TN 8 (09-17)

NL 00720.180 HIB Health Insurance Benefits

HIB002 TEMPORARY SUBSTITUTION OF NOTICE FOR HEALTH INSURANCE CARD (H23)

(Requested/Generated)

Caption: Information About Medicare

We will send  (1)  a Medicare card.  (2)  should take this card with  (3)  when  (4)   (5)  medical care. If  (6)   (7)  medical care before receiving the card and  (8)  coverage has already begun, use this letter as proof that  (9)  covered by Medicare.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Ms. plus Beneficiary's Last Name

Choice 2: Mr. plus Beneficiary's Last Name

Choice 3: Beneficiary's First Name

Choice 4: Beneficiary's Name

Choice 5: you

Fill-in (2) - Systems Generated

Choice 1: She

Choice 2: He

Choice 3: You

Fill-in (3) - Systems Generated

Choice 1: her

Choice 2: him

Choice 3: you

Fill-in (4) - Systems Generated

Choice 1: she

Choice 2: he

Choice 3: you

Fill-in (5) - Systems Generated

Choice 1: need

Choice 2: needs

Fill-in (6) - Systems Generated

Choice 1: she

Choice 2: he

Choice 3: you

Fill-in (7) - Systems Generated

Choice 1: need

Choice 2: needs

Fill-in (8) - Systems Generated

Choice 1: her

Choice 2: his

Choice 3: your

Fill-in (9) - Systems Generated

Choice 1: she is

Choice 2: he is

Choice 3: you are

HIB003 MEDICAL CLAIMANT ENROLLED BEFORE INITIAL ENROLLMENT PERIOD (H42)

(Requested)

Caption: Information About Medicare

 (1)  not entitled to  (2)  under Medicare because  (3)  application was filed too soon.  (4)  may apply again at any time during the period  (5)  through  (6)  .  (7)  must apply in the first three months of this period to make sure Medicare starts in the month  (8)   (9)  age 65.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You are

Choice 2: She is

Choice 3: He is

Fill-in (2) - Systems Generated

Choice 1: medical insurance coverage

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: her

Choice 3: his

Fill-in (4) - Systems Generated

Choice 1: You

Choice 2: She

Choice 3: He

Fill-in (5) - Systems Generated

Choice 1: Month and Year

Fill-in (6) - Systems Generated

Choice 1: Month and Year

Fill-in (7) - Systems Generated

Choice 1: You

Choice 2: She

Choice 3: He

Fill-in (8) - Systems Generated

Choice 1: you

Choice 2: she

Choice 3: he

Fill-in (9) - Systems Generated

Choice 1: reach

Choice 2: reaches

HIB004 MEDICAL CLAIMANT ENROLLED AFTER IEP AND BEFORE GENERAL ENROLLMENT PERIOD (H43)

(Requested)

Caption: Information About Medicare

 (1)  not entitled to  (2)  under Medicare because  (3)  application was filed too late.  (4)  should have filed before  (5)  . However,  (6)  g 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.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You are

Choice 2: She is

Choice 3: He is

Fill-in (2) - Systems Generated

Choice 1: medical insurance coverage

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: her

Choice 3: his

Fill-in (4) - Systems Generated

Choice 1: You

Choice 2: She

Choice 3: He

Fill-in (5) - Systems Generated

Choice 1: Month and Year

Fill-in (6) - Systems Generated

Choice 1: you

Choice 2: she

Choice 3: he

HIB011 PREMIUM BILLING FOR HOSPITAL INSURANCE ONLY (H46)

(Requested)

Caption: Information About Medicare

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

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: her

Choice 3: his

Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: HPAC amount

Fill-in (3) - Requested As A One Position Alpha Character

Choice 1: (A) this premium

Choice 2: (B) the combined premium for hospital and medical insurance

Choice 3: (C) premiums

HIB015 CIVIL SERVICE BUY-IN (H31)

(Requested/Generated)

Caption: Information About Medicare

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

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary's Name possessive

Choice 2: your

Fill-in (2) - Systems Generated

Choice 1: him

Choice 2: her

Choice 3: you

HIB019 BENEFICIARY IS NOT ENTITLED TO MEDICARE PART A FOR FREE BUT ELIGIBLE TO BUY MEDICARE PART A (HOSPITAL INSURANCE) FOR A FEE

(Requested)

Caption: None

 (1)  cannot get Medicare Part A (hospital insurance) for free. However,  (2)  may be able to buy Medicare Part A for  (3)  a month. Please contact us for more information.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You

Choice 2: Beneficiary's full name

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (3) - Systems Generated

Beneficiary's monthly cost for Part A

HIB021 DUAL ENTITLEMENT AUXILIARY/SURVIVOR AWARD AFTER PRIMARY - MEDICARE ENTITLEMENT PREVIOUSLY ESTABLISHED (H84)

(Requested)

Caption: Information About Medicare

This letter does not affect  (1)  Medicare benefits.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 1: his

Choice 1: her

HIB022 COVERAGE TRANSFERRED TO ANOTHER CLAIM NUMBER (H09)

(Requested/Generated)

Caption: Information About Medicare

 (1)  still be entitled to  (2)  insurance coverage from Medicare under the claim number we have shown above. We will send  (3)  a new Medicare card with this number on it.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You will

Choice 2: He will

Choice 3: She will

Fill-in (2) - Requested As A One Position Alpha Character

Choice 1: (A) hospital

Choice 2: (B) hospital and medical

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

HIB033 HI COVERAGE - NO SMI ELECTED - PROVISIONAL BENEFITS CASE (P06)

(Requested)

Caption: Information About Medicare

 (1)  will have Medicare hospital insurance (Part A) coverage while  (2)  receiving these provisional benefits.  (3)  coverage will begin  (4)  .  (5)  hospital insurance (Part A) is free. If  (6)  provisional benefits end because  (7)  received 6 months of payments, then  (8)  Medicare coverage will end at the same time. If  (9)  provisional benefits end for any other reason, then  (10)  will get another letter telling  (11)  about  (12)  Medicare coverage.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You

Choice 2: Beneficiary's name

Fill-in (2) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (3) - Systems Generated

Choice 1: You

Choice 2: His

Choice 3: Her

Fill-in (4) - Systems Generated

Choice 1: Month CCYY (date Medicare coverage begins)

Fill-in (5) - Systems Generated

Choice 1: Your

Choice 2: His

Choice 3: Her

Fill-in (6) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (7) - Systems Generated

Choice 1: you have

Choice 2: he has

Choice 3: she has

Fill-in (8) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (9) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (10) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (11) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (12) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

HIB036 SMI COVERAGE ELECTED DURING PROVISIONAL PERIOD - PROVISIONAL BENEFITS CASE (P07)

(Requested)

Caption: Information About Medicare

 (1)  will have Medicare hospital insurance (Part A) and medical insurance (Part B) coverage while  (2)  receiving these provisional benefits.  (3)  coverage will begin  (4)  .  (5)  hospital insurance (Part A) is free.  (6)  medical insurance (Part B) premium will be deducted from the monthly payment. If  (7)  provisional benefits end because  (8)  received 6 months of payments, then  (9)  Medicare coverage will end at the same time. If  (10)  provisional benefits end for any other reason, then  (11)  will get another letter telling  (12)  about  (13)  g Medicare coverage.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You

Choice 2: Beneficiary's Name

Fill-in (2) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (3) - Systems Generated

Choice 1: Your

Choice 2: His

Choice 3: Her

Fill-in (4) - Systems Generated

Choice 1: Month CCYY (date Medicare coverage begins)

Fill-in (5) - Systems Generated

Choice 1: Your

Choice 2: His

Choice 3: Her

Fill-in (6) - Systems Generated

Choice 1: Your

Choice 2: His

Choice 3: Her

Fill-in (7) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (8) - Systems Generated

Choice 1: you have

Choice 2: he has

Choice 3: she has

Fill-in (9) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (10) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (11) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (12) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (13) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

HIB039 INITIAL PREMIUM BILLING BENEFITS SUSPENDED OR DEFERRED STATUS MATURING BEYOND CURRENT YEAR (H60)

(Requested/Generated)

Caption: Information About Medicare

We will charge a monthly premium for  (1)  medical insurance under Medicare. 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 payment is due.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

HIB040 MEDICARE COVERAGE WILL CONTINUE BASED ON EXTENDED MEDICARE PROVISIONS - PROVISIONAL BENEFITS CASE (P08)

(Requested)

Caption: Information About Medicare

 (1)  Medicare coverage will continue while  (2)  receiving these provisional benefits.  (3)  hospital insurance (Part A) is free. If  (4)  medical insurance (Part B)  (5)  will no longer get a bill for the premium.  (6)  premium will be deducted from the monthly payment.  (7)  Medicare coverage may end if we deny  (8)  request for reinstatement.  (9)  will get another letter telling  (10)  if  (11)  Medicare coverage will end.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Your

Choice 2: Beneficiary's Name

Fill-in (2) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (3) - Systems Generated

Choice 1: Your

Choice 2: His

Choice 3: Her

Fill-in (4) - Systems Generated

Choice 1: you have

Choice 2: he has

Choice 3: she has

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (6) - Systems Generated

Choice 1: Your

Choice 2: His

Choice 3: Her

Fill-in (7) - Systems Generated

Choice 1: Your

Choice 2: His

Choice 3: Her

Fill-in (8) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (9) - Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (10) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (11) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

HIB041 HI TERMINATION DUE TO DIB CESSATION OR MARRIAGE OF DAC (H80)

(Requested/Generated)

Caption: Information About Medicare

Since  (1)   (2)  no longer entitled to monthly Social Security benefits, we are stopping  (3)  hospital insurance coverage under Medicare.  (4)  hospital insurance coverage ends on the last day of  (5)  .  (6)  g Medicare card will no longer be valid after coverage ends, so please tear it up.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary name

Choice 2: you

Fill-in (2) - Systems Generated

Choice 1: is

Choice 2: are

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (4) - Systems Generated

Choice 1: Your

Choice 2: His

Choice 3: Her

Fill-in (5) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (6) - Systems Generated

Choice 1: Beneficiary's Name possessive

Choice 2: Your

HIB043 MEDICARE COVERAGE WILL CONTINUE BASED ON ESRD - PROVISIONAL BENEFITS CASE (P09)

(Requested)

Caption: Information About Medicare

 (1)  already entitled to  (2)  because  (3)  enrolled based on a kidney condition. If  (4)  medical insurance (Part B)  (5)  will no longer get a bill for the premium.  (6)  premium will be deducted from the monthly payment.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You are

Choice 2: Beneficiary's Name + is

Fill-in (2) - Requested As A One Position Alpha Character

Choice 1: (A) hospital insurance (Part A)

Choice 2: (B) hospital insurance (Part A) and medical insurance (Part B)

Fill-in (3) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (4) - Systems Generated

Choice 1: you have

Choice 2: he has

Choice 3: she has

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (6) - Systems Generated

Choice 1: Your

Choice 2: His

Choice 3: Her

HIB045 MEDICARE CLOSED PERIOD - PROVISIONAL BENEFITS CASE (P10)

(Requested)

Caption: Information About Medicare

 (1)   (2)  coverage under Medicare from  (3)  through  (4)  . The Medicare coverage has ended because  (5)  no longer receiving provisional benefits.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You have

Choice 2: She has

Choice 3: He has

Fill-in (2) - Requested As A One Position Alpha Character

Choice 1: (A) hospital insurance (Part A)

Choice 2: (B) hospital insurance (Part A) and medical insurance (Part B)

Fill-in (3) - Systems Generated

Choice 1: MM/CCYY (date Medicare coverage begins)

Fill-in (4) - Systems Generated

Choice 1: MM/CCYY (date Medicare coverage begins)

Fill-in (5) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

HIB052 SMI REFUSAL PROCEDURE (H24)

(Requested)

Caption: Information About Medicare

If you do not want medical insurance, please complete the enclosed card and return it to us in the envelope we have provided. You will need to do this by the date shown on the card. If you decide you do not want the insurance, we will return any premiums that you have paid.

Fill-in values:

None

HIB061 HMO ENROLLMENT CIVIL SERVICE INVOLVEMENT (H54)

(Requested)

Caption: Information About Medicare

The Office of Personnel Management will continue to deduct  (1)  medical insurance premiums from  (2)  annuity checks.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary Name, possessive

Choice 2: your

Fill-in (2) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

HIB092 HMO DISENROLLMENT. PRIVATE PREMIUM PAYMENT WILL CONTINUE. PENALTY INVOLVED. (H56)

(Requested)

Caption: Information About Medicare

 (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.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary Name, possessive

Choice 2: Your

Fill-in (2) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Choice 4: the

Fill-in (3) - Systems Generated

Choice 1: He

Choice 2: She

Choice 3: You

Choice 4: Beneficiary's Name

HIB093 HMO DISENROLLMENT. STATE WILL CONTINUE TO PAY PREMIUMS (H55)

(Requested)

Caption: Information About Medicare

Our records show that  (1)  will continue to pay the premiums for  (2)  Medicare  (3)  insurance coverage.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: the State

Choice 2: an organization

Fill-in (2) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (3) - Systems Generated

Choice 1: hospital and medical

Choice 2: medical

HIB095 CHANGE IN DATE OF ENTITLEMENT TO SMI (H13)

(Requested or Systems Generated)

Caption: Information About Medicare

We have changed the date of  (1)  entitlement to  (2)  insurance under Medicare.  (3)  new entitlement date is  (4)  . We will take any premiums due for the insurance out of  (5)  next payment.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary Name possessive

Fill-in (2) - Requested As A One Position Alpha Character

Choice 1: (A) hospital

Choice 2: (B) medical

Choice 3: (C) hospital and medical

Fill-in (3) - Systems Generated

Choice 1: Your

Choice 2: His

Choice 3: Her

Fill-in (4) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

HIB139 HEALTH INSURANCE – PENALTY FOR LATE ENROLLMENT (H21-2)

(Requested/Generated)

Caption: Information About Medicare

This medical insurance premium includes a penalty because  (1)  enrolled later than  (2)  could have.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's Name

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

HIB152 SMI DECLINED DURING IEP OR SMI DECLINED WHEN OFFERED THROUGH EQUITABLE RELIEF (H05)

(Requested/Generated)

Caption: Information About Medicare

 (1)   (2)  through  (3)  to enroll in Medicare Part B (medical insurance).

People who have Part B pay a monthly premium. If  (4)  not sign up for Part B when  (5)  first eligible,  (6)  may have to pay a late enrollment penalty for as long as  (7)  Part B.  (8)  monthly premium may go up 10 percent for each full 12-month period that  (9)  could have had Part B coverage, but did not sign up for it. Usually  (10)  will not have to pay a late enrollment penalty if (  (11) ) up during a special enrollment period.

If  (12)  to sign up for Part B after  (13) ,  (14)  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  (15)  up in the general enrollment period,  (16)  Part B coverage will start July 1 of the year  (17)  up.

 (18)  may also be able to sign up during a special enrollment period.  (19)  can do this if  (20)  one of the conditions listed below:

  •  (21)  covered under a group health plan through  (22)  current work or  (23)  spouse's current work,

  •  (24)  covered under a large group health plan through  (25)  current work or any family member's current work.

 (26)  may sign up for medical insurance at any time  (27)  covered under the group health plan. However,  (28)  may wait and sign up during the 8-month period that begins when the work ends or  (29)  coverage under the plan ends, whichever occurs first.  (30)  may also sign up if the type of plan  (31)  changes.

NOTE: COBRA and Retiree health coverage do not count as health insurance based on current employment.

Deciding when to sign up for Part B may depend on how  (32)  health insurance works with Medicare. For example, a group health plan is usually not the primary insurance if the employer has less than 20 employees. In this case, it is important to have Medicare coverage, and you may want to sign up now.

If  (33)  help deciding what to do, please contact  (34)  employee benefits office or contact us.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary's full name

Choice 2: You

Fill-in (2) - Systems Generated

Choice 1: has

Choice 2: have

Fill-in (3) - Requested As A Date In Format Shown Below

Choice 1: Show HI-START plus 3 months MM/CCYY

Fill-in (4) - Systems Generated

Choice 1: you do

Choice 2: he does

Choice 3: she does

Fill-in (5) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (6) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (7) - Systems Generated

Choice 1: you have

Choice 2: he has

Choice 3: she has

Fill-in (8) - Systems Generated

Choice 1: Your

Choice 2: His

Choice 3: Her

Fill-in (9) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (10) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (11) - Systems Generated

Choice 1: you sign

Choice 2: he signs

Choice 3: she signs

Fill-in (12) - Systems Generated

Choice 1: you want

Choice 2: he wants

Choice 3: she wants

Fill-in (13) - Systems Generated

Show HI-START plus 3 months MM/CCYY

Fill-in (14) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (15) - Systems Generated

Choice 1: you sign

Choice 2: he signs

Choice 3: she signs

Fill-in (16) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (17) - Systems Generated

Choice 1: you sign

Choice 2: he signs

Choice 3: she signs

Fill-in (18) - Systems Generated

Choice 1: Beneficiary's full name

Choice 2: You

Fill-in (19) - Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (20) - Systems Generated

Choice 1: you meet

Choice 2: he meets

Choice 3: she meets

Fill-in (21) - Systems Generated

Choice 1: You are

Choice 2: He is

Choice 3: She is

Fill-in (22) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill (23) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (24) Systems Generated

Choice 1: You are

Choice 2: He is

Choice 3: She is

Fill-in (25) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (26) Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (27) Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (28) Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (29) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (30) Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (31) Systems Generated

Choice 1: you have

Choice 2: he has

Choice 3: she has

Fill-in (32) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (33) Systems Generated

Choice 1: you need

Choice 2: he needs

Choice 3: she needs

Fill-in (34) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

HIB157 CHILDREN'S HEALTH INSURANCE PROGRAM (H18)

(Requested/Generated)

Caption: Health Insurance For Children

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.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: www.insurekidsnow.gov

HIB170 MONTHLY BENEFITS TERMINATED - HI/SMI CONTINUES - LAF U (H90)

(Requested/Generated)

Caption: Information About Medicare

Even though  (1)  no longer receiving monthly checks,  (2)  will still have hospital and medical insurance coverage under Medicare. Please keep  (3)  Medicare card.

There is a monthly premium for  (4)  medical insurance. Because we are stopping monthly checks, we will bill  (5)  g every 3 months for the premiums.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary name is

Choice 2: you are

Fill-in (2) - Systems Generated

Choice 1: he

Choice 2: she

Choice 3: you

Fill-in (3) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (4) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (5) - Systems Generated

Choice 1: her

Choice 2: him

Choice 3: your

HIB171 CRD ENTITLEMENT MONTHLY BENEFITS TERMINATED HI/SMI CONTINUES STATE BUY-IN CONTINUES (H91)

(Requested/Generated)

Caption: Information About Medicare

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

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you are

Choice 2: Beneficiary's Name is

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (4) - Systems Generated

Choice 1: you live

Choice 2: he lives

Choice 3: she lives

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

HIB175 SMI PREMIUMS/ARREARAGE DEDUCTED FROM PMA ORCMA

(System Generated)

Caption: Information About Medicare

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

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Name possessive

Choice 2: your

HIB182 IRMAA – MEDICARE PART B PREMIUM BASED ON INCOME (HA9)

(Requested/Generated)

Caption: Information About Medicare

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.

.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name Possessive

Fill-in (2) - Systems Generated

Choice 1: you have

Choice 2: she has

Choice 3: he has

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: she

Choice 3: he

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: her

Choice 3: his

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: her

Choice 3: his

Fill-in (6) - Systems Generated

Choice 1: your

Choice 2: her

Choice 3: his

Fill-in (7) - Systems Generated

Choice 1: you pay your

Choice 2: he pays his

Choice 3: she pays her

HIB183 IRMAA – BENEFICIARY/PAYEE – PRIOR NOTICE RECEIVED EXPLAINING IRMAA (HB1)

(Requested/Generated)

Caption: Information About Medicare

We sent you another letter that explained how we determined the amount of  (1)  g premium.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

HIB184 ADVISES BENEFICIARY/PAYEE THAT WE WILL CONTINUE TO BILL FOR PART B PREMIUMS (HB4)

(Requested/Generated)

Caption: Information About Medicare

We will continue to bill  (1)  for  (2)  Medicare Part B premiums.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: him

Choice 2: her

Choice 3: you

Fill-in (2) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

HIB185 IRMAA – CMA ADJUSTED DUE TO CHANGE IN PART B PREMIUM AMOUNT (HB3)

(Requested/Generated)

Caption: Information About Medicare

The amount you will receive around  (1)  was changed because of a change in  (2)  monthly Medicare Part B premium.

Fill-in values:

Fill-in (1) - Requested As A Date in Format Shown Below

Choice 1: Using the PCI, show the calendar date in which the COM check will be paid

MM/DD/CCYY

Choice 2: Using the PCI, show the calendar date in which the DPD check will be paid

MM/DD/CCYY

Fill-in (2) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

HIB186 ADVISES ATTAINER/NEW FILER THAT IRMAA MAY APPLY BASED ON INCOME LEVEL (HB5)

(Requested/Generated)

Caption: Information About Medicare

IMPORTANT: A Medicare law requires some higher income persons to pay higher premiums. The law applies to premiums for Medicare Part B (medical insurance) and prescription 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)  g . 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).

Fill-in values:

Fill-in (1) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Amount

Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Amount

Fill-in (3) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (4) - Systems Generated

Choice 1: he has

Choice 2: she has

Choice 3: you have

Fill-in (5) - Requested As A Date in Format Shown Below

Choice 1: SMI start Date MM/CCYY

HIB187 MEDICAL PREMIUM DEDUCTIONS CONTINUE (G24)

(System Generated)

Caption: Information About Medicare

We will continue to deduct Medicare premiums from  (1)  monthly checks.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's name possessive

HIB188 SMI REFUSAL (H01)

(Requested/Generated)

Caption: Your Benefits

 (1)  told us that  (2)  want medical insurance under Medicare. We will send  (3)  a new Medicare card in a few days. It will show that  (4)  g entitled to only hospital insurance.

We will stop taking premiums for medical insurance out of  (5)  checks. If we have taken out any premiums for months when  (6)  not entitled to medical insurance, we will return the money to  (7)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You

Choice 2: Beneficiary's Name

Fill-in (2) - Systems Generated

Choice 1: you do not

Choice 2: he does not

Choice 3: she does not

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (4) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (6) - Systems Generated

Choice 1: you were

Choice 2: he was

Choice 3: she was

Fill-in (7) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

HIB189 RAILROAD JURISDICTION (H02)

(Requested/Generated)

Caption: Information About Medicare

The Railroad Retirement Board is handling  (1)  hospital and medical insurance under Medicare.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's Name possessive

HIB190 REENTITLEMENT TO DIB - NEW 24 MONTH WAITING PERIOD NEEDED (H04)

(Requested)

Caption: Information About Medicare

Our records show that  (1)  had an earlier disability. The earlier disability is not the same as  (2)  disability now. Since the disabilities are different,  (3)  will need to wait 24 months for Medicare to begin. We will tell you in another letter when  (4)  can get Medicare.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's Name

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (4) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

HIB191 HI AND SMI DATE OF ENTITLEMENT (H11)

(Requested/Generated)

Caption: Information About Medicare

 (1)  entitled to hospital and medical insurance under Medicare beginning  (2)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You are

Choice 2: Beneficiary's Name is

Fill-in (2) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

HIB192 SUSPENSION OF 24 MONTH WAITING PERIOD - BENE DIAGNOSED WITH ALS (H16)

(Requested)

Caption: Information About Medicare

Because of a change in the law people receiving disability benefits because of Amyotrophic Lateral Sclerosis (ALS) no longer have to wait 24 months for Medicare coverage. We have therefore changed  (1)  entitlement dates to hospital insurance (Part A) and medical insurance (Part B) to  (2)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Requested As A Date In Format Shown Below

Choice 1: MM/DD/CCYY

HIB193 SMI PREMIUM AMOUNTS AND EFFECTIVE DATES (H21)

(Requested/Generated)

Caption: Information About Medicare

We charge a monthly premium for  (1)  medical insurance. The rates are shown below:

Beginning Date Amount

 (2)   (3) 

NOTE: To allow multiple repetitions of the date and premium rates in Fill-ins 2 and 3, HIB259 is automatically generated.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Amount of SMI premium

HIB194 STATE BUY-IN (H30)

(Requested/Generated)

Caption: Information About Medicare

The State where  (1)  will pay the premiums for  (2)  Medicare coverage beginning  (3)  .  (4)  may receive a refund for some of the premiums  (5)  may have paid, if the State is responsible for paying them.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you live

Choice 2: Beneficiary's Name lives

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (3) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (4) - Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

HIB195 PRIVATE GROUP BUY-IN (H32)

(Requested/Generated)

Caption: Information About Medicare

Beginning  (1)  , we will send the bills for  (2)  medical insurance premiums to the organization which  (3)  selected. Although we will send the bills to them,  (4)  will still be responsible for making sure that  (5)  premiums are paid. If the organization decides that it will no longer pay the premiums, we will start sending the premium bills to  (6)  again.

 (7)  may receive a refund for some of the premiums  (8)  g may have paid, if the organization is responsible for paying them.

Fill-in values:

Fill-in (1) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (3) - Systems Generated

Choice 1: you have

Choice 2: he has

Choice 3: she has

Fill-in (4) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (6) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (7) - Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (8) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

HIB196 TERMINATION OF PRIVATE GROUP BUY-IN (H40)

(Requested/Generated)

Caption: Information About Medicare

An organization has been paying  (1)  medical insurance premiums while  (2)  not receiving checks. Since we have started to pay  (3)  checks each month, we will take the premiums out of  (4)  checks beginning  (5)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Systems Generated

Choice 1: you were

Choice 2: he was

Choice 3: she was

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (5) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

HIB197 TERMINATION OF CIVIL SERVICE BUY-IN (H41)

(Requested/Generated)

Caption: Information About Medicare

 (1)  medical insurance premiums were taken out of  (2)  civil service annuity. Since we have started to pay  (3)  checks each month, we will take the premiums out of  (4)  Social Security checks beginning  (5)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Your

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (5) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

HIB198 OPENING PARAGRAPH - AUXILIARY MQGE APPLICANT ON NUMBER HOLDER'S WAGE RECORD (H44)

(Requested)

Caption: None

This notice refers to  (1)  claim for  (2)  based on  (3)  Government employment.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Requested As A One Position Alpha Character

Choice 1: (A) Medicare

Choice 2: (B) Medicare as a disabled individual

Fill-in (3) - Systems Generated

Choice 1: Number Holder's name (possessive)

HIB199 BILLING FOR BOTH HI AND SMI PREMIUMS (H45)

(Requested)

Caption: Information About Medicare

The monthly premium for  (1)  medical insurance is  (2)  . The monthly premium for  (3)  hospital insurance is  (4)  . We will bill  (5)  each month for the combined premium for hospital and medical insurance.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Systems Generated

Choice 1: Amount of SMI premium

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (4) - Systems Generated

Choice 1: Amount of HI premium

Fill-in (5) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

HIB200 FULLY INSURED FOR MEDICARE AT AGE 65 (H47)

(Requested)

Caption: Information About Medicare

Based on  (1)  earnings and on the date of birth,  (2)  g worked long enough under Social Security to qualify for Medicare coverage at age 65.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name, possessive

Fill-in (2) - Systems Generated

Choice 1: you have

Choice 2: he has

Choice 3: she has

HIB212 HI START DATE PRIOR TO AGE 65 - HI AWARD ACTION TAKEN IN AGE 65 ATTAINMENT MONTH OR LATER (H48)

(Requested)

Caption: Information About Medicare

Now that  (1)  65 years old,  (2)  Medicare coverage is no longer based on  (3)  disability.  (4)  Medicare coverage does not change because  (5)  65. Work does not affect  (6)  Medicare eligibility. This is because work restrictions only apply to Medicare beneficiaries under age 65 and disabled. If  (7)  condition improves, and  (8)  to return to work, it is not necessary to notify Social Security.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you are

Choice 2: Beneficiary's Name is

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (4) - Systems Generated

Choice 1: Your

Choice 2: Beneficiary's Name possessive

Fill-in (5) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (6) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (7) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (8) - Systems Generated

Choice 1: you decide

Choice 2: he decides

Choice 3: she decides

HIB213 TOTALIZATION MONTHLY BENEFITS AWARDED TO U.S. RESIDENT BETWEEN AGE 50 AND AGE 64 AND 9 MONTHS. (NO MEDICARE ENTITLEMENT ON ANOTHER SSN) (H50)

(Requested)

Caption: Information About Medicare

If  (1)  to be entitled to Medicare insurance when  (2)  age 65,  (3)  will need to apply for it. The separate application is necessary because  (4)  monthly benefits are based on a combination of U.S. and foreign Social Security credits. Please get in touch with us 3 months before  (5)  65 for more information about Medicare insurance.  (6)  may have to pay for this insurance.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you wish

Choice 2: Beneficiary's Name wishes

Fill-in (2) - Systems Generated

Choice 1: you reach

Choice 2: he reaches

Choice 3: she reaches

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (5) - Systems Generated

Choice 1: you become

Choice 2: he becomes

Choice 3: she becomes

Fill-in (6) - Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

HIB214 TOTALIZATION MONTHLY BENEFITS AWARDED TO U.S. RESIDENT AT LEAST AGE 64 AND 9 MONTHS OR ALREADY ENTITLED TO DIB BENEFITS FOR 24 MONTHS — WORKER (NO FREE HI ENTITLEMENT ON ANOTHER SSN) (H51)

(Requested)

Caption: Information About Medicare

 (1)  not entitled to free Medicare hospital insurance under the Social Security agreement. We can use only U.S. Social Security credits to entitle someone to this insurance. This is true even though we have used foreign credits to pay monthly benefits.

 (2)  a total of  (3)  credits of work under the U.S. Social Security system to be entitled to free hospital insurance.  (4)   (5)  credits.  (6)   (7)  more credits to become entitled.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You are

Choice 2: Beneficiary's Name is

Fill-in (2) - Systems Generated

Choice 1: You need

Choice 2: He needs

Choice 3: She needs

Fill-in (3) – Requested As A Number

Choice 1: Number of quarters needed to be insured for HI

Fill-in (4) - Systems Generated

Choice 1: You have

Choice 2: He has

Choice 3: She has

Fill-in (5) – Requested As A Number

Choice 1: Number of quarters earned

Fill-in (6) - Systems Generated

Choice 1: You need

Choice 2: He needs

Choice 3: She needs

Fill-in (7) – Requested As A Number

Choice 1: Number of quarters needed

HIB215 HI AND SMI TERMINATION DUE TO DIB CESSATION AFTER 25TH MONTH (H82)

(Requested/Generated)

Caption: Information About Medicare

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.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: he is

Choice 2: she is

Choice 3: you are

Fill-in (2) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (3) - Requested As A One Position Alpha Character

Choice 1: (A) hospital

Choice 2: (B) hospital and medical

Fill-in (4) - Systems Generated

Choice 1: His

Choice 2: Her

Choice 3: Your

Fill-in (5) - Requested As A One Position Alpha Character

Choice 1: (A) hospital

Choice 2: (B) hospital and medical

Fill-in (6) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (7) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

HIB216 TOTALIZATION MONTHLY BENEFIT AWARDED TO U.S. RESIDENT AT LEAST AGE 64 AND 9 MONTHS OR ENTITLED TO DISABILITY BENEFITS FOR 24 MONTHS AUXILIARY OR SURVIVOR (NO FREE HI ENTITLEMENT ON ANOTHER SSN) (H52)

(Requested)

Caption: Information About Medicare

 (1)  not entitled to free Medicare hospital insurance under the Social Security agreement. We can use only U.S. Social Security credits to entitle someone to this insurance. This is true even though we have used foreign credits to pay monthly benefits.

For  (2)  to be entitled to free hospital insurance,  (3)  needed to have earned  (4)  credits of work under the U.S. system. However, only  (5)  g credits were earned.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You are

Choice 2: Beneficiary's Name is

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (3) - Requested As A Language

Choice 1: Name of worker

Fill-in (4) – Requested A Number

Choice 1: Number of quarters needed to be insured for HI

Fill-in (5) - Requested As A Number

Choice 1: Number of quarters earned

HIB217 INITIAL PREMIUM BILLING DUE TO ONE-CHECK-ONLY ADJUSTMENT PLUS SUSPENSION (H61)

(Requested/Generated)

Caption: Information About Medicare

We are taking medical insurance premiums out of the check  (1)  will receive. We will bill  (2)  every 3 months for future premiums, and will send  (3)  the bill shortly before payment is due.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

HIB218 FINAL PREMIUM ADJUSTMENT DUE TO TERMINATION OF BENEFITS (CAN BE USED FOR CONVERSION FROM T TO A.) (H62)

(Requested/Generated)

Caption: Information About Medicare

When we figured the amount of  (1)  payment, we took into account all medical insurance premiums which were already paid or still due.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

HIB219 PREMIUM ADJUSTMENT DUE TO DEFERRED ACTION THAT WILL MATURE IN CURRENT YEAR (H63)

(Requested/Generated)

Caption: Information About Medicare

We will change  (1)  next check to account for medical insurance premiums that are due or already paid.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

HIB220 INITIAL PREMIUM ADJUSTMENT DUE TO SMI ENTITLEMENT (H64)

(Requested/Generated)

Caption: Information About Medicare

We are taking medical insurance premiums due through  (1)  out of the check  (2)  will receive around  (3)  . These premiums total  (4)  . We will deduct medical insurance premiums 1 month in advance.

Fill-in values:

Fill-in (1) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's Name

Fill-in (3) - Requested As A Date In Format Shown Below

Choice 1: MM/DD/CCYY

Fill-in (4) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Amount of premiums

HIB221 PREMIUM ADJUSTMENT DUE TO CURRENT SMI ENTITLEMENT AND PRIOR PERIOD OF SMI ENTITLEMENT (H65)

(Requested/Generated)

Caption: Information About Medicare

We will  (1)  the payment  (2)  will receive shortly after  (3)  by  (4)  because of medical insurance premiums. When we figured the amount of  (5)  payment, we took into account all the medical insurance premiums which were previously paid or still due. We will deduct medical insurance premiums 1 month in advance.

Fill-in values:

Fill-in (1) - Requested As A One Position Alpha Character

Choice 1: (A) reduce

Choice 2: (B) increase

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's Name

Fill-in (3) - Requested As A Date In Format Shown Below

Choice 1: MM/DD/CCYY

Fill-in (4) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Amount (PDA)

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

HIB223 SUBSEQUENT PREMIUM AND PINQ RECORD ADJUSTMENT (H66)

(System Generated)

Caption: Information About Medicare

We will  (1)  the payment  (2)  will receive after  (3)  by  (4)  because of medical insurance premiums which were  (5)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: increase

Choice 2: reduce

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (3) - Systems Generated

Choice 1: MM/DD/CCYY

Fill-in (4) - Systems Generated

Choice 1: Amount (PDA)

Fill-in (5) - Requested As A One Position Alpha Character

Choice A: already paid

Choice B: owed

HIB224 PREMIUM AND PINQ RECORD ADJUSTMENT DUE TO RESUMPTION OF BENEFITS (H67)

(Requested/Generated)

Caption: Information About Medicare

We are  (1)   (2)  next payment by  (3)  because of the medical insurance premiums  (4)  . After that we will take premiums out of  (5)  regular checks each month.

Fill-in values:

Fill-in (1) - Requested As A One Position Alpha Character

Choice 1: (A) reducing

Choice 2: (B) increasing

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (3) - Requested As A Money Amount in Format $$$$$.¢¢

Choice 1: Amount

Fill-in (4) - Requested As A One Position Alpha Character

Choice 1: (A) you owe

Choice 2: (B) he owes

Choice 3: (C) she owes

Choice 4: (D) already paid

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

HIB228 SMI PREMIUM CHANGED TO VARIABLE RATE DUE TO DELAYED DECEMBER COM PROCESSING (H72)

(Requested)

Caption: Information About Medicare

We have determined that the premium amount of  (1)  , which  (2)  now being charged, should be reduced to  (3)  effective with January of this year. This reduction in  (4)  premium is being made because the increase in  (5)  premium as of January 1st resulted in a decrease in  (6)  monthly Social Security check. The law permits us to reduce the Part B premium amount as necessary (but not below the amount  (7)  paid in December of last year) if the yearly change in the premium would cause the Social Security checks  (8)  this year to be lower than the checks  (9)  last year.

Fill-in values:

Fill-in (1) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: SMI premium rate

Fill-in (2) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: New variable SMI rate

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (6) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (7) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (8) - Systems Generated

Choice 1: you receive

Choice 2: he receives

Choice 3: she receives

Fill-in (9) - Systems Generated

Choice 1: you received

Choice 2: he received

Choice 3: she received

HIB229 REVIEW REQUESTED VARIABLE SMI PREMIUM APPLIES (H73)

(Requested)

Caption: Information About Medicare

As  (1)  requested, we reviewed the amount of the premium  (2)  each month for medical insurance. We've decided that  (3)  premium should have been  (4)  since January  (5)  . Because we've been charging  (6)   (7)  , it caused  (8)  to get less money in  (9)  Social Security check. This is why we'll lower  (10)  premium.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you

Choice 2: Beneficiary's Name

Fill-in (2) - Systems Generated

Choice 1: you pay

Choice 2: he pays

Choice 3: she pays

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (4) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Variable premium for SMI, plus surcharge amount

Fill-in (5) - Requested As A Date In Format Shown Below

Choice 1: CCYY

Fill-in (6) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (7) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Current base premium for SMI, plus surcharge, if applicable

Fill-in (8) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (9) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (10) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

HIB231 ERRONEOUS SMI TERMINATION EQUITABLE RELIEF GIVEN (H75)

(Requested)

Caption: Information About Medicare

We stopped  (1)  Medical insurance coverage under Medicare in  (2)  by mistake. We are sorry if our error caused  (3)  any inconvenience. We have corrected the mistake, and are starting  (4)  coverage again beginning  (5)  .

It might be to  (6)  advantage to start  (7)  medical coverage at an earlier date. We can start the coverage beginning  (8)  . However,  (9)  would have to pay the premiums for this insurance. The total amount of premiums from  (10)  through  (11)  is  (12)  .

If  (13)  coverage to start at the earlier date, please let us know within 60 days.  (14)  will need to tell us whether  (15)  to pay us directly for the premiums or have us take the money for the premiums out of  (16)  checks.

If  (17)  would like to have coverage beginning  (18)  , but it would be a hardship for  (19)  g to pay the premiums at one time, please let us know.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (5) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (6) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name, possessive

Fill-in (7) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (8) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (9) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (10) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (11) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (12) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Premium amount due

Fill-in (13) - Systems Generated

Choice 1: you want

Choice 2: he wants

Choice 3: she wants

Fill-in (14) - Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (15) - Systems Generated

Choice 1: you want

Choice 2: he wants

Choice 3: she wants

Fill-in (16) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (17) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (18) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (19) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

HIB232 PART B PREMIUM SURCHARGE ROLLBACK (H78)

(Requested)

Caption: Information About Medicare

We reduced the premium  (1)  paying for  (2)  medical insurance under Medicare. This is because of  (3)  health insurance coverage under an employer's health plan.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

HIB233 PART B ENROLLEE BENEFITS SUSPENDED FOR WORK (H79)

(Requested)

Caption: Information About Medicare

 (1)  not getting benefits because  (2)  working, so  (3)  to know some special facts about Medicare.  (4)  to consider these facts if  (5)  working for an employer who has 20 or more employees:

  • If  (6)  covered under  (7)  employer's group health plan, it will pay first for  (8)  g health care needs.

  • Medicare will not pay any expenses that the group health plan pays for.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You are

Choice 2: Beneficiary's Name is

Fill-in (2) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (3) - Systems Generated

Choice 1: you need

Choice 2: he needs

Choice 3: she needs

Fill-in (4) - Systems Generated

Choice 1: You only need

Choice 2: He only needs

Choice 3: She only needs

Fill-in (5) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (6) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (7) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (8) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

HIB234 SMI WITHDRAWAL (H81)

(Requested/Generated)

Caption: Information About Medicare

 (1)  asked that we stop  (2)  medical insurance coverage under Medicare. This coverage ends the last day of  (3)  . If  (4)  g hospital insurance coverage, it will continue.

 (5) 

If  (6)  in the future that  (7)  would like to have medical insurance coverage again, please get in touch with us.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You

Choice 2: Beneficiary's Name

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (3) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (4) - Systems Generated

Choice 1: you have

Choice 2: he has

Choice 3: she has

Fill-in (5) - Requested As A One Position Alpha Character

Choice 1: (A) We will stop taking premiums out of your Social Security checks. We will change your next payment to account for any premiums still due or any which you have already paid.

Choice 2: (B) Null

Fill-in (6) - Systems Generated

Choice 1: you decide

Choice 2: he decides

Choice 3: she decides

Fill-in (7) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

HIB235 INELIGIBLE FOR HI/SMI DIB CESSATION PRIOR TO 25TH MONTH (H83)

(System Generated)

Caption: Information About Medicare

Since  (1)  no longer entitled to monthly Social Security benefits,  (2)  will not be eligible for Medicare insurance. Please disregard any information we may have given  (3)  about Medicare.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you are

Choice 2: Beneficiary's Name is

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

HIB236 PREMIUM ADJUSTMENT DUE TO SMI TERMINATION (H85)

(Requested/Generated)

Caption: Information About Medicare

Because we stopped  (1)  medical insurance, under Medicare, we will change the payment  (2)  will receive around  (3)  by  (4)  to account for premiums which were  (5)  g .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (3) - Requested As A Date In Format Shown Below

Choice 1: MM/DD/CCYY

Fill-in (4) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Money amount

Fill-in (5) - Requested As A One Position Alpha Character

Choice 1: (A) still due

Choice 2: (B) already paid

HIB237 DISABILITY CESSATION PREMIUMS DUE FOR FUTURE MONTH(S) (H86)

(Requested/Generated)

Caption: Information About Medicare

The premiums for medical insurance under Medicare are paid 1 month in advance. Since  (1)  premiums have been paid only through  (2)  ,  (3)  should send us  (4)  to pay for the remaining premiums.

Please make your check or money order payable to the Centers for Medicare & Medicaid Services. Include  (5)  claim number (shown above) on your check or money order. Send your payment to:

Centers for Medicare & Medicaid Services

Medicare Premium Collection Center

PO BOX 790355

St Louis, MO 63179-0355

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (4) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Money amount

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

HIB238 INTRODUCTORY UTI FOR HEALTH PLAN PREMIUMS AND MEDICARE PRESCRIPTION DRUG PLAN COSTS (H88)

(Requested/Generated)

Caption: Information About Health Plan Premiums And Prescription Drug Plan Costs

As  (1)  requested, we will begin deducting  (2)  health plan premiums and Medicare prescription drug plan costs from  (3)  monthly benefit.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary's full name

Choice 2: you

Fill-in (2) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (3) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

HIB239 CRD ENTITLEMENT MONTHLY BENEFITS TERMINATED HI ENTITLEMENT CONTINUES (H92)

(Requested/Generated)

Caption: Information About Medicare

Even though  (1)  no longer receiving monthly checks,  (2)  will still have hospital insurance coverage under Medicare. Please keep  (3)  Medicare card.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you are

Choice 2: Beneficiary's name is

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's name, possessive

HIB240 ADDRESS CHANGED TO FOREIGN COUNTRY ENTITLED TO HI ONLY (H95)

(Requested)

Caption: Information About Medicare

In most cases, Medicare will only pay for hospital services which  (1)  in the United States. Since  (2)  living outside the U.S., Medicare will not pay for hospital services unless  (3)  to the U.S. for services.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you receive

Choice 2: Beneficiary's Name receives

Fill-in (2) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (3) - Systems Generated

Choice 1: you return

Choice 2: he returns

Choice 3: she returns

HIB241 FOREIGN ADDRESS GENERAL MEDICARE ELIGIBILITY (H96)

(Requested)

Caption: Information About Medicare

In most cases, Medicare will only pay for hospital and medical services which  (1)  in the United States.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you receive

Choice 2: Beneficiary's Name receives

HIB242 AUXILIARY BENEFICIARY AGE 65 OR OVER TERMINATED T3, T8 OR T9 NEW HEALTH INSURANCE CARD SMI ONLY (H98)

(Requested/Generated)

Caption: Information About Medicare

Even though  (1)  no longer receiving monthly checks and  (2)  not have hospital insurance coverage under Medicare,  (3)  will still have medical insurance coverage. We will send  (4)  a new Medicare card, which will show that  (5)  medical insurance only.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you are

Choice 2: Beneficiary's name is

Fill-in (2) - Systems Generated

Choice 1: do

Choice 2: does

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (4) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (5) - Systems Generated

Choice 1: you now have

Choice 2: he now has

Choice 3: she now has

HIB243 3RD PARTY BUY-IN FOR AUXILIARY BENEFICIARY AGE 65 OR OVER TERMINATED T3, T8 or T9 (H99)

(Requested/Generated)

Caption: Information About Medicare

We charge monthly premiums for  (1)  medical insurance under Medicare.  (2)  will continue to pay these premiums.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Requested As A One Position Alpha Character

Choice 1: (A) The State where you live

Choice 2: (B) The organization you choose

HIB244 DIB CESSATION OVERPAYMENT AND PREMIUMS DUE FOR A FUTURE MONTH (H87)

(Requested/Generated)

Caption: Information About Medicare

 (1)  overpayment includes the Medicare medical insurance premiums of  (2)  which we took out of  (3)  checks during the time when  (4)  overpaid. Also,  (5)  not paid  (6)  premiums for  (7)  . For this reason, when  (8)  back  (9)  overpayment  (10)  should include  (11)  to pay for all premiums due.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Your

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Requested As A Money Amount in Format $$$$$.¢¢

Choice 1: Amount

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (4) - Systems Generated

Choice 1: you were

Choice 2: he was

Choice 3: she was

Fill-in (5) - Systems Generated

Choice 1: you have

Choice 2: he has

Choice 3: she has

Fill-in (6) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (7) - Requested As A Date In Format Shown Below

Choice 1: MMCCYY

Fill-in (8) - Systems Generated

Choice 1: you pay

Choice 2: he pays

Choice 3: she pays

Fill-in (9) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (10) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (11) - Requested As A Money Amount in Format $$$$$.¢¢

Choice 1: Amount

HIB249 EQUITABLE RELIEF FOR V-SMI CASES ONLY (HC2)

(Requested/Generated)

Caption: Information About Medicare

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)  g ;

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)  .

Fill-in values:

Fill-in (1) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (2) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (3) - Requested As A Money Amount in Format $$$$$.¢¢

Choice 1: Amount

Fill-in (4) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (5) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (6) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (7) - Requested As A Money Amount in Format $$$$$.¢¢

Choice 1: Amount

Fill-in (8) - Requested As A Money Amount in Format $$$$$.¢¢

Choice 1: Amount

HIB250 CHANGE IN RESIDENCE AFFECTS PREMIUM AMOUNT CATASTROPHIC LEGISLATION (H76)

(System Generated)

Caption: Information About Medicare

Beginning  (1)  we are changing  (2)  monthly Medicare premium rate to  (3)  because of  (4)  change in residence.

Fill-in values:

Fill-in (1) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Premium Amount

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

HIB251 WORK REINSTATEMENT NO SMI (H77)

(Requested)

Caption: Information About Medicare

 (1)  getting benefits because  (2)  stopped working, so  (3)  to know some special facts about Medicare.  (4)  to consider these facts if  (5)  covered under an employer group health plan while  (6)  working:

  1.  (7)  may enroll for medical insurance under Medicare up until 8 months after  (8)  working.

  2. If  (9)  for medical insurance during the 8 months,  (10)  coverage will start sooner than if  (11)  until the regular enrollment time of January through March.

  3. Also,  (12)  may have to pay a premium penalty if  (13)  a full 12 months when  (14)  could have been, but  (15)  not, covered by Medicare. We do not count months of employer group health plan coverage when figuring the 12-month period.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You are

Choice 2: Beneficiary name is

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (3) - Systems Generated

Choice 1: you need

Choice 2: he needs

Choice 3: she needs

Fill-in (4) - Systems Generated

Choice 1: You only need

Choice 2: He only needs

Choice 3: She only needs

Fill-in (5) - Systems Generated

Choice 1: you were

Choice 2: he was

Choice 3: she was

Fill-in (6) - Systems Generated

Choice 1: you were

Choice 2: he was

Choice 3: she was

Fill-in (7) - Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (8) - Systems Generated

Choice 1: you stop

Choice 2: he stops

Choice 3: she stops

Fill-in (9) - Systems Generated

Choice 1: you enroll

Choice 2: he enrolls

Choice 3: she enrolls

Fill-in (10) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (11) - Systems Generated

Choice 1: you wait

Choice 2: he waits

Choice 3: she waits

Fill-in (12) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (13) - Systems Generated

Choice 1: you have

Choice 2: he has

Choice 3: she has

Fill-in (14) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (15) - Systems Generated

Choice 1: were

Choice 2: was

HIB252 EQUITABLE RELIEF UNTIMELY PROCESSING (H49)

(Requested/Generated)

Caption: Information About Medicare

We did not give  (1)  earlier medical insurance because we did not process it timely. If  (2)  to have these benefits earlier,  (3)  can choose medical insurance benefits beginning  (4)  . If  (5)  this benefit to start earlier,  (6)  must do the following things within 60 days after the date of this notice:

  • tell us in writing that  (7)  the medical insurance benefits beginning  (8)  ;

  • pay us  (9)  (this covers the premiums due from  (10)  through  (11)  ); or,

  • tell us we can withhold this amount from the check.

If  (12)  the benefits beginning  (13)  but  (14)  it hard to pay the premium amount in a lump sum, ask us about other ways to pay the money.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary name

Choice 2: you

Fill-in (2) - Systems Generated

Choice 1: you want

Choice 2: he wants

Choice 3: she wants

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (4) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (5) - Systems Generated

Choice 1: you want

Choice 2: he wants

Choice 3: she wants

Fill-in (6) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (7) - Systems Generated

Choice 1: you want

Choice 2: he wants

Choice 3: she wants

Fill-in (8) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (9) - Requested As A Money Amount in Format $$$$$.¢¢

Choice 1: Total amount of medical insurance premiums

Fill-in (10) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (11) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (12) - Systems Generated

Choice 1: you want

Choice 2: he wants

Choice 3: she wants

Fill-in (13) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (14) - Systems Generated

Choice 1: find

Choice 2: finds

HIB254 CHANGE IN DATE OF ENTITLEMENT TO HI AND SMI (H14)

(Requested/Generated)

Caption: Information About Medicare

We have changed the date of  (1)  entitlement to hospital and medical insurance under Medicare.  (2)  new entitlement date is  (3)  . We will take any premiums due for the insurance out of  (4)  g next check.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Systems Generated

Choice 1: Your

Choice 2: His

Choice 3: Her

Fill-in (3) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

HIB255 CHANGE IN DATE OF ENTITLEMENT TO HI (H15)

(Requested/Generated)

Caption: Information About Medicare

We have changed the date of  (1)  entitlement to hospital insurance under Medicare.  (2)  new entitlement date is  (3)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary's Name possessive

Fill-in (2) - Systems Generated

Choice 1: Your

Choice 2: His

Choice 3: Her

Fill-in (3) - Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

HIB256 FUTURE MEDICARE COVERAGE (H07)

(Requested/Generated)

Caption: Information About Medicare

 (1)  may be able to buy Medicare coverage in the future. If  (2)  a citizen of the United States,  (3)  can buy Medicare as soon as  (4)  to this country. If  (5)  not a citizen,  (6)  can buy Medicare only after  (7)  lived in the United States for five years in a row. These must be the five years right before  (8)  for Medicare. Also, as an alien  (9)  must be lawfully admitted for permanent residence.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: You

Choice 2: Beneficiary's name

Fill-in (2) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (4) - Systems Generated

Choice 1: you return

Choice 2: he returns

Choice 3: she returns

Fill-in (5) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (6) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (7) - Systems Generated

Choice 1: you have

Choice 2: he has

Choice 3: she has

Fill-in (8) - Systems Generated

Choice 1: you apply

Choice 2: he applies

Choice 3: she

Fill-in (9) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

HIB257 WHAT HOSPITAL INSURANCE WILL PAY (H27)

(Requested/Generated)

Caption: Information About Medicare

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  (1)  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.  (2)  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  (3)  planning changes in any other hospital or medical insurance  (4)  , remember that Social Security health insurance coverage will be effective with the dates shown on this notice.

If  (5)  help with medical expenses before  (6)  health insurance coverage begins, or if  (7)  aid in meeting medical expenses not covered by  (8)  health insurance,  (9)  may want to get in touch with the nearest social services office to see whether  (10)  eligible under a program of medical assistance.

Notify any Social Security office immediately if  (11)   (12)  address so that  (13)  health insurance card and any claims or informational material may reach  (14)  promptly.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you are

Choice 2: Beneficiary's name + is

Fill-in (2) - Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (3) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (4) - Systems Generated

Choice 1: you now have

Choice 2: he now has

Choice 3: she now has

Fill-in (5) - Systems Generated

Choice 1: you need

Choice 2: he needs

Choice 3: she needs

Fill-in (6) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (7) - Systems Generated

Choice 1: you need

Choice 2: he needs

Choice 3: she needs

Fill-in (8) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (9) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (10) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (11) - Systems Generated

Choice 1: you change

Choice 2: he changes

Choice 3: she changes

Fill-in (12) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (13) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (14) - Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

HIB258 OPENING INTRO WHEN BENEFICIARY IS ENTITLED TO MEDICARE BENEFITS UNDER TITLE XVIII

(Requested/Generated)

Caption: None

This certifies that  (1)  entitled under Title XVIII of the Social Security Act to the Medicare benefits shown, beginning with the date indicated.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you are

Choice 2: Beneficiary's name + is

HIB259 SMI PREMIUM AMOUNTS AND EFFECTIVE DATES (H21 DETAIL LINE)

(Systems Generated)

Caption: Information About Medicare

 (1)   (2) 

NOTE: This UTI is automatically generated whenever HIB193 is requested/generated and there is more than one row of data to display in Fill-ins two and three under the headers in the chart.

Fill-in values:

Fill-in (1) - Systems Generated As A Date In Format Shown Below

Choice 1: MM/CCYY

Fill-in (2) - Systems Generated As A Money Amount In Format $$$$$.¢¢

Choice 1: Amount of SMI premium

HIB260 IRMAA

(System Generated)

Caption: Information About Medicare

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

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Name possessive

Choice 2: your

HIB261 IRMAA

(System Generated)

Caption: Information About Medicare

You owe  (1)  for Medicare Part B (medical insurance) premiums for  (2)   (3)   (4)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Total Amount in $$$$$¢¢ format

Fill-in (2) - Systems Generated

Choice 1: MM/CCYY

Fill-in (3) - Systems Generated

Choice 1: null

Choice 2: and

Choice 3: through

Fill-in (4) - Systems Generated

Choice 1: null

Choice 2: MM/CCYY

HIB262 IRMAA D

(System Generated)

Caption: Information About Medicare

You owe  (1)  for Medicare prescription drug coverage income-related monthly adjustment amounts for  (2)   (3)   (4)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Total Amount in $$$$$¢¢ format

Fill-in (2) - Systems Generated

Choice 1: MM/CCYY

Fill-in (3) - Systems Generated

Choice 1: null

Choice 2: and

Choice 3: through

Fill-in (4) - Systems Generated

Choice 1: null

Choice 2: MM/CCYY

HIB263 IRMAA B and D

(System Generated)

Caption: Information About Medicare

The total past-due Medicare amounts you owe are  (1)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Total Amount in $$$$$¢¢ format

HIB264 IRMAA Waiver Request

(System Generated)

Caption: Information About Medicare

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)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: he owes

Choice 2: she owes

Choice 3: you owe

Fill-in (2) - Systems Generated

Choice 1: he owes

Choice 2: she owes

Choice 3: you owe

Fill-in (3) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (4) - Systems Generated

Choice 1: MM/CCYY (COM + 2 months)

HIB265 IRMAA Deduction

(System Generated)

Caption: Information About Medicare

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

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Name possessive

Choice 2: your

Fill-in (2) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (3) - Systems Generated

Choice 1: MM/CCYY (COM)

HIB266 IRMAA B Deduction

(System Generated)

Caption: Information About Medicare

We will also deduct  (1)  for past-due Medicare Part B (medical insurance) premiums.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Amount in $$$$$¢¢ format

HIB267 IRMAA D Deduction

(System Generated)

Caption: Information About Medicare

We will also deduct  (1)  for past-due Medicare prescription drug coverage income-related monthly adjustment amounts.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Amount in $$$$$¢¢ format

HIB268 IRMAA Partial Recovery

(System Generated)

Caption: Information About Medicare

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)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: MM/CCYY (COM)

Fill-in (2) - Systems Generated

Choice 1: Amount in $$$$$¢¢ format

HIB269 IRMAA Total Withholding

(System Generated)

Caption: Information About Medicare

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

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Name possessive

Choice 2: your

Fill-in (2) - Systems Generated

Choice 1: he owes

Choice 2: she owes

Choice 3: you owe

HIB270 IRMAA PART B Arrearage

(System Generated)

Caption: Information About Medicare

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)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: MM/CCYY (COM)

Fill-in (2) - Systems Generated

Choice 1: Amount in $$$$$.¢¢ format

HIB271 IRMAA D and/or B Installment Payment

(System Generated)

Caption: Information About Your Installment Payment

As you requested, we will withhold  (1)  from  (2)  monthly Social Security payments beginning  (3)  for past due Medicare amounts owed. We will withhold  (4)  each month until you have paid all of the past due Medicare amounts you owe.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Amount in $$$$$.¢¢ format

Fill-in (2) - Systems Generated

Choice 1: Name possessive

Choice 2: your

Fill-in (3) - Systems Generated

Choice 1: MM/CCYY (COM)

Fill-in (4) - Systems Generated

Choice 1: Amount in $$$$$.¢¢ format

HIBR60 MEDICAL INSURANCE INFORMATION PRIMARY IS IMPRISONED OR CONFINED (H03)

(Requested)

Caption: Information About Medicare

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 re-enroll 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 re-enroll. 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 a 3-month period and will be sent to you shortly before the payment is due.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: you receive

Choice 2: Beneficiary's Name receives

Fill-in (2) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (3) - Requested As A One Position Alpha Character

Choice 1: (A) imprisoned

Choice 2: (B) confined in a institution

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (5) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (6) - Systems Generated

Choice 1: prison

Choice 2: the institution

Fill-in (7) - Systems Generated

Choice 1: You

Choice 2: He

Choice 3: She

Fill-in (8) - Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (9) - Systems Generated

Choice 1: prison

Choice 2: the institution

Fill-in (10) - Systems Generated

Choice 1: you

Choice 2: he

Choice 3: she

Fill-in (11) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900720180
NL 00720.180 - HIB Health Insurance Benefits - 09/13/2017
Batch run: 09/13/2017
Rev:09/13/2017