The University has partnered with GoHealth, a marketplace for Medicare plans, to assist employees in finding a plan that best meet your needs. Please see the following GoHealth flyers for more information and helpful tips:

• Find Medicare Coverage
• What You Need To Know When You Turn 65
• Navigating Medicare

Contact GoHealth at (866) 246-9681 (TTY Users 711) to speak with a licensed agent. 

Who Can Use This Application

People with Medicare who have Part A but not Part B

When Do You Use This Application

• If you're in your Initial Enrollment Period (IEP) and live in Puerto Rico. You must sign up for Part B using this form.
• If you're in your IEP and refused Part B or did not sign up when you applied for Medicare, but now want Part B.
• If you want to sign up for Part B during the General Enrollment Period (GEP) from January 1 – March 31 each year.
• If you refused Part B during your IEP because you had group health plan (GHP) coverage through your or your spouse's current employment. You may sign up during your 8-month Special Enrollment Period (SEP).
• If you have Medicare due to disability and refused Part B during your IEP because you had group health plan coverage through your, your spouse or family member's current employment.
• You may sign up during your 8-month SEP.

NOTE: Your IEP lasts for 7 months. It begins 3 months before your 65th birthday (or 25th month of disability) and ends 3 months after you reach 65 (or 3 months after the 25th month of disability)

Access the application.

What Is The Purpose Of This Form

In order 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.

The employer that provides the group health plan coverage completes the information about your health care coverage and dates of employment.

How Is The Form Completed

• Complete the first section of the form so that the employer can find and complete the information about your coverage and the employment of the person through which you have that health Coverage.
• The employer fills in the information in the second section and signs at the bottom.

Access the request for employment information form.