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 - 12/06/2013
Batch run: 12/06/2013
Rev:12/06/2013