TN 25 (01-04)
HI 01001.275 Sample Notice- State or Local Government Retirement System Will Pay the Premium Surcharge
for Medicare Part B -- Beneficiary in Current Pay Status
Northeastern Program Service Center
1 Jamaica Center Plaza
Jamaica, New York 11432-3898
Date: October 16, 1997
1212 Oak Street
Alexandria, VA ZIP
We must charge a premium surcharge on your Medicare medical insurance because you
enrolled later than you could have. Your State or local government retirement system
will pay your late enrollment premium surcharge beginning MM/YYYY. However, you must
pay the basic Medicare medical insurance premium.
What We Plan To Do
We will deduct the basic Medicare Part B premium of $XX.XX from your monthly payment.
After we deduct this amount, you will receive a monthly benefit payment of $XXX.XX
around MM/DD/YYYY. Below we tell you what to do if you disagree with this change in
the amount of your monthly payment.
If You Disagree With The Decision
If you disagree with the change we have made to your monthly payment, you have the
right to appeal. We will review your case again and consider any new facts you have.
A person who did not make the first decision will decide your case.
You have 60 days to ask for an appeal.
The 60 days start the day after you receive this letter. We assume you got this letter
5 days after the date on it unless you show us that you did not get it within the
You must have a good reason if you wait more than 60 days to ask for an appeal.
You have to ask for an appeal in writing. We will ask you to sign a Form SSA-561-U2,
[ ] Request for Reconsideration.
[ ] Contact one of our offices if you want help.
If You Have Any Questions
If you have any questions about the State or local government retirement system, please
contact that office.
If you have any questions about Medicare, you may call us toll-free at 1-800-772-1213,
or call your local Social Security office. The office that serves your area is located
6295 Edsall Road
Alexandria, VA 22312
If you do call or visit an office, please have this letter with you. It will help
us answer your questions. Also, if you plan to visit an office, you may call ahead
to make an appointment. This will help us serve you more quickly when you arrive at
Assistant Regional Commissioner,
Processing Center Operations