TN 4 (08-12)

NL 00720.210 MHP Medicare Health Plan

MHP001 ENROLLMENT IN HMO – PART B PREMIUM REDUCTION STARTS OR CHANGES (H33)

(Requested)

Caption: Information About Medicare

 (1)  enrolled in a Medicare health plan which reduces  (2)  Medicare Part B premium.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary Full Name + has
Choice 2: You have
Fill-in (2) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your

MHP002 PART B PREMIUM AFTER REDUCTION AMOUNT IS APPLIED (H34)

(Requested)

Caption: Information About Medicare

 (1)  Part B premium is  (2)  beginning  (3)  .


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary First Name possessive
Choice 2: Your
Fill-in (2) - Systems Generated
Choice 1: reduced SMI premium $amount
Fill-in (3) - Systems Generated
Choice 1: MCR Start DATE, corr. to amount above

MHP003 DISENROLLMENT IN HMO – PART B PREMIUM REDUCTION STOPS (H35)

(Requested)

Caption: Information About Medicare

 (1)  no longer enrolled in a Medicare health plan which reduces  (2)  Medicare Part B premium.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary Full Name + is
Choice 2: You are
Fill-in (2) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your

MHP004 ERRONEOUS ENROLLMENT IN A MEDICARE HEALTH PLAN – WIPEOUT (H36)

(Requested)

Caption: Information About Medicare

 (1)  not enrolled in a Medicare health plan which reduces  (2)  Medicare Part B premium.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary Full Name + is
Choice 2: You are
Fill-in (2) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your

MHP005 ENROLLMENT IN A HMO – CLOSED PERIOD REDUCTION OF PART B (H37)

(Requested)

Caption: Information About Medicare

 (1)  enrolled in a Medicare health plan which reduced  (2)  Medicare Part B premium.  (3)  Part B premium was reduced to  (4)  from  (5)  through  (6)  .


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary Full Name + was
Choice 2: You were
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
Fill-in (4) - Systems Generated
Choice 1: Reduced SMI premium amount
Fill-in (5) - Systems Generated
Choice 1: MCR start date
Fill-in (6) - Systems Generated
Choice 1: MCR stop date

MHP009 INTRODUCTORY UTI FOR HEALTH PLAN PREMIUMS (H17)

(Requested/Generated)

Caption: Information About Health Plan Premiums

As  (1)  requested, we will begin deducting  (2)  health plan premiums from  (3)  monthly benefit.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary's Full Name
Choice 2: you
Choice 3: he
Choice 4: she
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

MHP012 (H25)

(Requested/Generated)

Caption: Information About Health Plan Premiums

This represents all health plan premiums due to date.


Fill-in values:

 

None

MHP013 ADVISES BENEFICIARY THAT SOME MANAGED HEALTH PLANS OFFER PREMIUM DEDUCTION (H57)

(Requested/Generated)

Caption: Information About Health Plan Premiums

Some Medicare plans may reduce  (1)  Medicare Part B premium as a plan benefit.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary's Full Name possessive
Choice 2: your
Choice 3: his
Choice 4: her

MHP015 HEALTH PLAN PREMIUMS CONTINUING TO BE DEDUCTED FROM ONGOING MONTHLY BENEFITS (H22)

(Requested/Generated)

Caption: Information About Health Plan Premiums

Each month, we will continue to deduct  (1)  for  (2)  health plan premiums.


Fill-in values:
Fill-in (1) - Requested As A Money Amount in Format $$$$$.¢¢
Choice 1: Money amount
Fill-in (2) - Systems Generated
Choice 1: Beneficiary's Full Name possessive
Choice 2: your
Choice 3: his
Choice 4: her

MHP016 CHANGE IN HEALTH PLAN PREMIUM DEDUCTION AMOUNT (H58)

(Requested/Generated)

Caption: Information About Health Plan Premiums

There has been a change in the amount withheld for  (1)  health plan premiums.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary's Full Name possessive
Choice 2: your
Choice 3: his
Choice 4: her

MHP017 HEALTH PLAN PREMIUMS NO LONGER BEING DEDUCTED (H29)

(Requested/Generated)

Caption: Information About Health Plan Premiums

We will no longer deduct money for  (1)  health plan premium(s) from  (2)  monthly benefits.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary's Full Name possessive
Choice 2: your
Choice 3: his
Choice 4: her
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Choice 4: the

MHP018 ADVISES BENEFICIARY/PAYEE TO CONTACT HEALTH PLAN CARRIER FOR QUESTIONS ABOUT THEIR HEALTH PLAN PREMIUMS (H38)

(Requested/Generated)

Caption: Information About Health Plan Premiums

If you have any questions about  (1)  health plan premiums, please contact  (2)  health plan(s).


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Choice 4: the
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Choice 4: the

MHP033 INTRODUCTORY UTI FOR MEDICARE PRESCRIPTION DRUG PLAN COSTS (H08)

(Requested/Generated)

Caption: Information About Medicare prescription drug plan costs

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


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary's 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

MHP035 HEALTH PLAN PREMIUMS DEDUCTED FROM PMA PAYMENT (H19)

(Requested/Generated)

Caption: Information About Health Plan Premiums

We deducted  (1)  for  (2)  health plan premiums from the check you will receive on or about  (3)  .


Fill-in values:
Fill-in (1) - Requested As A Money Amount in Format $$$$$.¢¢
Choice 1: Amount
Fill-in (2) - Systems Generated
Choice 1: Beneficiary's Name
Choice 2: your
Fill-in (3) - Requested As A Date In Format Shown Below
Choice 1: MM/DD/CCYY

MHP036 MEDICARE PRESCRIPTION DRUG PLAN COSTS DEDUCTED FROM PMA PAYMENT (H68)

(Requested/Generated)

Caption: Information About Medicare prescription drug plan costs

We deducted  (1)  for  (2)  Medicare prescription drug plan costs from the check you will receive on or about  (3)  .


Fill-in values:
Fill-in (1) - Requested As A Money Amount in Format $$$$$.¢¢
Choice 1: Amount
Fill-in (2) - Systems Generated
Choice 1: Beneficiary's Name
Choice 2: your
Fill-in (3) - Requested As A Date In Format Shown Below
Choice 1: MM/DD/CCYY

MHP037 HEALTH PLAN PREMIUMS AND MEDICARE PRESCRIPTION DRUG PLAN COSTS DEDUCTED FROM PMA PAYMENT (H89)

(Requested/Generated)

Caption: Information about health plan premiums and prescription drug plan costs

We deducted  (1)  for  (2)  health plan premiums and  (3)  for  (4)  Medicare prescription drug plan costs from the check you will receive on or about  (5)  .


Fill-in values:
Fill-in (1) - Requested As A Money Amount in Format $$$$$.¢¢
Choice 1: Amount
Fill-in (2) - Systems Generated
Choice 1: Beneficiary's Name
Choice 2: your
Fill-in (3) - Requested As A Money Amount in Format $$$$$.¢¢
Choice 1: Amount
Fill-in (4) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Fill-in (5) - Requested As A Date In Format Shown Below
Choice 1: MM/DD/CCYY

MHP038 HEALTH PLAN PREMIUMS DEDUCTED FROM CMA PAYMENT (H20)

(Requested/Generated)

Caption: Information About Health Plan Premiums

We deducted  (1)  for  (2)  health plan premiums from the check you will receive for  (3)  on or about  (4)  .


Fill-in values:
Fill-in (1) - Requested As A Money Amount in Format $$$$$.¢¢
Choice 1: Amount
Fill-in (2) - Systems Generated
Choice 1: Beneficiary's Name possessive
Choice 2: your
Fill-in (3) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (4) - Requested As A Date In Format Shown Below
Choice 1: MM/DD/CCYY

MHP039 MEDICARE PRESCRIPTION DRUG PLAN COSTS DEDUCTED FROM CMA PAYMENT (H69)

(Requested/Generated)

Caption: Information About Medicare Prescription Drug Costs

We deducted  (1)  for  (2)  Medicare prescription drug plan costs from the check you will receive for  (3)  on or about  (4)  .


Fill-in values:
Fill-in (1) - Requested As A Money Amount in Format $$$$$.¢¢
Choice 1: Amount
Fill-in (2) - Systems Generated
Choice 1: Beneficiary's Name possessive
Choice 2: your
Fill-in (3) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (4) - Requested As A Date In Format Shown Below
Choice 1: MM/DD/CCYY

MHP040 HEALTH PLAN PREMIUMS AND MEDICARE PRESCRIPTION DRUG PLAN COSTS DEDUCTED FROM CMA PAYMENT (H93)

(Requested/Generated)

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

We deducted  (1)  for  (2)  Medicare approved health plan premiums and  (3)  for  (4)  Medicare prescription drug plan costs. We deducted these amounts from the payment  (5)  will receive for  (6)  on or about  (7)  .


Fill-in values:
Fill-in (1) - Requested As A Money Amount in Format $$$$$.¢¢
Choice 1: Amount
Fill-in (2) - Systems Generated
Choice 1: Beneficiary's Name possessive
Choice 2: your
Fill-in (3) - Requested As A Money Amount in Format $$$$$.¢¢
Choice 1: Amount
Fill-in (4) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Fill-in (5) - Systems Generated
Choice 1: he
Choice 2: she
Choice 3: you
Fill-in (6) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (7) - Requested As A Date In Format Shown Below
Choice 1: MM/DD/CCYY

MHP041 ALL MEDICARE PRESCRIPTION DRUG PLAN COSTS DUE TO DATE WITHHELD (HA1)

(Requested/Generated)

Caption: Information About Medicare Prescription Drug Costs

This represents all Medicare prescription drug plan costs due to date.


Fill-in values:

 

None

MHP042 ALL HEALTH PLAN PREMIUMS AND MEDICARE PRESCRIPTION DRUG PLAN COSTS DUE TO DATE WITHHELD (HA2)

(Requested/Generated)

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

This represents all health plan premiums and Medicare prescription drug plan costs due to date.


Fill-in values:

 

None

MHP043 MEDICARE PRESCRIPTION DRUG PLAN COSTS CONTINUING TO BE DEDUCTED FROM ONGOING MONTHLY BENEFITS (H70)

(Requested/Generated)

Caption: Information About Medicare Prescription Drug Costs

Each month, we will continue to deduct  (1)  for  (2)  Medicare prescription drug plan costs.


Fill-in values:
Fill-in (1) - Requested As A Money Amount in Format $$$$$.¢¢
Choice 1: Amount
Fill-in (2) - Systems Generated
Choice 1: Beneficiary's Name possessive
Choice 2: your

MHP044 HEALTH PLAN PREMIUMS AND MEDICARE PRESCRIPTION DRUG PLAN COSTS CONTINUING TO BE DEDUCTED FROM ONGOING MONTHLY BENEFITS (H94)

(Requested/Generated)

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

Each month, we will continue to deduct  (1)  for  (2)  health plan premiums and  (3)  for  (4)  Medicare prescription drug plan costs.


Fill-in values:
Fill-in (1) - Requested As A Money Amount in Format $$$$$.¢¢
Choice 1: Amount
Fill-in (2) - Systems Generated
Choice 1: Beneficiary's Name (possessive)
Choice 2: your
Fill-in (3) - Requested As A Money Amount in Format $$$$$.¢¢
Choice 1: Amount
Fill-in (4) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your

MHP045 CHANGE IN MEDICARE PRESCRIPTION DRUG PLAN COSTS (HA7)

(Requested/Generated)

Caption: Information About Medicare prescription drug plan costs

There has been a change in the amount withheld for  (1)  Medicare prescription drug plan costs.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary's Name possessive
Choice 2: your

MHP046 CHANGE IN HEALTH PLAN PREMIUM DEDUCTION AMOUNT AND MEDICARE PRESCRIPTION DRUG PLAN COSTS (HA8)

(Requested/Generated)

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

There has been a change in the amount withheld for  (1)  health plan premiums and  (2)  Medicare prescription drug plan costs.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary's Name possessive
Choice 2: your
Fill-in (2) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your

MHP047 MEDICARE PRESCRIPTION DRUG PLAN COSTS NO LONGER BEING DEDUCTED (HA3)

(Requested/Generated)

Caption: Information About Medicare prescription drug plan costs

We will no longer deduct money for  (1)  Medicare prescription drug plan costs from  (2)  monthly benefits.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary's Name possessive
Choice 2: your
Fill-in (2) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your

MHP048 HEALTH PLAN PREMIUMS AND MEDICARE PRESCRIPTION DRUG PLAN COSTS NO LONGER BEING DEDUCTED (HA4)

(Requested/Generated)

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

We will no longer deduct money for  (1)  health plan premiums and  (2)  Medicare prescription drug plan costs from  (3)  monthly benefits.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary's 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: his
Choice 2: her
Choice 3: your

MHP049 ADVISES BENEFICIARY/PAYEE TO CONTACT MEDICARE PRESCRIPTION DRUG PLAN CARRIER FOR QUESTIONS ABOUT THEIR MEDICARE PRESCRIPTION DRUG PLAN COSTS (HA5)

(Requested/Generated)

Caption Information About Medicare Prescription Drug Plan Costs

If you have any questions about  (1)  Medicare prescription drug plan costs, please contact  (2)  Medicare prescription drug plan.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary's Name possessive
Choice 2: your
Fill-in (2) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your

MHP050 ADVISES BENEFICIARY/PAYEE TO CONTACT HEALTH PLAN CARRIER AND MEDICARE PRESCRIPTION DRUG PLAN CARRIER FOR QUESTIONS ABOUT THEIR HEALTH PLAN PREMIUMS AND MEDICARE PRESCRIPTION DRUG PLAN COSTS (HA6)

(Requested/Generated)

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

Please contact  (1)  Medicare health plan or  (2)  Medicare prescription drug plan if  (3)  questions about  (4)  premiums or costs.


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 have
Choice 2: he has
Choice 3: she has
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

MHP053 ENROLLMENT INFORMATION FOR MEDICARE PRESCRIPTION DRUG PLAN (HB6)

(Requested/Generated)

Caption: Prescription Drug Plan Enrollment

Now that  (1)   (2)  eligible for Medicare,  (3)  can enroll in a Medicare prescription drug plan (Part D).

To learn more about the Medicare prescription drug plans and when  (4)  can enroll, visit  (5)  or call 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048). Medicare also can tell  (6)  about agencies in  (7)  area that can help  (8)  choose  (9)  prescription drug coverage.

If  (10)  limited income and resources, we encourage  (11)  to apply for the extra help that is available to assist with Medicare prescription drug costs. The extra help can pay the monthly premiums, annual deductibles and prescription co-payments. To learn more or apply, please visit  (12)  call 1-800-772-1213 (TTY 1-800-325-0778) or visit the nearest Social Security office.


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: he
Choice 2: she
Choice 3: you
Fill-in (4) - Systems Generated
Choice 1: he
Choice 2: she
Choice 3: you
Fill-in (5) - Systems Generated
www.medicare.gov
Fill-in (6) - Systems Generated
Choice 1: him
Choice 2: her
Choice 3: you
Fill-in (7) - Systems Generated
Choice 1: your
Choice 2: him
Choice 3: her
Fill-in (8) - Systems Generated
Choice 1: him
Choice 2: her
Choice 3: you
Fill-in (9) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Fill-in (10) - Systems Generated
Choice 1: he has
Choice 2: she has
Choice 3: you have
Fill-in (11) - Systems Generated
Choice 1: him
Choice 2: her
Choice 3: you
Fill-in (12) - Systems Generated
www.socialsecuirty.gov

MHP054 TERMINATION OF STATE BUY-IN (H39)

(Requested/Generated)

Caption: Information About Medicare

 (1)  State Public Assistance Agency has stopped paying the premiums for  (2)  medical insurance under Medicare.  (3)  must start to pay the premiums beginning  (4)  .

If  (5)  to cancel  (6)  medical insurance, please let us know.

If  (7)  within 30 days of the date of this letter, we will stop  (8)  medical insurance at the same time the State stopped paying  (9)  premiums.

If  (10)  within 6 months of the month when the State stopped paying  (11)  premiums, we will stop the insurance at the end of the month when  (12)  asked us to cancel.  (13)  will have to pay the premiums for all the months before  (14)  .

 (15)  can still cancel after the 6-month period is over. We will stop the insurance at the end of the month after the month when  (16)  us to cancel.


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: her
Choice 3: his
Fill-in (3) - Systems Generated
Choice 1: You
Choice 2: She
Choice 3: He
Fill-in (4) - Requested As A Date In Format Shown
Choice 1: MM/CCYY
Fill-in (5) - Systems Generated
Choice 1: you want
Choice 2: she wants
Choice 3: he wants
Fill-in (6) - Systems Generated
Choice 1: your
Choice 2: her
Choice 3: his
Fill-in (7) - Systems Generated
Choice 1: you cancel
Choice 2: she cancels
Choice 3: he cancels
Fill-in (8) - Systems Generated
Choice 1: your
Choice 2: her
Choice 3: his
Fill-in (9) - Systems Generated
Choice 1: your
Choice 2: her
Choice 3: his
Fill-in (10) - Systems Generated
Choice 1: you cancel
Choice 2: she cancels
Choice 3: he cancels
Fill-in (11) - Systems Generated
Choice 1: your
Choice 2: her
Choice 3: his
Fill-in (12) - Systems Generated
Choice 1: you
Choice 2: she
Choice 3: he
Fill-in (13) - Systems Generated
Choice 1: You
Choice 2: She
Choice 3: He
Fill-in (14) - Systems Generated
Choice 1: you cancel
Choice 2: she cancels
Choice 3: he cancels
Fill-in (15) - Systems Generated
Choice 1: You
Choice 2: She
Choice 3: He
Fill-in (16) - Systems Generated
Choice 1: you ask
Choice 2: she asks
Choice 3: he asks

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900720210
NL 00720.210 - MHP Medicare Health Plan - 12/05/2013
Batch run: 03/29/2017
Rev:12/05/2013