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

HIB001 – ENTITLED TO HI AND/OR SMI

(1) Medicare (2) (3) (4) (5).

HIB002 -TEMPORARY SUBSTITUTION OF NOTICE FOR HEALTH INSURANCE CARD

(1) will get a Medicare card within 2 weeks. (2) show this card when (3) medical care.  To learn more about what Medicare covers, visit Medicare.gov. If (4) questions about (5) Medicare coverage, call 1-800-MEDICARE (1-800-633-4227).

HIB005 – SMI PREMIUM BILLING

(1) monthly premium for Medicare Part B (medical insurance) is (2) beginning (3) (4) (5).

HIB008 – SMI PREMIUM DEDUCTIONS

We will start to take premiums out of (1) (2) check.

HIB011 – HI PREMIUM BILLING

The monthly premium for (1) hospital insurance is (2). We will bill you each month for (3).

HIB013 – MEDICARE HI/SMI PREMIUM PENALTY

(1) a penalty because (2) enrolled later than (3) could have.

HIB015 – PREMIUMS DEDUCTED FROM CIVIL SERVICE ANNUITY

The Office of Personnel Management will deduct the premiums from (1) annuity checks. They will let (2) know when this will start.

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

(1) (2) will pay (3) Medicare hospital insurance premiums beginning (4). (5)

(6) (7) will pay (8) Medicare medical insurance premiums beginning (9). (10)

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

(1) (2) will no longer pay (3) Medicare hospital insurance premiums after (4).

(5) must pay the premiums beginning (6).

(7) (8) will no longer pay (9) Medicare medical insurance premiums after (10).

(11) must pay the premiums beginning (12).

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

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

(5) (6) paid (7) Medicare medical insurance premium for (8).

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

The organization that was paying (1) Medicare hospital insurance premium will no longer pay it after (2). (3) must pay the premium beginning (4).

The organization that was paying (5) Medicare medical insurance premium will no longer pay it after (6). (7) must pay the premium beginning (8).

HIB034 –ADVISE THAT SMI DEDUCTION WILL START/CONTINUE

We will (1) to deduct Medicare Part B (medical insurance) premium of (2) from (3) payments.

HIB038 – MEDICARE DISALLOWANCE CRIME AGAINST UNITED STATES

(1) cannot qualify for Medicare because (2) been convicted of a crime against the Security of the United States.

HIB042 – MEDICARE DISALLOWANCE FEHB ACT OF 1959

(1) cannot qualify for Medicare because (2) 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)

(1) not entitled to (2) insurance coverage under Medicare because the application was not filed during an enrollment period and (3) did not qualify for a special enrollment period. However, (4) 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 (1) had any expenses that (2) should be covered by Medicare (3) 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 (1) while (2) (3). However, you may want to pay (4) Medicare medical insurance premiums for two reasons:

• •

  The premiums may be higher if you cancel the Medicare medical insurance now and reenroll after (5) released from (6).

• •

  (7) may not have medical insurance for a period of time after (8) released from (9). This is because (10) 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 (11) 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 (1) medical insurance premiums from (2) annuity checks.

HIB066 – HI/SMI PREMIUMS ALREADY PAID

Any (1) insurance premiums (2) already paid will be credited to (3) record.

HIB067 – SMI PREMIUM BILLING

We will send (1) first bill for the premiums within a month. Each bill after that will be for a 3-month period.

HIB068 – HI/SMI EQUITABLE RELIEF

If (1) these benefits earlier, (2) can choose (3) insurance benefits beginning (4). To start benefits earlier, within 60 days after the date of this notice (5) must tell us in writing that (6) (7) insurance benefits beginning (8). In addition, (9) must:

• •

  pay us (10) (this covers premiums due from (11) through (12)); or

(13)

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

(1) Medicare premium (2) for (3) insurance was not paid within the time limit. Therefore, (4) (5) insurance coverage has stopped. (6) last month of coverage (7) (8). Benefits will not be paid for any (9) services (10) after (11) last month of coverage.

HIB070 – PREMIUM HI DWI CONTINUES SMI TERMINATES NON-PAYMENT

This decision does not affect (1) (2) insurance coverage. (3) should continue to pay (4) 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 (1) (2) a railroad beneficiary, the RRB will start to withhold medical insurance premiums from (3) Railroad Retirement annuity. If (4) not currently receiving a Railroad Retirement annuity, the Social Security Administration will let the RRB know when (5) next premium is due. The RRB will send (6) a bill for premiums.

HIB073 – RRB SENDS NEW MEDICARE CARD

(1) protection under Medicare will continue without any change in coverage.

The RRB will send (2) a new Medicare card. Until then, (3) may use (4) old card.

HIB074 – NEW MEDICARE CARD

We will send (1) a new health insurance card. It will show that (2) entitled to (3) insurance.

HIB075 – EQUITABLE RELIEF/HARDSHIP

If (1) benefits beginning (2) but (3) 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 (1) not sign up for Part B when (2) first eligible, (3) may have to pay a late enrollment penalty for as long as (4) Part B. (5) monthly premium may go up 10 percent for each full 12-month period that (6) could have had Part B coverage, but did not sign up for it. Usually, (7) will not have to pay a late enrollment penalty if (8) up during a special enrollment period.



 If (9) to sign up for (10) later, (11) 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 (12) up in the general enrollment period, (13) Part B coverage will start the month after (14).

HIB077 – SMI TERMINATION INFORMATIONAL

People who have Medicare Part B (medical insurance) pay a monthly premium. If (1) not sign up for Part B when (2) first eligible, (3) may have to pay a late enrollment penalty for as long as (4) Part B. (5) monthly premium may go up 10 percent for each full 12-month period that (6) could have had Part B coverage, but did not sign up for it. Usually, (7) will not have to pay a late enrollment penalty if (8) up during a special enrollment period.

HIB078 – HI TERMINATION INFORMATIONAL

(1) monthly premium for hospital insurance may be 10 percent higher when (2).

HIB079 – VOLUNTARY TERMINATION FOR PREMIUM HI OR SMI

Because (10) canceling (2) (3) insurance coverage, (4) no longer entitled to (5) insurance coverage. (6) hospital and medical insurance coverage ends on the last day of (7).

HIB080 – VOLUNTARY SMI TERMINATION CIVIL SERVICE INVOLVED

The Office of Personnel Management will no longer deduct the medical insurance premiums from (1) annuity checks. They will let (2) know when the deductions will stop.

HIB082 – HI AND/OR SMI VOLUNTARY TERMINATION

(1) asked that we stop (2) (3) insurance coverage under Medicare. This coverage ends the last day of (4).

HIB083 – SPECIAL ENROLLMENT PERIOD DISABILITY

(1) may also be able to enroll during a special enrollment period. (2) can do this if (3) (4) one of the conditions listed below:

• •

  (5) covered under a group health plan through (6) current work or (7) spouse's current work, or

• •

  (8) covered under a large group health plan through (9) current work or any family member's current work.

(10) may enroll for Medicare (11) insurance at any time (12) covered under the group health plan. However, (13) may wait and enroll during the 8-month period that begins when the work ends or (14) coverage under the plan ends, whichever occurs first. (15) may also enroll if the type of plan (16) changes.

HIB084 – SPECIAL ENROLLMENT PERIOD AGED

(1) may also be able to enroll during a special enrollment period. (2) can do this if (3) all of the conditions listed below:

• •

  (4) health insurance coverage is under an employer's plan because (5) or (6) spouse is working, and

• •

  (7) had health insurance coverage under that plan since (8) became age 65.

(9) may enroll for Medicare (10) insurance at any time (11) covered under the group health plan. However, (12) may wait and enroll during the 8-month period that begins when the work ends or (13) coverage under the plan ends, whichever occurs first.

HIB085 – VOLUNTARY SMI TERMINATION CURRENT PAY

We will stop taking premiums for medical insurance out of (1) checks.

HIB086 – VOLUNTARY HI/SMI TERMINATION PREMIUMS DUE

(1) (2) (3) in premiums through (4). Please make (5) check or money order payable to the "Centers for Medicare & Medicaid Services" and mail it to us in the enclosed envelope. Include (6) Medicare number on (7) check or money order.

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

(1) (2) coverage will continue.

HIB088 – HI/SMI FOREIGN ADDRESS

Normally, Medicare will only pay for (1) services which (2) (3) in the United States. Since (4) living outside the U.S., Medicare will not pay for (5) services unless (6) to the U.S. for services.

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

Since (1) no longer receiving provisional monthly Social Security benefits, we are stopping (2) (3) insurance coverage. This coverage ends the last day of (4). Please destroy (5) Medicare card after coverage ends.

HIB090 – TERMINATION ALL MEDICARE COVERAGE

(1) Medicare card will not be valid when (2) (3) coverage ends. Please destroy (4) card after (5) coverage ends.

HIB092 – STATE/LOCAL GOVT CONTINUES TO PAY SMI PREMIUM

(1) State or local government retirement system will continue to pay (2) Medicare medical insurance late enrollment premium penalty. (3) 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 (2) Medicare (3) insurance coverage.

HIB101 – MEDICARE STATE BUY-IN

(1) (2) will pay (3) Medicare (4) insurance premium beginning (5). (6)

HIB102 – STATE BUY-OUT

(1) (2) will no longer pay (3) Medicare (4) insurance premiums after (5). (6) must pay the premiums beginning (7).

HIB103 – LIMITED BUY-IN AND BUY-OUT

(1) (2) paid (3) Medicare (4) insurance premium for (5).

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 (1) premiums through (2).

HIB106 – STATE BUYIN FOR SMI PREMIUM PENALTY ONLY

We must charge a premium penalty on (1) Medicare medical insurance because (2) enrolled later than (3) could have. (4) State or local government retirement system will pay (5) medical insurance late enrollment premium penalty beginning (6). However, (7) must pay the basic Medicare medical insurance premium.

HIB107 – STATE STOPS PAYING SMI PREMIUM PENALTY

(1) State or local government retirement system will no longer pay (2) Medicare medical insurance late enrollment premium penalty after (3). (4) must pay the basic premium and the penalty beginning (5).

HIB108 – GROUP PAYER BUY-OUT

The organization that was paying (1) Medicare (2) insurance premium will no longer pay it after (3). (4) must pay the premium beginning (5).

HIB109 – 3RD Party SMI PREMIUM DEDUCTED FROM MBA

We will deduct the (1) of (2) from (3) monthly payment. Later in this letter, we tell (4) what to do if (5) with this change in the amount of (6) monthly payment.

HIB110 – SMI PREMIUM DEDUCTED FROM MBA PAST DUE PREMIUMS

We will deduct the (1) of (2) from (3) monthly payment. We will also deduct the past due premiums, which total (4). Later in this letter, we tell (5) what to do if (6) with this change in the amount of (7) monthly payment.

HIB111 – BUY-IN AND REFUND OF MEDICARE PREMIUMS

This is the money due (1) for the Medicare insurance premiums that (2) already paid.

HIB112 – BUYIN PREMIUM NO LONGER DEDUCTED FROM MBA

We will no longer deduct the premium from (1) monthly payment. Later in this letter, we tell (2) what to do if (3) with this change in the amount of (4) monthly payment.

HIB113 – BUY-OUT NOT IN PAY STATUS PREMIUM BILLING

We will send (1) first bill for the (2) within a month. The monthly (3) (4). (5) Please contact us if (6) not receive the first bill within a month.

HIB114 – BENEFITS TERM PROFRA MEDICARE CONTINUES

(1) Medicare coverage will continue because (2) age 65 or older.

HIB115 – HI/SMI BUY-OUT

If (1) to cancel this insurance, please contact the local Social Security office at the telephone number and address shown below. Remember that the date (2) insurance coverage ends depends on when (3) it:

If (4) it within 30 days from the date of this notice, (5) coverage will end at the same time the State stopped paying the premiums.

If (6) it after 30 days but within six months of when the State stopped paying the premiums, coverage will stop at the end of the same month in which (7) us.

If (8) more than 6 months to contact us, coverage will stop at the end of the month after the month in which (9) us.

HIB119 – BILLING TO CONFIRM GROUP PAYER

(1) recently arranged for an organization to pay (2) Medicare (3) insurance premium. Although we will send the bills to this organization, (4) responsible for seeing that they are paid.

If this organization decides to stop paying (5) premium, we will again send the bills to (6).

If there is any other change in (7) Medicare premium, we will let (8) know.

HIB120 – BUY-OUT FOR HI AND SMI

(1) can cancel hospital insurance coverage and keep medical insurance coverage, or cancel both. However, (2) cannot keep hospital insurance coverage without medical insurance coverage. So if (3) 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

We are writing to tell (1) that Medicare coverage based on (2) kidney condition ends with the last day of (3).

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

We are writing to tell (1) that (2) hospital insurance coverage ended on the last day of (3). (4) medical insurance coverage will end on the last day of (5).

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 (2) unless before then (3) again:

• •

  (4) regular dialysis, or

• •

  (5) a kidney transplant

Since (6) in (7), (8) Medicare coverage should have ended the last day of (9). (10) hospital insurance did end on that date. But, because we didn't take action in time, we must continue (11) medical insurance coverage until the date shown above.

HIB136 – TERMINATION OF ESRD COVERAGE

Let us know right away if (1) regular dialysis again or (2) a kidney transplant so (3) can file a new claim for Medicare coverage based on (4) 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 (3):

• •

  a kidney transplant, or

• •

  resume regular dialysis.

Our records show that (4) (5) (6).

HIB142 – CURRENT PAY TO SUSPENSE OR DEFERRED STATUS

We will continue to charge a monthly premium for (1) 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 (1) (2) for Medicare medical insurance based on (3) age, (4) monthly medical insurance premium amount has been reduced from (5) to (6).

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

(1) must pay the premium beginning (2).

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

(1) working for an employer who has 20 or more employees? (2) 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 (1) 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 (1) cancellation of (2) earlier request that (3) Medicare (4) 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 (5) could reenroll. This difference is important because there are months for which (6) not have Medicare (7) insurance coverage.

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

We stopped (1) Medicare (2) insurance at (3) request. Then (4) decided that (5) still wanted it. (6) decided too late for us to start (7) Medicare (8) insurance again at this time.

HIB162 – REFUSAL OVER AUTOMATIC ENROLLMENT

(1) told us that (2) not want (3) insurance under Medicare.

HIB163 – SMI REFUSAL CURRENT PAY REFUND OF PREMIUMS

(1) not have to pay a premium for any months (2) not entitled to Medicare Part B (medical insurance). If we took out premiums for any of these months, we will return the money to (3).

HIB164 – SMI REFUSAL PREMIUM BILLING AND NO OPEN THIRD PARTY

Since our records were previously annotated to show that (1) enrolled for Medicare (2) insurance, a premium billing notice may have been prepared for mailing to (3). If (4) a billing notice, (5) should destroy it.

HIB165 – REFUSAL/WITHDRAWAL STATE BUY-IN ESTABLISHED

Our records show that (1) State has agreed to pay the premiums for (2) Medicare (3) insurance coverage. Therefore, (4) 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 (1) no longer receiving monthly payments, (2) will still have (3) coverage under Medicare. (4)

(5)

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

Even though (1) no longer receiving monthly payments, (2) will still have Part A (hospital insurance) and Part B (medical insurance) coverage under Medicare. (3) The State where (4) will continue to pay the premiums for (5) Part B coverage.

HIB175 – SMI PREMIUMS/ARREARAGE DEDUCTED FROM PMA OR CMA

We are deducting past-due premiums (1) from (2) check.

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

Since benefits are again payable we will resume withholding (1) 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 (1) 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 (2) prescription drug coverage, (3) also must pay a prescription drug coverage IRMAA. The IRMAA is in addition to (4) monthly premium. We base the IRMAA on (5) income. We deduct the IRMAA from (6) monthly Social Security benefits, regardless of how (7) premiums.

HIB183 – USE WITH HIB182 WHEN IRMAA AFFECTS PART B RATE

We sent you another letter that explained how we determined the amount of (1) 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 (2) 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 (3) income. If we decide that (4) to pay higher premiums, we will send a letter explaining our decision. The higher amount will be effective (5). 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 (1) no longer entitled to monthly Social Security benefits, we are stopping (2) (3) insurance coverage under Medicare. (4) (5) insurance coverage ends on the last day of (6). Please destroy (7) Medicare card after the coverage ends.

HIB218 – REASON SMI PREMIUM/ARREARAGE IS BEING DEDUCTED

When we figured the amount of (1) 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

(1) monthly medical insurance premium is (2). The monthly benefit that (3) should get is less than (4) medical insurance premiums. We are stopping (5) monthly benefits starting (6) to pay for part of this premium. After adjusting for (7) monthly benefits, we find that we must bill (8) for (9).

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

We are stopping (1) monthly benefit starting (2). When we take (3) monthly medical insurance premium of (4) from (5) monthly benefit, the amount left is less than a dollar. At the end of the year, we will adjust (6) record and pay all money (7) due.

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

Currently, (1) not eligible for free Medicare hospital insurance. However, (2) may be eligible to buy hospital insurance for the reduced premium of (3) 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).

HIB260 – PREMIUM RELIEF ESTABLISHED DUE TO IRMAA B AND/OR IRMAA D

As we told you in another letter, you owe more Medicare premiums because (1) income-related monthly adjustment amounts changed.

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 (1) 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 (2) out of (3) monthly Social Security payments beginning (4).

HIB265 – DEDUCTION OF CURRENT SMI PREMIUMS

We will deduct (1) current Medicare Part B (medical insurance) premium from (2) monthly Social Security payments beginning (3).

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 (1) monthly payments until you have paid all of the past-due Medicare amounts (2).

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

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).

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 (1), 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

• •

  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.

• •

  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

HIB327 – IMMUNOSUPPRESSIVE DRUG COVERAGE ELIGIBILITY

(1) 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 (2) expect to get other health insurance such as:

• •

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

• •

  TRICARE for Life

• •

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

• •

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

  Fill-in values:
  Fill-in (1)
  Choice 1	You
  Choice 2	BGN plus BLN (non-possessive)
  Fill-in (2)
  Choice 1	you do not have and do not
  Choice 2	BGN plus BLN (non-possessive) + does not have and does not

HIB331 – APPLY FOR MEDICARE THREE MONTHS PRIOR TO TURNING 65

If (1) 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.

HIB333 – REPORT FRAUD FOR USPS SEP ENROLLMENTS IN 2024

Suspect Social Security or Medicare Fraud?

If you suspect Social Security fraud, please visit (1) 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 (2) 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 (1) subject to these penalties, (2) not required to pay them.

HIB335 – 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 (3) income. If we decide that (4) 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 (5) tax return. If (6) had a life-changing event that reduced (7) household income, (8) 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).

HIB336 – AUTOMATIC ENROLLMENT OF MEDICARE PART D FOR USPS SEP IN 2024

If (1) enrolled in a Postal Service Health Benefit plan, Part D prescription drug coverage will be included in (2) plan automatically. (3) not need to elect separate Part D coverage for (4) or for any family members on (5) plan.