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Medicare Eligibility Statement - Wisconsin Department of

Medicare Eligibility Statement - Wisconsin Department of 2026

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The document is a Medicare Eligibility Statement from the Wisconsin Department of Employee Trust Funds, requiring individuals to provide their Medicare information for enrollment in health insurance. It outlines the necessity for both Hospital Part A and Medical Part B enrollment, details on prescription drug coverage, and instructions for submitting the form. Additionally, it includes important information regarding changes in health plans upon Medicare enrollment and nondiscrimination policies.

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Click ‘Get Form’ to open the Medicare Eligibility Statement in the editor.
Begin by entering your personal information, including your name, telephone number, and mailing address. Ensure that all details are accurate and legible.
In the section for 'All Persons Insured Under Your Group Health Insurance Policy', list everyone covered under your plan. For each individual, provide their Medicare number and effective dates for both Hospital (Part A) and Medical (Part B).
Indicate whether you will use the state’s Navitus MedicareRX plan by selecting 'Yes' or 'No'. If you choose 'No', specify which plan you will use.
Sign and date the form at the bottom. Make sure to attach a copy of your Medicare card or any relevant documentation before submitting.
Once completed, save your document and return it via mail or fax to ETF as instructed.

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Versions	Form popularity	Fillable & printable
2024	4.1 Satisfied (56 Votes)
2020	4.1 Satisfied (47 Votes)
2014	4.9 Satisfied (59 Votes)

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How do you get Medicare at age 55?

If you are age 65 or older and receive Social Security benefits, you will be automatically enrolled in Part A. Part A coverage begins up to 6 months before the month you apply if you are over 65. Contributing to a Health Savings Account (HSA) after your Medicare coverage begins may result in additional taxes.

Can you get on Medicare at age 62?

You can be eligible for Medicare before 65 if you meet specific requirements, e.g., receive a pension from the Railroad Retirement Board, have permanent kidney failure, or other exceptions specified by Medicare. If you receive coverage through Medicaid.

How much is Medicare in Wisconsin?

Medicare Individual and Medicare All Rates Health PlanIndividualMedicare All Health PlanIndividualMedicare All GHC of Eau Claire Greater WI $845.56 $1,662.94 GHC of Eau Claire River Region $904.32 $1,780.46 GHC-SCW Dane Choice $589.40 $1,150.6218 more rows

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