TN 30 (03-96)

NL 00703.600 Notice of Award to Medicare Beneficiary (HI/SMI) — Reduced HI Premium — NH, Spouse, Divorced Spouse, Widow(er) or Surviving Divorced Spouse

Document Identifier for Word Processor: E3600

A. EXHIBIT LETTER

Information About Medicare

HIB001 (1)   (2) entitled to (3) .
HIB005 The monthly (1) for (2) supplemental medical insurance (3)   (4)
  (5) .
HIB011 The monthly premium for (1) hospital insurance is (2) . We will bill you each month for (3) .
(Optional)  
MQ03 You have not worked long enough under Social Security to receive monthly benefits or premium-free hospital insurance under Medicare.
 Work under Social Security is figured in credits. Please read the enclosed pamphlet, “How You Earn Social Security Credits,” which explains how the credits are earned and how many a person needs to receive benefits.
 To qualify for monthly benefits, you need a total of (1) work credits. For hospital insurance, you need (2) credits. You have earned (3) credits.

Your Medicare Card

 You may earn the additional credits you need by working under Social Security. If you earn the credits, you should get in touch with us to apply again.

What Medicare Will Pay

HIB002 We will send (1) Medicare card in about 4 weeks. (2) should take this card with (3) when (4)   (5) medical care. If (6)   (7) medical care before you receive the card, use this letter as proof that (8) covered by Medicare.
MH18 Hospital insurance will pay most hospital bills and certain post-hospital expenses. Medical insurance will help pay much of the medical expenses incurred for physicians and other medical services. This notice shows whether you are entitled to hospital insurance only, medical insurance only, or both hospital and medical insurance. Benefits are payable if covered services were rendered on or after the entitlement date shown. You will receive by mail a health insurance card and a booklet explaining how to use the card, what services are covered, and the methods of claiming benefits for covered services. If you are planning changes in any other hospital or medical insurance you now have, remember that Social Security health insurance coverage will be effective with the dates shown on this notice.
 If you need help with medical expenses before your health insurance coverage begins, or if you need aid in meeting medical expenses not covered by your health insurance, you may want to get in touch with the nearest social services office to see whether you are eligible under a program of medical assistance.

Other Social Security Benefits

 Notify any Social Security office immediately if you change your address so that your health insurance card and any claims or informational material may reach you promptly.
CLO002 The (1) described in this letter (2)   (3) can receive from Social Security. If you think that (4) might qualify for another kind of Social Security benefit in the future, you will have to file another application.

Things To Remember For The Future

(Optional)  

If You Disagree With The Decision

3600C Your hospital insurance costs less than the regular amount. This is because you are the (1) of (2) who has at least 30 work credits. Please let us know right away if your marital status changes.

3600D

If you disagree with the decision, you have the right to appeal. A person who did not make the first decision will decide your case. We will review those parts of the decision you disagree with and consider any new facts you have. We may also review those parts you agree with and may make them unfavorable or less favorable to you.

  • 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 that you did not get it within the 5-day period.

  • You must have a good reason for waiting 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, called “Request for Reconsideration.” Contact one of our offices if you want help.

If You Want Help With Your Appeal

(Optional)  
3100E You can have a friend, lawyer or someone else help you. There are groups that can help you find a lawyer or give you free legal services if you qualify. There are also lawyers who do not charge unless you win your appeal. Your local Social Security office has a list of groups that can help you with your appeal.

If You Have Any Questions

 If you get someone to help you, you should let us know. If you hire someone, we must approve the fee before he or she can collect it. And if you hire a lawyer, we will withhold up to 25 percent of any past due benefits to pay toward the fee.

 (2) 

MG23 If you have any questions, call us toll-free at 1-800-772-1213 (1) . We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves your area is located at:
 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 the office.
OR  
MG20 If you have any questions, call us at 1-800-772-1213. We can answer most questions over the phone. If you prefer to visit one of our offices, please check the local telephone directory for the office nearest you. Or call us and we can give you the office address. Please have this letter with you if you call or visit an office. It will help us answer your questions.
  (1)    

B. REQUESTING INSTRUCTIONS

The PC adjudicator will request this notice in Premium HI (BIC M) cases where the individual will pay a reduced HI premium because he/she has at least 30 QCs. Also, use this notice if the beneficiary is eligible for the reduced premium as the spouse, divorced spouse, widow(er) or surviving divorced spouse of someone with at least 30 QCs.

  • Use paragraphs HIB001, HIB005, HIB002, MH18, CLO002 and 3600D in all cases.

  • Use paragraph HIB011 in all cases beginning January 1994.

  • Use paragraphs MQ03 and 3100E when an RSI claim is being disallowed.

  • Use paragraph 3600C if the person receiving the reduced premium is eligible as the spouse of someone who has at least 30 QCs.

  • Use paragraph MG23 if the field office (FO) telephone number and address are available from the TRIDE.

  • Use paragraph MG20 if the FO telephone number and address are not available from the TRIDE.

     

Fill-ins:

HIB001 (1) “You”/NH's full name
 (2) “are”/“is”
 

(3)

A =

“Medicare hospital and medical insurance beginning (month and year)”

B =

“Medicare hospital insurance beginning (month and year)”

C =

“Medical insurance beginning (month and year)”

D =

“Medicare hospital insurance beginning (month and year) and medical insurance beginning (month and year)”

HIB005 (1) “premium”/“premiums”
 (2) “your”/“his”/“her”
 (3) “is”/“are”
 (4) SMI money amount beginning month and year/null
 (5) SMI money amount beginning month and year and SMI money amount beginning month and year
HIB011 (1) “your”/“his”/“her”
 (2) HI premium amount
 (3) “this premium”/“the combined premium for hospital and medical insurance”
MQ03 (1) number of required quarters for insured status
 (2) number of required quarters for HIB
 (3) number of acquired quarters
HIB002 (1) “your”/“his”/“her”
 (2) “you”/“he”/“she”
 (3) “you”/“him”/“her”
 (4) “you”/“he”/“she&#