, P.O. Box, or Route)

City

State

Zip Code

State

Zip Code

4. Permanent AddressMailing Address (if different from homemailing address)

City

5. Phone Number (including area code)

(

)

–

Formatted: Tab stops: 3.1", Left

Email Address(optional)

By using this form to enroll in Part B for Immunosuppressive Drug Coverage,
I authorize Social Security and Medicare to send me emails about my benefits and coverage.
Formatted: Indent: Left: 0"

I attest that:
(Check Yes or No)

I am enrolled in, or expect to enroll in, certain other health insurance coverage.*
I will notify Social Security within 60 days if I enroll in other health insurance coverage.

No. If No,
No

Yes
Yes

*Please refer to page 1 for a complete description of the health insurance coverage that would preclude Part B-ID enrollment.

I understand that anyone who, knowingly and willfully —
(1) falsifies, conceals, or covers up by any trick, scheme, or device a material fact;
or
(2) makes any materially false, fictitious, or fraudulent statements or representations, or makes or uses any
materially false writing or document knowing the same to contain any materially false, fictitious, or fraudulent
statement or entry, in connection with the delivery of or payment for health care benefits, items, or services,
shall be fined or imprisoned not more than 5 years, or both.1
I don’t have any of the following coverage:
• Employer Group Health Plan or IndividualHealth Plan (defined in section 2791 of the Public Health
Service Act)
• TRICARE for Life (established at 10 USC 1086(d))
• Medicaid (Title XIX of the Social Security Act) or State Children’s Health Insurance Program (CHIP)
(Title XXI of the Social Security Act) if such coverage includes immunosuppressive drugs
• Enrolled in the patient enrollment system of the Department of Veterans Affairs (VA) (38 USC 1705) or
otherwise eligible to receive immunosuppressive drugs from the VA
If I enroll in any of these excluded health coverages I’ll notify Social Security within 60 days
of obtaining that coverage
I understand that anyone who makes a false statement to enrollin a health care benefit program may be
fined or imprisoned or both1
Signature (DO NOT PRINT)
SIGN HERE

Formatted: Indent: Left: 0.31", No bullets or
numbering

Date Signed

/

/

IF THIS APPLICATIO N HAS BEEN SIGNED BY MARK (X), A WITN ESS WHO KNOWS THE APPLICANT
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Form Approved
OMB No. 0938-1428
Expires: 02/25

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Application for Medicare Part B Immunosuppressive Drug CoverageAPPLICATION FOR
ENROLLMENT IN PARTMUST
B IMMUNOSUPPRESSIVE
DRUG COVERAGE
SUPPLY THE INFORMATION REQUE STED BELO W. If this application has
been signed by mark (x), a witness who know s the person must also sign below.

Name of Witness (First and Last Name)Signature of Witness

Date Signed

/

/

Address of WitnessSignature of Witness

1

18 U.S. Code § 1035 - False statements relating to health care matters
(a) Whoever, in any matter involving a health care benefit program, knowingly and willfully—
(1) falsifies, conceals, or covers up by any trick, scheme, or device a material fact;
or
(2) makes any materially false, fictitious, or fraudulent statements or representations, or makes or uses any materially false writing or
document knowing the same to contain any materially false, fictitious, or fraudulent statement or entry, in connection with the delivery
of or payment for health care benefits, items, or services, shall be fined under this title or imprisoned not more than 5 years, or both.
(b) As used in this section, the term “health care benefit program” has the meaning given such term in section 24(b) of this title.

Submit this form by mail
Mail your completed, signed form to:
Social Security Administration Office of Central Operations PO Box 32914 Baltimore, Maryland 21298
You can also apply for Part B-ID by calling 1-877-465-0355. TTY users can call 1-800-325-0778.

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Form Approved
OMB No. 0938-1428
Expires: 02/25

STEP BY STEP INSTRUCTIONS FOR FILLING OUT THIS APPLICATION
1.

Applicant’s social security number (or applicant’s Medicare Number): Enter your Social Security Number, or if you already
have Medicare, you can enter your Medicare Number instead.

2.

Name: Enter your name. List your last name, first name, and middle name (if you have one) in that order.

3.

Mailing address: Enter your full mailing address, including the number and street name, city, state, and ZIP code. You can
enter a P.O. Box or route.

4.

Address of permanent residence: If you live at a different address than where you get mail, enter the full address,
including the number and street name, city, state and ZIP code.

5.

Phone number: Enter your daytime phone number in case a representative needs to contact you for additional
information.

Enrollment in the Part B-ID Benefit
Check the box to attest that you meet the requirements for entitlement to the Part B-ID benefit.
Refer to page 1 under the description of Other Health Insurance Coverage.
PRIVACY ACT STATEMENT: Social Security is authorized to collect your information under sections
1836, 1840, and 1872 of the Social Security Act, as amended (42 U.S.C. 1395o, 1395s, and
1395ii) for your enrollment in Medicare Part B. Social Security and the Centers for Medicare &
Medicaid Services (CMS) need your information to determine if you’re entitled to Part B. While you
don’t have to give your information, failure to give all or part of the information requested on
this form could delay your application for enrollment.
Social Security and CMS will use your information to enroll you in Part B. Your information may be
also be used to administer Social Security or CMS programs or other programs that coordinate
with Social Security or CMS and in accordance with System of Records Notice (SORN) “HHS/
CMS/CBC Enrollment Database”, System No. 09-70-0502, 73 Federal Register 10249, February
26th, 2008 and as permitted by the Privacy Act of 1974, to:
1) Determine your rights to Social Security benefits and/or Medicare coverage.
2) Comply with Federal laws requiring Social Security and CMS records (like to the Government

Accountability Office and the Veterans Administration)
3) Assist with research and audit activities necessary to protect integrity and improve Social

Security and CMS programs (like to the Bureau of the Census and contractors of Social
Security and CMS). We may verify your information using computer matches that help
administer Social Security and CMS programs in accordance with the Computer Matching and
Privacy Protection Act of 1988 (P.L. 100-503).

PRA DISCLOSURE STATEMENT: 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 0938-1428. The time required to
complete this information collection is estimated to average 10 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 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 212441850.

CMS-10798

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Form Approved
OMB No. 0938-1428
Expires: 02/25

PRIVACY ACT STATEMENT: Social Security is authorized to collect your information under sections 1836, 1840, and 1872 of the Social Security
Act, as amended (42 U.S.C. 1395o, 1395s, and 1395ii) for your enrollment in Medicare Part B. Social Security and the Centers for Medicare &
Medicaid Services (CMS) need your information to determine if you’re entitled to Part B. While you don’t have to give your information, failure to
give all or part of the information requested on this form could delay your application for enrollment.
Social Security and CMS will use your information to enroll you in Part B. Your information may be also be used to administer Social Security or
CMS programs or other programs that coordinate with Social Security or CMS and in accordance with System of Records Notice (SORN) “HHS/
CMS/CBC Enrollment Database”, System No. 09-70-0502, 73 Federal Register 10249, February 26th, 2008 and as permitted by the Privacy Act of
1974, to:
1) Determine your rights to Social Security benefits and/or Medicare coverage.
2) Comply with Federal laws requiring Social Security and CMS records (like to the Government Accountability Office and the Veterans
Administration)
3) Assist with research and audit activities necessary to protect integrity and improve Social Security and CMS programs (like to the Bureau of
the Census and contractors of Social Security and CMS). We may verify your information using computer matches that help administer Social
Security and CMS programs in accordance with the Computer Matching and Privacy Protection Act of 1988 (P.L. 100-503).

PRA DISCLOSURE STATEMENT: 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 0938-1428. The time
required to complete this information collection is estimated to average 10 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 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.
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 the Social Security Administration at 1-800-772-1213. TTY users can call 1-800-325-0778.

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