TN 77 (01-19)

NL 00703.636 MBA Less than SMI Premium (LESSDO) - Failure to Bill - Equitable Relief Period Ends

Document Identifier for Word Processor: E4035

A. Requesting instructions

This letter is used when no past-due premium remittance is received and the equitable relief period ends.

B. Exhibit letter

LIS004

 

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

 

HIBC01

 

Information About Medicare

 

HIB707

We told you in our letter dated (1), our records show you did not receive a bill for Medicare medical insurance premiums owed for (2). In our previous letter, we explained you could contact your local Social Security office if paying the past due amount would create a severe hardship for (3).

We have not received a request for relief or a request for an alternate method of payment. Therefore, we must bill (4) for $(5) in past due Medicare medical insurance premiums and $(6) for (7). We are enclosing a bill for $(8), which represents all premiums due for (9).

If the full payment of $(10) for premiums owed through (11) is not received by (12), (13) Medicare Part B will end on (14) which is the last day of the third month following the month of this notice.

 

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

HIB707

  1. 1. 

    Month DD, YYYY

  2. 2. 

    Month YYYY through Month YYYY

  3. 3. 

    you or Beneficiary’s name

  4. 4. 

    you, him or her

  5. 5. 

    Past due arrearage

  6. 6. 

    Current premium due

  7. 7. 

    Month YYYY through Month YYYY

  8. 8. 

    Total billing amount

  9. 9. 

    Month YYYY through Month YYYY

  10. 10. 

    Total billing amount

  11. 11. 

    last month of the past due premium arrearage

  12. 12. 

    Last day of third month after date of notice

  13. 13. 

    your, his or her

  14. 14. 

    Last day of third month after date of notice

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/0900703636
NL 00703.636 - MBA Less than SMI Premium (LESSDO) - Failure to Bill - Equitable Relief Period Ends - 01/03/2019
Batch run: 01/03/2019
Rev:01/03/2019