HBN001 – AUTOMATED CMS BILLING NOTICE USED WITH HIB225

(appears after the signature page of the notice)

NOTICE OF MEDICARE PREMIUM PAYMENT DUE

CENTERS FOR MEDICARE & MEDICAID SERVICES

BILLING DATE: (1)

MEDICAL PREMIUMS FOR

PERIOD ENDING: (2)

CURRENT AMOUNT DUE: (3)

PAYMENT DUE BY: (4)

• •

  Return the bottom portion of this notice with your payment and use the enclosed envelope to mail your payment.

• •

  You must pay by check or money order. Include your Medicare number at the top of your check or money order. Make the check or money order payable to: CMS MEDICARE INSURANCE.

• •

  If you have changed your address, be sure to write your new address in the space provided below.

 

PLEASE DETACH AT DOTTED LINE

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------

CMS-500A

 

Medicare Number: (5) Amount Due: (6)

Name: (7)

( ) Check here if your Make Checks Payable To:

address has changed. CMS MEDICARE INSURANCE

Show new address below.

Send To:

Medicare Premium Collection Center
P.O. Box 790355
St. Louis, MO 63179-0355

 

HDR030 - DATE AND BENEFICIARY NOTICE CONTROL NUMBER

HIBC01 – CAPTION

Information About Medicare

HIBC02 – CAPTION

Health Insurance For Children

HIBC05 – CAPTION

Why (1) Cannot Quality For Medicare

 

HIBC14 – CAPTION

How to Apply for Immunosuppressive Drug Coverage

HIBC15 – CAPTION

To Cancel This Insurance

HIBC16 – CAPTION

If You Need Coverage for Immunosuppressive Drugs Only

HIBC18 – CAPTION

If You Need Help With Costs for the Immunosuppressive Drug Coverage

HIBC19 – CAPTION

Notice of Group Billing

HIBC20 – CAPTION

Apply for Medicare

HIBC21 – CAPTION

If You Need Health Coverage through Marketplace or Medicaid

HIB350 – ENTITLED TO HI AND/OR SMI

Your Medicare (1) (2) (3) (4).

HIB002 -TEMPORARY SUBSTITUTION OF NOTICE FOR HEALTH INSURANCE CARD

You will get a Medicare card within 2 weeks. You should show this card when you need medical care. To learn more about what Medicare covers, visit Medicare.gov. If you have questions about your Medicare coverage, call 1-800-MEDICARE (1-800-633-4227).

HIB344 – SMI PREMIUM BILLING

Your monthly premium for Medicare Part B (medical insurance) is (1) beginning (2) (3) (4).

HIB345 – SMI PREMIUM DEDUCTIONS

We will start to take premiums out of your (1) check.

HIB011 – HI PREMIUM BILLING

The monthly premium for your hospital insurance is (1). We will bill you each month for (2).

HIB346 – MEDICARE HI/SMI PREMIUM PENALTY

(1) a premium surcharge because you enrolled later than you could have.

HIB015 – PREMIUMS DEDUCTED FROM CIVIL SERVICE ANNUITY

The Office of Personnel Management will deduct the premiums from your annuity checks. They will let you know when this will start.

HIB026 – 3RD PARTY BUYIN TP STARTS DATES/CODES DO NOT MATCH

(1) (2) will pay your Medicare hospital insurance premiums beginning (3). (4)

(5) (6) will pay your Medicare medical insurance premiums beginning (7). (8)

HIB027 – 3RD PARTY BUYOUT TP STARTS DATES/CODES DO NOT MATCH

(F1) (F2) will no longer pay your Medicare hospital insurance premiums after (F3). You must pay the premiums beginning (F4).

(F5) (F6) will no longer pay yourMedicare medical insurance premiums after (F7). You must pay the premiums beginning (F8).

HIB029 – LIMITED BUYIN FOR HI/SMI DATES/CODES DO NOT MATCH

(1) (2) paid your Medicare hospital insurance premium for (3).

(4) (5) paid your Medicare medical insurance premium for (6).

HIB030 – GROUP PAYER STOPS FOR HI/SMI DATES NOT EQUAL

The organization that was paying your Medicare hospital insurance premium will no longer pay it after (F1). You must pay the premium beginning (F2).

The organization that was paying your Medicare medical insurance premium will no longer pay it after (F3). You must pay the premium beginning (F4).

HIB034 –ADVISE THAT SMI DEDUCTION WILL START/CONTINUE

We will (1) to deduct Medicare Part B (medical insurance) premium of (2) from your payments.

HIB347 – MEDICARE DISALLOWANCE CRIME AGAINST UNITED STATES

You cannot qualify for Medicare because you been convicted of a crime against the Security of the United States.

HIB348 – MEDICARE DISALLOWANCE FEHB ACT OF 1959

You cannot qualify for Medicare because you would be covered under the Federal Employees Health Benefits Act

HIB050 – MED DISAL NH AGE 65 BEFORE END OF WAITING PERIOD

You do not qualify for Medicare based on disability because your coverage cannot start before you reach age 65.

To receive Medicare coverage before age 65, a person must be disabled under our rules for 29 months before coverage begins. Based on the date you said you became disabled, coverage could not begin until after you reach age 65. For this reason, we have not decided whether or not you are disabled.

You may qualify for Medicare when you reach age 65, whether or not you are disabled under our rules.

HIB053 – PREMIUM HI DENIED AND/OR SMI DISALLOWED (RDD 107)

You are not entitled to (F1) insurance coverage under Medicare because the application was not filed during an enrollment period and you did not qualify for a special enrollment period. However, you may apply for coverage again during the next general enrollment period. A general enrollment period takes place in January, February and March of each year.

HIB054 – HI AND/OR SMI PERIOD NOT PREVIOUSLY COVERED

If you have had any expenses that you believe should be covered by Medicare (F1) insurance, please contact your local Social Security office. The telephone number and address are shown below.

HIB060 – SUSPENSE FOR PRISON/MENTAL ADVISES OF SMI PREMIUMS

Generally, Medicare will not pay for hospital or medical items or services you receivewhile you are (F1). However, you may want to pay your Medicare medical insurance premiums for two reasons:

• The premiums may be higher if you cancel the Medicare medical insurance now and reenroll after you arereleased from (F2).

• You may not have medical insurance for a period of time after you are released from (F3). This is because you will have to wait until a general enrollment period to reenroll. A general enrollment period takes place in January, February and March of each year.

If you want to cancel your medical insurance, please let us know. If you decide to keep Medicare medical insurance, we will bill you for the premium. The first bill we send will be for all premiums now due. After that, each bill we send will be for a 3-month period and will be sent to you shortly before the payment is due.

HIB061 – SMI PREMIUM CONTINUES DEDUCTION FROM CS ANNUITY

The Office of Personnel Management will continue to deduct your medical insurance premiums from your annuity checks.

HIB066 – HI/SMI PREMIUMS ALREADY PAID

Any (1) insurance premiums you have already paid will be credited to your record.

HIB067 – SMI PREMIUM BILLING

We will send your first bill for the premiums within a month. Each bill after that will be for a 3-month period.

HIB349 – HI/SMI EQUITABLE RELIEF

If you want these benefits earlier, you can choose (1) insurance benefits beginning (2). To start benefits earlier, within 60 days after the date of this notice you must tell us in writing that you want (3) insurance benefits beginning (4). In addition, you must:

• •

  pay us (5) (this covers premiums due from (6) through (7)); or

(8)

HIB069 – HI/SMI TERMINATION FOR NON-PAYMENT OF PREMIUMS

Your Medicare premium (F1) for (F2) insurance was not paid within the time limit. Therefore, your (F3) insurance coverage has stopped. Your last month of coverage(F4) (F5) . Benefits will not be paid for any (F6) services you receive after your last month of coverage.

HIB070 – PREMIUM HI DWI CONTINUES SMI TERMINATES NON-PAYMENT

This decision does not affect your (F1) insurance coverage. You should continue to pay (F2) insurance premiums to keep this coverage.

HIB071 – RRB JURIS STARTS AND COLLECTS MEDICARE PREMIUMS

The Social Security Administration is no longer responsible for deducting Medicare premiums from Social Security payments. The Railroad Retirement Board (RRB) is now responsible for collecting medical insurance premiums for all railroad beneficiaries and their families. This includes beneficiaries who are also entitled to Social Security benefits.

HIB072 – RRB JURIS STARTS AND COLLECTS MEDICARE PREMIUMS

Since you are a railroad beneficiary, the RRB will start to withhold medical insurance premiums from your Railroad Retirement annuity. If you are not currently receiving a Railroad Retirement annuity, the Social Security Administration will let the RRB know when your next premium is due. The RRB will send you a bill for premiums.

HIB073 – RRB SENDS NEW MEDICARE CARD

Your protection under Medicare will continue without any change in coverage.

The RRB will send you a new Medicare card. Until then, you may use your old card.

HIB074 – NEW MEDICARE CARD

We will send you a new health insurance card. It will show that you are entitled to (1) insurance.

HIB075 – EQUITABLE RELIEF/HARDSHIP

If you want benefits beginning (1) but find it hard to pay the premium amount in a lump sum, ask us about other ways to pay the money.

HIB076 – HI/SMI TERMINATION INFORMATIONAL

If you do not sign up for Part B when you are first eligible, you may have to pay a late enrollment penalty for as long as you have Part B. Your monthly premium may go up 10 percent for each full 12-month period that you could have had Part B coverage, but did not sign up for it. Usually, you will not have to pay a late enrollment penalty if you sign up during a special enrollment period.

 If you want to sign up for (1) later, you will usually have to wait until the general enrollment period. The general enrollment period takes place in January, February, and March of each year. If you sign up in the general enrollment period, your Part B coverage will start the month after you enroll.

HIB077 – SMI TERMINATION INFORMATIONAL

People who have Medicare Part B (medical insurance) pay a monthly premium. If you do not sign up for Part B when you are first eligible, you may have to pay a late enrollment penalty for as long as you have Part B. Your monthly premium may go up 10 percent for each full 12-month period that you could have had Part B coverage, but did not sign up for it. Usually, you will not have to pay a late enrollment penalty if you sign up during a special enrollment period.

HIB078 – HI TERMINATION INFORMATIONAL

Your monthly premium for hospital insurance may be 10 percent higher when you enroll.

HIB079 – VOLUNTARY TERMINATION FOR PREMIUM HI OR SMI

Because you are canceling your (3) insurance coverage, you are no longer entitled to (2) insurance coverage. your hospital and medical insurance coverage ends on the last day of (3).

HIB080 – VOLUNTARY SMI TERMINATION CIVIL SERVICE INVOLVED

The Office of Personnel Management will no longer deduct the medical insurance premiums from your annuity checks. They will let you know when the deductions will stop.

HIB082 – HI AND/OR SMI VOLUNTARY TERMINATION

You asked that we stop your (1) insurance coverage under Medicare. This coverage ends the last day of (2).

HIB083 – SPECIAL ENROLLMENT PERIOD DISABILITY

You may also be able to enroll during a special enrollment period. You may do this if you meet one of the conditions listed below:

• •

  You have covered under a group health plan through your current work or your spouse's current work, or

• •

  You have covered under a large group health plan through your current work or any family member's current work.

You can use a special enrollment period during these times:

• •

  At any time you, your spouse, or your family member is working, and you havecoverage under that group health plan.

• •

  During the eight months after the work ends or your coverage under that plan ends, whichever happens first.

• •

  When the type of plan changes.

HIB084 – SPECIAL ENROLLMENT PERIOD AGED

You may also be able to enroll during a special enrollment period. You can do this if you meet all of the conditions listed below:

• •

  You have health insurance coverage under an employer's group plan because you or your spouse works.

• •

  You have had coverage under that plan since you became age 65.

• •

  You can use a special enrollment period during these times:

• •

  At any time you or your spouse is working, and you have coverage under that employer’s group health plan, and

• •

  During the eight months after the work ends or your coverage under that plan ends, whichever happens first.

HIB085 – VOLUNTARY SMI TERMINATION CURRENT PAY

We will stop taking premiums for medical insurance out of your checks.

HIB086 – VOLUNTARY HI/SMI TERMINATION PREMIUMS DUE

You were (1) in premiums through (2). Please make your check or money order payable to the "Centers for Medicare & Medicaid Services" and mail it to us in the enclosed envelope. Include your Medicare number on your check or money order.

HIB087 – VOLUNTARY SMI TERMINATION HI CONTINUES / MEDICARE WILL CONTINUE AFTER REQUEST FOR STATUTORY BENEFIT CONTINUATION (SBC) IS PROCESSED

Your (1) coverage will continue.

HIB088 – HI/SMI FOREIGN ADDRESS

Normally, Medicare will only pay for (1) services which you receive in the United States. Since you are living outside the U.S., Medicare will not pay for your services unless you return to the U.S. for services.

HIB089 – BENE AT FRA PROVISION PAYMENTS END HI/SMI ENDS

Since you are no longer receiving provisional monthly Social Security benefits, we are stopping your (1) insurance coverage. This coverage ends the last day of (2). Please destroy your Medicare card after coverage ends.

HIB090 – TERMINATION ALL MEDICARE COVERAGE

Your Medicare card will not be valid when your (1) coverage ends. Please destroy your card after your coverage ends.

HIB092 – STATE/LOCAL GOVT CONTINUES TO PAY SMI PREMIUM

 

Your State or local government retirement system will continue to pay your Medicare medical insurance late enrollment premium penalty. You must continue to pay the basic Medicare medical insurance premium.

HIB093 – STATE OR GROUP CONTINUES TO PAY SMI PREMIUMS

Our records show that (1) will continue to pay the premiums for your Medicare (2) insurance coverage.

HIB101 – MEDICARE STATE BUY-IN

(1) (2) will pay your Medicare (3) insurance premium beginning (4). (5)

HIB102 – STATE BUY-OUT

(1) (2) will no longer pay your Medicare (3) insurance premiums after (4). You must pay the premiums beginning (5).

If you disagree or have questions about the State’s determination to stop paying the premiums, please call the State Medicaid office. If you recently received a notice from the State Medicaid office telling you that you lost benefits, follow the instructions in the notice about the best way to contact them.

HIB103 – LIMITED BUY-IN AND BUY-OUT

(1) (2) paid your Medicare (3) insurance premium for (4).

HIB104 – LIMITED ST BUY-IN/BUY-OUT NO CHANGE IN COVERAGE

This does not change our records, which show that (1) Medicare (2) insurance coverage.

HIB105 – RETRO BUYIN/BUYOUT PAST DUE PREMIUMS

Our records also show that you still owe premiums through (1).

HIB106 – STATE BUYIN FOR SMI PREMIUM PENALTY ONLY

We must charge a premium penalty on your Medicare medical insurance because you enrolled later than you could have. Your State or local government retirement system will pay your medical insurance late enrollment premium penalty beginning (1). However, you must pay the basic Medicare medical insurance premium.

HIB107 – STATE STOPS PAYING SMI PREMIUM PENALTY

Your State or local government retirement system will no longer pay your Medicare medical insurance late enrollment premium penalty after (1). You must pay the basic premium and the penalty beginning (2).

HIB108 – GROUP PAYER BUY-OUT

The organization that was paying your Medicare (1) insurance premium will no longer pay it after (2). You must pay the premium beginning (3).

HIB109 – 3RD Party SMI PREMIUM DEDUCTED FROM MBA

We will deduct the (1) of (2) from your monthly payment. Later in this letter, we tell you what to do if you disagree with this change in the amount of your monthly payment.

HIB110 – SMI PREMIUM DEDUCTED FROM MBA PAST DUE PREMIUMS

We will deduct the (1) of (2) from your monthly payment. We will also deduct the past due premiums, which total (3). Later in this letter, we tell you what to do if you disagree with this change in the amount of your monthly payment.

HIB111 – BUY-IN AND REFUND OF MEDICARE PREMIUMS

• •

  This money is a refund owed to you for Medicare (1) premiums you paid since (2).

HIB112 – BUYIN PREMIUM NO LONGER DEDUCTED FROM MBA

We will no longer deduct the premium from your monthly payment. Later in this letter, we tell you what to do if you disagree with this change in the amount of your monthly payment.

HIB113 – BUY-OUT NOT IN PAY STATUS PREMIUM BILLING

We will send your first bill for the (1) within a month. The monthly (2) (3). (4) Please contact us if you do not receive the first bill within a month.

HIB114 – BENEFITS TERM PROFRA MEDICARE CONTINUES

Your Medicare coverage will continue because you are age 65 or older.

HIB115 – HI/SMI BUY-OUT

If you want to cancel your Medicare (1), please contact us. If you cancel your insurance, the date your coverage stops de-pends on when you cancel it:

• If you cancel it within 30 days from the date of this letter, your coverage stops when the State stops paying your premiums.

• If you cancel it after 30 days but within 6 months from the date of this letter, your coverage stops at the end of the month in which you ask us to cancel it.

• If you cancel it after 6 months from the date of this letter, your coverage stops at the end of the next month after you contact us.

HIB119 – BILLING TO CONFIRM GROUP PAYER

You recently arranged for an organization to pay your Medicare (1) insurance premium. Although we will send the bills to this organization, you are responsible for seeing that they are paid.

If this organization decides to stop paying your premium, we will again send the bills to you.

If there is any other change in your Medicare premium, we will let you know.

HIB120 – BUY-OUT FOR HI AND SMI

You can cancel hospital insurance coverage and keep medical insurance coverage, or cancel both. However, you cannot keep hospital insurance coverage without medical insurance coverage. So if you cancel medical insurance coverage, hospital insurance coverage will end at the same time.

HIB131 – MEDICARE CONTINUES BASED ON AGE, DIB, OR ESRD

However, Medicare coverage will continue because (1) (2).

HIB132 – ESRD TERMINATES AND RRB JURISDICTION

However, since the Railroad Retirement Board (RRB) handles (1) hospital and medical insurance (2) Medicare coverage will continue unless the RRB tells (3) they are stopping (4) coverage.

HIB133 – ESRD TERMINATION - SAME HI/SMI TERMINATION DATES

Your Medicare coverage based on your kidney condition ends (1)

HIB134 – ESRD TERM HI TERM DATE EARLIER THAN SMI TERM DATE

Your hospital insurance coverage ended on (1).  Your medical insurance coverage will end on (2).

HIB135 – ESRD TERM HI TERM DATE EARLIER THAN SMI TERM DATE

Medicare coverage based on a kidney condition usually ends the last day of the (1) month after the month you get a transplant unless before then you again:

• begin regular dialysis, or

• get a kidney transplant.

Since (2) in (3), your Medicare coverage should have ended the last day of (4). Your hospital insurance did end on that date. But, because we didn't take action in time, we must continue your medical insurance coverage until the date shown above.

HIB136 – TERMINATION OF ESRD COVERAGE

Let us know right away if you resume regular dialysis again or get a kidney transplant so you can file a new claim for Medicare coverage based on your kidney condition.

HIB137 – ESRD TERMINATES SAME HI/SMI TERMINATION DATES

Medicare coverage based on a kidney condition ends the last day of the (1) month after (2), unless before then you get:

• •

  a kidney transplant, or

• •

  resume regular dialysis.

Our records show that you (3) (4).

HIB142 – CURRENT PAY TO SUSPENSE OR DEFERRED STATUS

We will continue to charge a monthly premium for your medical insurance under Medicare.

HIB143 – SMI PENALTY RATE TO BASE RATE AT AGE 65

Under a special provision of the Social Security Act, now that you qualify for Medicare medical insurance based on your age, your monthly medical insurance premium amount has been reduced from (1) to (2).  

HIB151 – LIMITED BUY-IN/BUY-OUT - COVERAGE CONTINUES

You must pay the premium beginning (1).

HIB154 – EXPLANATION OF BENFITS WHEN MEDICARE IS THE SECONDARY PAYER WHEN THE BENEFICARY IS WORKING AND COVERED BY HIS OR HER EMPLOYER

Are you working for an employer who has 20 or more employees? Are you covered under this employer's group health plan? If so, the employer’s plan will pay first for health care services. Medicare will pay secondary benefits when the employer's plan doesn't cover all of the expenses.

Contact your nearest Social Security office for more information about Part B Medicare special enrollment.

HIB157 – PIC C'S NOTICE WHEN CHILD < AGE 19 AND NO OPEN HI

If this notice is for a child under age 19 who is not covered by health insurance, there is a Children's Health Insurance Program that may help. To find out more, you can look on the Internet at www.insurekidsnow.gov or call, toll free, 1-877-KIDS-NOW (1-877-543-7669). The number connects you to your state program.

HIB160 – HI/SMI REVERSAL - NOT TIMELY BUT IN GEP

We received your cancellation of your earlier request that your Medicare (1) insurance coverage be terminated. Although this cancellation request was filed too late for the coverage to be reinstated without interruption, it was filed during a period in which you could reenroll. This difference is important because there are months for which you do not have Medicare (2) insurance coverage.

HIB161 – HI/SMI REVERSAL NOT FILED TIMELY NOT IN GEP

We stopped your Medicare (1) insurance at your request. Then you decided that you still wanted it. You decided too late for us to start your Medicare (2) insurance again at this time.

HIB162 – REFUSAL OVER AUTOMATIC ENROLLMENT

You told us that you do not want (1) insurance under Medicare.

HIB163 – SMI REFUSAL CURRENT PAY REFUND OF PREMIUMS

You do not have to pay a premium for any months you were not entitled to Medicare Part B (medical insurance).  If we took out premiums for any of these months, we will return the money to you.

HIB164 – SMI REFUSAL PREMIUM BILLING AND NO OPEN THIRD PARTY

You do not have Medicare (1) coverage. If you get a bill for Medicare (2) premiums, please destroy it. 

HIB165 – REFUSAL/WITHDRAWAL STATE BUY-IN ESTABLISHED

Our records show that your State has agreed to pay the premiums for your Medicare (1) insurance coverage. Therefore, you will continue to be enrolled.

HIB170 – MEDICARE COVERAGE WILL CONTINUE WHILE MEDICAL CESSATION APPEAL IS PENDING EVEN THOUGH PAYMENTS HAVE CEASED (STATE BUY-IN IS NOT INVOLVED)

Even though you are no longer receiving monthly payments, you will still have (1) coverage under Medicare. (2)

(3)

HIB171 – MEDICARE COVERAGE WILL CONTINUE WHILE MEDICAL CESSATION APPEAL IS PENDING EVEN THOUGH PAYMENTS HAVE CEASED (STATE BUY-IN IS INVOLVED)

Even though you are no longer receiving monthly payments, you will still have Part A (hospital insurance) and Part B (medical insurance) coverage under Medicare. (1) The State where you live will continue to pay the premiums for your Part B coverage. 

HIB175 – SMI PREMIUMS/ARREARAGE DEDUCTED FROM PMA OR CMA

We are deducting past-due premiums (1) from your payment.

If the deduction of past-due premiums causes a financial hardship, ask us about options for financial relief.

HIB176 – SMI PREMIUMS/ARREARAGE DEDUCTED FROM PMA OR CMA WHEN BENEFITS ARE RESUMED

Since benefits are again payable we will resume withholding your medical premiums due to date.

HIB182 – IRMAA AMOUNT STARTS, IRMAA AMOUNT CHANGES OR IRMAA AMOUNT NO LONGER APPLIED TO SMI PREMIUM (PART B)

In an earlier letter, we told you that your Medicare Part B (medical insurance) premium includes:

• •

  the standard Part B premium amount,

• •

  any surcharge that may apply for late enrollment or reenrollment, and

• •

  an income-related monthly adjustment amount (IRMAA).

If you have prescription drug coverage, you also must pay a prescription drug coverage IRMAA. The IRMAA is in addition to your monthly premium. We base the IRMAA on your income. We deduct the IRMAA from your monthly Social Security benefits, regardless of how you pay your premiums.

HIB183 – USE WITH HIB182 WHEN IRMAA AFFECTS PART B RATE

We sent you another letter that explained how we determined the amount of your premium.

HIB184 – USE WITH HIB182 WHEN BENEFICIARY WILL CONTINUE TO BE BILLED FOR PART B SMI PREMIUMS

We will continue to bill you for (1) Medicare Part B premiums.

HIB185 – USE WHEN HIB182 IS GENERATED AS THE INTRODUCTORY UTI AND BENEFICIARY'S LAF IS CURRENT PAY OR DEFERRED

The amount you will receive around (1) was changed because of a change in your monthly Medicare Part B premium.

HIB186 – SMI MATURITY AND NO IRMAA DATA ON POST MBR

IMPORTANT: A Medicare law requires some higher income persons to pay higher premiums. The law applies to premiums for Medicare Part B (medical insurance), prescription drug coverage, and Medicare Part B Immunosuppressive Drug coverage. The law generally affects individuals with incomes higher than (1) and couples with incomes higher than (2). We will contact the Internal Revenue Service to get information about your income. If we decide that you have to pay higher premiums, we will send a letter explaining our decision. The higher amount will be effective (3). For more information, please visit www.socialsecurity.gov on the Internet or call us toll-free at 1-800-772-1213 (TTY 1-800-325-0778).

HIB215 – T2 BENEFITS TERMINATE HI/SMI TERMINATES

Since you are no longer entitled to monthly Social Security benefits, we are stopping your (1) insurance coverage under Medicare. Your (2) insurance coverage ends on the last day of (3). Please destroy your Medicare card after the coverage ends.

HIB218 – REASON SMI PREMIUM/ARREARAGE IS BEING DEDUCTED

When we figured the amount of your payment, we took into account all medical insurance premiums which were already paid or still due (2).

HIB225 – HRFST LESSDO MBA LESS THAN SMI PREMIUM

Your monthly medical insurance premium is (1). The monthly benefit that you should get is less than your medical insurance premiums. We are stopping your monthly benefits starting (2) to pay for part of this premium. After adjusting for your monthly benefits, we find that we must bill you for (3).

HIB226 – HRFST LESSDO MBA > SMI BUT LESS THAN A DOLLAR

We are stopping your monthly benefit starting (1). When we take your monthly medical insurance premium of (2) from your monthly benefit, the amount left is less than a dollar. At the end of the year, we will adjust your record and pay all money you are due.

HIB248 – PREMIUM HI REDUCTION WHEN 30 QUARTERS ATTAINED NO OPEN ENTITLEMENT TO PREMIUM HI

Currently, you are not eligible for free Medicare hospital insurance. However, you may be eligible to buy hospital insurance for the reduced premium of (1) per month. You can get more information about this hospital insurance by contacting any Social Security office.

HIB249 – OFFER RELIEF FOR SMI PREMIUMS (VSMI RATES)

If you want your medical insurance to start earlier, you can choose to have it start in (1). To start your medical insurance earlier, you must do the following things within 60 days after the date of this notice:

• •

  tell us in writing that you want medical insurance beginning (2);

AND

• •

  pay us (3) or tell us we can withhold this amount from your check. This amount covers the premiums due from (4) through (5).

If you would find it hard to pay the premium amount you would owe in a lump sum, ask us about other ways to pay the premium.

If you choose to have your medical insurance start in (6), your current monthly premium will be (7). If you do not choose the earlier date, your monthly premium will be (8).

HIB253 – PREMIUM RELIEF ESTABLISHED DUE TO IRMAA B AND/OR IRMAA D

We deduct Medicare medical insurance (Part B) premiums 1 month in advance.

HIB261 – PREMIUM RELIEF ESTABLISHED DUE TO IRMAA B

You owe (1) for Medicare Part B (medical insurance) premiums for (2) (3) (4).

HIB262 – PREMIUM RELIEF ESTABLISHED DUE TO IRMAA D

You owe (1) for Medicare prescription drug coverage income-related monthly adjustment amounts for (2) (3) (4).

HIB263 – PREMIUM RELIEF ESTABLISHED DUE TO IRMAA B AND ALSO IRMAA D

The total past-due Medicare amounts you owe are (1).

HIB264 – PREMIUM RELIEF ESTABLISHED - ALTERNATIVES TO FULL WITHHOLDING OF BENEFITS

If you would find it hard to pay the past-due Medicare amounts you owe at one time, please ask us about other ways to pay them. You may ask for waiver of these past-due Medicare amounts if paying them would be a severe financial hardship for you. If we do not hear from you within 30 days after the date of this letter, we will take the Medicare amounts you owe out of your monthly Social Security payments beginning (1).

HIB265 – DEDUCTION OF CURRENT SMI PREMIUMS

We will deduct your current Medicare Part B (medical insurance) premium from your monthly Social Security payments beginning (1).

HIB266 – FULL WITHHOLDING OF PART B RELIEF PREMIUMS WHEN CURRENT SMI PREMIUMS ARE ALSO DEDUCTED

We will also deduct (1) for past-due Medicare Part B (medical insurance) premiums.

HIB267 – FULL WITHHOLDING OF IRMAA D RELIEF PREMIUMS WHEN CURRENT SMI PREMIUMS ARE BEING DEDUCTED

We will also deduct (1) for past-due Medicare prescription drug coverage income-related monthly adjustment amounts.

HIB268 – FULL WITHHOLDING OF IRMAA D RELIEF PREMIUMS WHEN NO CURRENT SMI PREMIUMS BEING DEDUCTED

We will deduct past-due Medicare prescription drug coverage income-related monthly adjustment amounts from your monthly Social Security payments beginning (1). The total amount we will deduct is (2).

HIB269 – FULL WITHHOLDING CONTINUES UNTIL PREMIUMS PAID IN FULL

We will withhold your monthly payments until you have paid all of the past-due Medicare amounts you owe.

HIB270 – FULL WITHHOLDING OF PART B RELIEF PREMIUMS WHEN NO CURRENT SMI PREMIUMS BEING DEDUCTED

We will deduct past-due Medicare Part B (medical insurance) premiums from your monthly Social Security payments beginning (1). The total amount we will deduct is (2).

HIB271 – PARTIAL RECOVERY OF PART B OR IRMAA D RELIEF PREMIUMS

As you requested, we will withhold (1) from your monthly Social Security payments beginning (2) for past due Medicare amounts owed. We will withhold (3) each month until you have paid all of the past due Medicare amounts you owe.

HIB288 – SUBSEQUENT NOTICE WITH CMS BILLING STATEMENT AND INSTRUCTIONS FOR COMPLETING THE PAYMENT COUPON

We told you in another letter your Centers for Medicare & Medicaid Services (CMS) Billing Statement would be mailed in another envelope. At the end of this letter, you will find the CMS Billing Statement and instructions for completing the payment coupon.

HIB289 – (CMS) BILLING STATEMENT WILL BE MAILED IN ANOTHER ENVELOPE

Your Centers for Medicare & Medicaid Services (CMS) Billing Statement will be mailed in another envelope.

HIB316 – ADDITIONAL SOURCES FOR OBTAINING HEALTH INSURANCE

For questions about Marketplace or Medicaid coverage, visit HealthCare.gov, or call the Marketplace Call Center at 1-800-318-2596 (TTY 1-855-889-4325).

HIB317 – HOW TO APPLY FOR HELP WITH THE COST OF IMMUNOSUPPRESSIVE DRUG COVERAGE

Contact your state Medicaid agency to find out if you qualify for help paying for the premium and cost-sharing for your immunosuppressive drug benefit. Visit Medicaid.gov to find contact information for your state.

HIB318 – HOW TO APPLY FOR IMMUNOSUPPRESSIVE DRUG COVERAGE

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  Call us toll-free at 1-877-465-0355 between 8:30 a.m. – 6:00 p.m. EST, Monday through Friday, to enroll over the phone.

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  You can also use "Application for Enrollment in Part B Immunosuppressive Drug Coverage" Form CMS-10798. You may go to CMS.gov to find the form. Mail the completed form to:

SOCIAL SECURITY ADMINISTRATION
OFFICE OF CENTRAL OPERATIONS
PO BOX 32914
BALTIMORE, MARYLAND 21298-2703

HIB351 – IMMUNOSUPPRESSIVE DRUG COVERAGE ELIGIBILITY

You may be eligible for a Medicare benefit called Part B Immunosuppressive Drug Coverage (Part B-ID) that helps pay for immunosuppressive drugs. This coverage is only for immunosuppressive drugs and not any other Medicare services or prescriptions. You may be eligible to enroll in Part B-ID, but you are only eligible for payment of immunosuppressive drugs under Part B-ID if you are eligible for those drugs under Medicare Part B.

You can only sign up for this benefit if you expect to get other health insurance such as:

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  Employer group health plan or individual health plan (including Marketplace)

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  TRICARE for Life

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  Medicaid or the State Children’s Health Insurance Program (CHIP) coverage that includes immunosuppressive drugs

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

HIB352 – APPLY FOR MEDICARE THREE MONTHS PRIOR TO TURNING 65

If you are within three months of turning age 65 or older, contact Social Security to file an application for Medicare Part A and Part B. You must file an application to enroll in additional benefits under Medicare. Visit www.ssa.gov to file your application online or get the phone number for your local office.

HIB353 – REPORT FRAUD FOR USPS SEP ENROLLMENTS IN 2024

Suspect Social Security or Medicare Fraud?

If you suspect Social Security fraud, please visit https://oig.ssa.gov/report or call the Inspector General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101). If you suspect Medicare fraud, please visit https://www.cms.gov/About-CMS/components/CPI/CPIReportingFraud or call the Health and Human Services Office of the Inspector General at 1-800-447-8477 (TTY 1-800-377-4950).

HIB334 – LATE ENROLLMENT PENALTY IS PAID BY USPS SEP IN 2024

Individuals who have Medicare Part B pay a monthly premium. Eligible United States Postal Service (USPS) annuitants and their eligible family members who enrolled in Medicare Part B during the one-time Special Enrollment Period may be subject to Part B late enrollment penalties for as long as they have Part B, if they did not sign up for Part B when first eligible. However, the USPS will pay these penalties directly to the Centers for Medicare & Medicaid Services. Therefore, if you are subject to these penalties, you are not required to pay them.

HIB354 – INCOME-RELATED MONTHLY ADJUSTMENT OF SMI-ENROLLMENT PREMIUM FOR USPS SEP IN 2024

IMPORTANT: A Medicare law requires some higher income persons to pay higher premiums. The law applies to premiums for Medicare Part B (Medical Insurance), prescription drug coverage, and Medicare Part B Immunosuppressive Drug coverage. The law generally affects individuals who reported incomes higher than (1) and couples with incomes higher than (2).

We will contact the Internal Revenue Service to get information about your income. If we decide that you need to pay higher premiums, we will send a letter explaining our decision.

The higher amount will be effective January 2025 for the entire calendar year, and can change annually, depending on the income reported on your tax return. If you have had a life-changing event that reduced your household income, you can ask to lower the additional amount.

For more information, please visit www.ssa.gov on the Internet or call us toll-free at 1-800-772-1213 (TTY 1-800-325-0778).

HIB355 – AUTOMATIC ENROLLMENT OF MEDICARE PART D FOR USPS SEP IN 2024

If you are enrolled in a Postal Service Health Benefit plan, Part D prescription drug coverage will be included in your plan automatically. You do not need to elect separate Part D coverage for yourself or for any family members on your plan.

HIB356 – Retroactive MEDICARE Benefits Language

For retroactive Medicare benefits, please give a copy of this letter to your provider or supplier immediately. Ask them to include a copy of this letter when they submit claims to Medicare for items and services they provided to you on or before the date you gave them a copy of this letter. The time limit for the provider or supplier to submit a claim will be extended through the last day of the sixth calendar month following the month they received notification of your retroactive enrollment. For example, if the doctor receives notice of your retroactive enrollment on January 15th, the doctor must submit a claim on or before July 31st of the same calendar year. If you are concerned that the provider or supplier will not submit a claim by the deadline mentioned above, then you should submit the claim. If you are submitting a claim directly to Medicare, you must submit the claim on or before the last day of the sixth calendar month after receiving this notice. If you need assistance submitting these claims, contact 1-800-MEDICARE (1-800-633-4227) (TTY 1-877-486-2048).

HIB357 – MEDICARE WILL NOT PAY FOR SERVICES NOTLAW SUSPENSE

Based on the information we have, Medicare cannot pay for items and services beginning (1).

Medicare will not pay for hospital or medical items or services while you are not lawfully present in the U.S.

HIB358 – DEFINITION OF ALIEN FOR MEDICARE NOTLAW SUSPENSE

For Medicare to pay for items and services, you must be a U.S. citizen or national, or lawfully present in the U.S., defined by the Attorney General as an alien;

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  lawfully admitted for permanent residence;

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  admitted as a refugee under section 207 of the Immigration and Nationality Act (INA);

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  paroled under section 212 (d)(5) of the INA (except for aliens paroled for an exclusion hearing or prosecution in the U.S.);

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  an alien whose deportation has been withheld under section 243(h) of the INA as in effect prior to April 1, 1997, or whose removal has been withheld under section 241(b)(3) of the INA.

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  granted conditional entry as a refugee under section 203(a)(7) of the INA as in effect prior to April 1, 1980;

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  inspected and admitted to the U.S. and who has not violated the applicable terms of his/her status;

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  with a pending application for political asylum under section 208 of the INA or a pending application for withholding of deportation under section 243(h) of the INA, and employment authorization; or

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  belonging to any specific class of aliens permitted to remain in the U.S. under U.S. law or policy, for humanitarian or other public policy reasons.

HIB359 – TO CANCEL THIS INSURANCE

If you want to cancel the insurance, please let us know.