TN 77 (01-19)

NL 00703.633 MBA Less than SMI Premium (LESSDO) - Prior Year Premium Balance Less than 3 Months

Document Identifier for Word Processor: E4032

A. Requesting instructions

This letter is used when COLA or No COLA applies, a premium arrearage balance from the prior year(s) exists, and the prior year(s) balance is less than three months premiums at the standard rate. See HI 01001.041B.3.b.

B. Exhibit letter

LIS004

 

We are writing to give you new information about the (1) benefits which (2) on this Social Security record.

 

CHKC09

Your Benefits

 

CHK084 (1) monthly benefit amount is $(2) effective (3) and (4) monthly Medicare medical insurance premium is $(5).

HIBC01

 

Information About Medicare

 

HIB704

Since (1) monthly benefit amount is less than (2) Medicare premium, we will withhold (3) monthly benefits to pay part of (4) Medicare premium. The difference between the premiums (5) for (6) and (7) monthly benefit amount for (8) is $(9).

In addition, our records show that (10) $(11) in past due premiums for (12).

Enclosed is a bill for the total amount due of $(13), and a return envelope. We will continue to bill (14) on a yearly basis as long as (15) monthly benefit is lower than the monthly Medicare medical insurance premium.

 

CTDO

 

Suspect Social Security Fraud?

Please visit http://oig.ssa.gov/r or call the Inspector General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).

If You Have Questions

We invite you to visit our website at www.socialsecurity.gov on the Internet to find general information about Social Security. If you have any specific questions, you may call us toll-free at 1-800-772-1213, or call your local Social Security office at 1-(3)-(4)-(5). We can answer most questions over the phone. If you are deaf or hard of hearing, you may call our TTY number, 1-800-325-0778. You can also write or visit any Social Security office. The office that serves your area is located at:

(6)

(7)

(8)

(9)(10)-(11)

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.

 

HBN001

MEDICARE PREMIUM BILL

CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)

 

 

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.

  • If you have any questions concerning this Medicare Premium Bill, please write or visit any Social Security Office.

 

PLEASE DETACH AT DOTTED LINE

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

CMS-500A

 

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

Name: (7)

 

Make Checks Payable To:

CMS MEDICARE INSURANCE

 

Send To:

Medicare Premium Collection Center

P.O. Box 790355

St. Louis, MO 63179-0355

 

 

( ) Check here if your address has changed.

Show new address below.

________________________________________

________________________________________

 

PAYMENTS BY CHECK

 

When you provide a check as a payment, you authorize the Medicare Premium Collection Center (MPCC) to use the information from your check to make a one-time electronic funds transfer from your bank account. When the MPCC uses information from your check to make an electronic funds transfer, they may withdraw funds from your bank account as soon as the same day they receive your payment. You will not get your check back from your bank. If the MPCC cannot process your payment electronically, they will process it as a check transaction. Your bank statement will show the transaction as "CMS Medicare" and this is your proof of payment.

 

C. Exhibit fill-ins

LIS004

1. Case Number

CHK084

  1. 1. 

    Your, His or Her

  2. 2. 

    Monthly benefit amount

  3. 3. 

    Month YYYY

  4. 4. 

    your, his or her

  5. 5. 

    Current SMI premium amount

HIB704

  1. 1. 

    your, his or her

  2. 2. 

    your, his or her

  3. 3. 

    your, his or her

  4. 4. 

    your, his or her

  5. 5. 

    you owe, he owes or she owes

  6. 6. 

    Month YYYY through Month YYYY

  7. 7. 

    your, his or her

  8. 8. 

    Month YYYY through Month YYYY

  9. 9. 

    Money amount difference

  10. 10. 

    you owe, he owes or she owes

  11. 11. 

    Billing Amount for arrearage

  12. 12. 

    Month YYYY through Month YYYY

  13. 13. 

    Total Billing Amount

  14. 14. 

    you, him or her

  15. 15. 

    your, his or her

 

CTDO

  1. 1. 

    Zipcode

  2. 2. 

    Zip+4 or DO Code

  3. 3. 

    Telephone Area Code

  4. 4. 

    Phone Exchange

  5. 5. 

    Phone Number

  6. 6. 

    Local Office Address Line #1

  7. 7. 

    Local Office Address Line #2

  8. 8. 

    Local Office Address Line #3

  9. 9. 

    City & State of Local Office

  10. 10. 

    Local Office Zipcode

  11. 11. 

    Zip+4 of Local Office

HBN001

  1. 1. 

    Billing Date (Equal to the Date of the Notice)

  2. 2. 

    Month YYYY

  3. 3. 

    SMI premiums due

  4. 4. 

    Month DD, YYYY

  5. 5. 

    Medicare Beneficiary Identifier

  6. 6. 

    SMI premiums due

  7. 7. 

    Beneficiary’s Full Name


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900703633
NL 00703.633 - MBA Less than SMI Premium (LESSDO) - Prior Year Premium Balance Less than 3 Months - 01/03/2019
Batch run: 01/03/2019
Rev:01/03/2019