Medicare Acknowledgement Form

(If you continue to work past age 65 or are Medicare eligible AND have Group Coverage, please complete this form.)

If you are working and eligible for benefits, you and your covered Medicare eligible dependents do not have to enroll in Medicare. The Tax Equality and Fiscal Responsibility Act of 1982 (TEFRA) mandates that employer group health plans remain the primary and Medicare would be your secondary insurance. Enrollment in Medicare as an active employee will not reduce your group premiums. If you want Medicare coverage to be primary insurance you must discontinue your group coverage within 31 days of the effective date of your Medicare coverage. NOTE: you can enroll in Medicare coverage when you retire and not pay a penalty as long as you are not enrolled in certain High Deductible Health Plans.

Please complete the form below, indicating your choice of primary insurance payer- if you will continue to be employed after you become eligible for Medicare coverage. The decision to enroll in Medicare while actively working and eligible for employer sponsored benefits should be based on your personal circumstances.
Employer Group Benefit Plan
Medicare Coverage Election
(Complete ONLY if you are continuing to work after age 65 or eligible for Medicare prior to age 65 and eligible for employer group benefits)

I have read the information concerning TEFRA legislation and understand that my employer is required to pay primary benefits as long as I remain eligible for benefits and continue to carry group coverage as an active employee for my dependents and myself when I become eligible for Medicare unless I choose to discontinue group coverage.
Primary Payer Election
(Select One of these Statements)
Choose One: (based on your decision after your call with your advisor*

I desire to keep my Employer Plan (group coverage) as my primary payer of Health benefits if I remain an active and eligible employee.I desire to have Medicare as my primary payer of health benefits. I understand that I must discontinue my group coverage and enroll in Medicare for Medicare to pay primary benefits. I also understand that re-enrollment into the group plan is limited and that I cannot re-enroll in my group plan is limited. I will not be able to re-enroll until the next Open Enrollment period. I understand that Open Enrollment is limited to active eligible employees and dependents.
If you elected Medicare as your primary coverage, please complete the following fields:
Part A Effective Date:

MonthDayYear
Date
Part B Effective Date:

MonthDayYear
Date
Group Disenrollment Date:

MonthDayYear
Date
I understand the options that I have and the decision I have made was with no encouragement, incentive or enticement from my employer. I have made this decision on my own based on my personal circumstances.
Name:*
Employer Name:*
Signature:

Clear
Date*

MonthDayYear
Date
Should be Empty:

Employer Group Benefit Plan

Medicare Coverage Election

Primary Payer Election

(Select One of these Statements)