TN 26 (08-17)

NL 00730.116 “H” Paragraphs and Captions

A. List of “H” paragraphs and captions

HBN001 – AUTOMATED CMS BILLING NOTICE USED WITH HIB225

(appears after the signature page of the notice)

NOTICE OF MEDICARE PREMIUM PAYMENT DUE

CENTER FOR MEDICARE & MEDICAID SERVICES

BILLING DATE: (1)

MEDICAL PREMIUMS FOR

PERIOD ENDING (2)

CURRENT AMOUNT DUE (3)

PAYMENT DUE BY (4)

Return the bottom portion of this notice with your payment and use the enclosed envelope to mail your payment.

You must pay by check or money order. Show the claim number at the top of your check or money order. Make the check or money order payable to: CMS MEDICARE INSURANCE.

If you have changed your address, be sure to write your new address in the space provided below.

If you should have any questions concerning this Notice of Medicare Premium Payment Due, please write or visit any Social Security Office.

PLEASE DETACH AT DOTTED LINE

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

CMS-500A

CLAIM NUMBER: (5) AMOUNT DUE: (6)

NAME: (7)

MAKE CHECKS PAYABLE TO:

CMS MEDICARE INSURANCE

SEND TO:

Medicare Premium Collection Center

PO Box 790355

St. Louis, MO 63179-0355

( )      Check here if your address has changed. Show new address below.

            ________________________________________________________

      

Fill-in values:

 

Fill-in (1)

the date of the T2Redesign notice in the format June 27, 2001

Fill-in (2)

December of the current operating year, unless the COM is December of the COY, then December of the following COY in the format December 2001

Fill-in (3)

SMI premiums due

Fill-in (4)

the 20th day of the third calendar month after the date of the T2Redesign notice in the format September 20, 2001

Fill-in (5)

CLAIM NUMBER

Fill-in (6)

SMI premiums due

Fill-in (7)

BGN plus BLN

B. “HIB” UNIVERSAL TEXT IDENTIFIERS – HEALTH INSURANCE BENEFITS

HIBC01 – CAPTION

Information About Medicare

HIBC02 – CAPTION

Health Insurance For Children

HIBC05 – CAPTION

Why (1) Cannot Quality For Medicare

Fill-in values:

 

Fill-in (1)

show the BGN plus BLN

HIBC15 – CAPTION

To Cancel This Insurance

HIBC19 – CAPTION

Notice of Group Billing

HIB001 – ENTITLED TO HI AND/OR SMI

(1) Medicare (2) (3) (4) (5).

Fill-in values:

 

Fill-in (1)

 

Choice 1

Your

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)

Fill-in (2)

 

Choice 1

Part A (hospital insurance) starts

Choice 2

Part B (medical insurance) starts

Choice 3

Part A (hospital insurance) and Part B (medical insurance) start

Fill-in (3)

Date in format Month CCYY

Fill-in (4)

 

Choice 1

and Part B (medical insurance) starts

Choice 2

Null

Fill-in (5)

 

Choice 1

Date in format Month CCYY

Choice 2

Null

HIB005 – SMI PREMIUM BILLING

(1) monthly premium for Medicare Part B (medical insurance) is (2) beginning (3) (4) (5).

Fill-in values:

 

Fill-in (1)

 

Choice 1

Your

Choice 2

His

Choice 3

Her

Fill-in (2)

Amount of Part B premium in $$$$$.¢¢ format

Fill-in (3)

Date in MMCCYY format

Fill-in (4)

 

Choice 1

null

Choice 2

and

Fill-in (5)

 

Choice 1

null

Choice 2

Show the amount of the Part B premium in the format $$$$$¢¢ plus the word “beginning” plus show the start date that corresponding to the second premium rate returned from the HSA utility in the format MMCCYY

HIB008 – SMI PREMIUM DEDUCTIONS

We will start to take premiums out of (1) (2) check.

Fill-in values:

 

Fill-in (1)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (2)

 

Choice 1

next

Choice 2

MMDDYYYY (using the PCI, show the calendar date for the month following COM (e.g. if PCI = 2 and the COM = 4/98, then fill-in 2 will equal the calendar date for the second Wednesday in May)

HIB011 – HI PREMIUM BILLING

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (2)

Show the current HI premium rate in the format 999.99

Fill-in (3)

 

Choice 1

this premium

Choice 2

the combined premium for hospital and medical insurance

HIB013 – MEDICARE HI/SMI PREMIUM PENALTY

(1) a penalty because (2) enrolled later than (3) could have.

Fill-in values:

 

Fill-in (1)

 

Choice 1

This medical insurance premium includes

Choice 2

This hospital insurance premium includes

Choice 3

These hospital and medical insurance premiums include

Fill-in (2)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

HIB015 – PREMIUMS DEDUCTED FROM CIVIL SERVICE ANNUITY

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN possessive

Choice 2

your

Fill-in (2)

 

Choice 1

him

Choice 2

her

Choice 3

you

HIB026 – 3RD PARTY BUYIN TP STARTS DATES/CODES DO NOT MATCH

(1) (2) will pay (3) Medicare hospital insurance premiums beginning (4). (5)

(6) (7) will pay (8) Medicare medical insurance premiums beginning (9). (10)

Fill-in values:

 

Fill-in (1)

 

Choice 1

Leave Blank

Choice 2

The State of

Fill-in (2)

show State name

Fill-in (3)

 

Choice 1

BGN plus BLN possessive

Choice 2

your

Fill-in (4)

Show the TP START DATE in the format MMCCYY

Fill-in (5)

 

Choice 1

This also means that he is entitled to this Medicare coverage for an earlier period than shown on his current Medicare card.

Choice 2

This also means that she is entitled to this Medicare coverage for an earlier period than shown on her current Medicare card.

Choice 3

This also means that you are entitled to this Medicare coverage for an earlier period than shown on your current Medicare card.

Choice 4

Null

Fill-in (6)

 

Choice 1

Leave Blank

Choice 2

The State of

Fill-in (7)

show State name

Fill-in (8)

 

Choice 1

BGN plus BLN possessive

Choice 2

your

Fill-in (9)

Show the TP START date in the format MMCCYY

Fill-in (10)

 

Choice 1

This also means that he is entitled to this Medicare coverage for an earlier period than shown on his current Medicare card.

Choice 2

This also means that she is entitled to this Medicare coverage for an earlier period than shown on her current Medicare card.

Choice 3

This also means that you are entitled to this Medicare coverage for an earlier period than shown on your current Medicare card.

Choice 4

Null

HIB027 – 3RD PARTY BUYOUT TP STARTS DATES/CODES DO NOT MATCH

(1) (2) will no longer pay (3) Medicare hospital insurance premiums after (4).

(5) must pay the premiums beginning (6).

(7) (8) will no longer pay (9) Medicare medical insurance premiums after (10).

(11) must pay the premiums beginning (12).

Fill-in values:

 

Fill-in (1)

 

Choice 1

Leave Blank

Choice 2

The State of

Fill-in (2)

Show State name

Fill-in (3)

 

Choice 1

BGN plus BLN possessive

Choice 2

your

Fill-in (4)

Show TP STOP date in the format MMCCYY

Fill-in (5)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (6)

Show the TP STOP date plus 1 month in the format MMCCYY

Fill-in (7)

 

Choice 1

Leave Blank

Choice 2

The State of

Fill-in (8)

Show State name

Fill-in (9)

 

Choice 1

BGN plus BLN possessive

Choice 2

your

Fill-in (10)

Show the TP STOP date in the format MMCCYY

Fill-in (5)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (12)

Show the TP STOP date plus 1 month in the format MMCCYY

HIB029 – LIMITED BUYIN FOR HI/SMI DATES/CODES DO NOT MATCH

(1) (2) paid (3) Medicare hospital insurance premium for (4).

(5) (6) paid (7) Medicare medical insurance premium for (8).

Fill-in values:

 

Fill-in (1)

 

Choice 1

Leave Blank

Choice 2

The State of

Fill-in (2)

Show the State name

Fill-in (3)

 

Choice 1

BGN plus BLN possessive

Choice 2

your

Fill-in (4)

 

Choice 1

MMCCYY

Choice 2

MMCCYY and MMCCYY

Choice 3

MMCCYY through MMCCYY

Fill-in (5)

 

Choice 1

Leave Blank

Choice 2

The State of

Fill-in (6)

Show the State name

Fill-in (7)

 

Choice 1

BGN plus BLN possessive

Choice 2

your

Fill-in (8)

 

Choice 1

MMCCYY

Choice 2

MMCCYY and MMCCYY

Choice 3

MMCCYY through MMCCYY

HIB030 – GROUP PAYER STOPS FOR HI/SMI DATES NOT EQUAL

The organization that was paying (1) Medicare hospital insurance premium will no longer pay it after (2). (3) must pay the premium beginning (4).

The organization that was paying (5) Medicare medical insurance premium will no longer pay it after (6). (7) must pay the premium beginning (8).

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN possessive

Choice 2

your

Fill-in (2)

MMCCYY

Fill-in (3)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (4)

MMCCYY

Fill-in (5)

 

Choice 1

BGN plus BLN possessive

Choice 2

your

Fill-in (6)

MMCCYY

Fill-in (7)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (8)

MMCCYY

HIB034 –ADVISE THAT SMI DEDUCTION WILL CONTINUE

We will continue to deduct Medicare Part B (medical. insurance) premium of (1) from (2) payments.

Fill-in values:

 

Fill-in (1)

Show the total of DAH-ITEMS = 430, 435 and 440 in the format $$$$$

Fill-in (2)

 

Choice 1

your

Choice 2

BGN plus BLN possessive

HIB038 – MEDICARE DISALLOWANCE CRIME AGAINST UNITED STATES

(1) cannot qualify for Medicare because (2) been convicted of a crime against the Security of the United States.

Fill-in values:

 

Fill-in (1)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (2)

 

Choice 1

he has

Choice 2

she has

Choice 3

you have

HIB042 – MEDICARE DISALLOWANCE FEHB ACT OF 1959

(1) cannot qualify for Medicare because (2) covered under the Federal Employees Health Benefits Act

Fill-in values:

 

Fill-in (1)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (2)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Choice 4

he could be

Choice 5

she could be

Choice 6

you could be

HIB050 – MED DISAL NH AGE 65 BEFORE END OF WAITING PERIOD

You do not qualify for Medicare based on disability because your coverage cannot start before you reach age 65.

To receive Medicare coverage before age 65, a person must be disabled under our rules for 29 months before coverage begins. Based on the date you said you became disabled, coverage could not begin until after you reach age 65. For this reason, we have not decided whether or not you are disabled.

You may qualify for Medicare when you reach age 65, whether or not you are disabled under our rules.

HIB053 – PREMIUM HI DENIED AND/OR SMI DISALLOWED (RDD 107)

(1) not entitled to (2) insurance coverage under Medicare because (3) application was filed too late. However, (4) 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)

 

Choice 1

Beneficiary Full Name plus the word “is”

Choice 2

You are

Fill-in (2)

 

Choice 1

medical

Choice 2

hospital

Choice 3

hospital and medical

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

he

Choice 2

she

Choice 3

you

HIB054 – HI AND/OR SMI PERIOD NOT PREVIOUSLY COVERED

If (1) had any expenses that (2) should be covered by Medicare (3) insurance, please contact your local Social Security office. The telephone number and address are shown below.

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN the word “has”

Choice 2

Beneficiary First Name plus the word “has”

Choice 3

you have

Fill-in (2)

 

Choice 1

he believes

Choice 2

she believes

Choice 3

you believe

Fill-in (3)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

HIB060 – SUSPENSE FOR PRISON/MENTAL ADVISES OF SMI PREMIUMS

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 reenroll 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 reenroll. 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 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 the payment is due.

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN plus the word “receives”

Choice 2

you receive

Fill-in (2)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (3)

 

Choice 1

imprisoned

Choice 2

confined in an institution

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (6)

 

Choice 1

prison

Choice 2

the institution

Fill-in (7)

 

Choice 1

BGN plus BLN

Choice 2

You

Fill-in (8)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (9)

 

Choice 1

prison

Choice 2

the institution

Fill-in (10)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (11)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB061 – SMI PREMIUM CONTINUES DEDUCTION FROM CS ANNUITY

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

Beneficiary Full Name possessive

Choice 2

your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB066 – HI/SMI PREMIUMS ALREADY PAID

Any (1) insurance premiums (2) already paid will be credited to (3) record.

Fill-in values:

 

Fill-in (1)

 

Choice 1

medical

Choice 2

hospital

Choice 3

hospital and medical

Fill-in (2)

 

Choice 1

BGN plus BLN plus “has”

Choice 2

BGN plus “has”

Choice 3

you have

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB067 – SMI PREMIUM BILLING

We will send (1) first bill for the premiums within a month. Each bill after that will be for a 3-month period.

Fill-in values:

 

Fill-in (1)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB068 – HI/SMI EQUITABLE RELIEF

If (1) these benefits earlier, (2) can choose (3) insurance benefits beginning (4). To start benefits earlier, within 60 days after the date of this notice (5) must tell us in writing that (6) (7) insurance benefits beginning (8). In addition, (9) must:

  • pay us (10) (this covers premiums due from (11) through (12)); or

(13)

Fill-in values:

 

Fill-in (1)

 

Choice 1

he wants

Choice 2

she wants

Choice 3

you want

Fill-in (2)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (3)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (4)

 

Choice 1

Show the HI-NONEQRELST date in MMCCYY

Choice 2

Show the SMI-NONEQRELST date in MMCCYY

Fill-in (5)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (6)

 

Choice 1

he wants

Choice 2

she wants

Choice 3

you want

Fill-in (7)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (8)

 

Choice 1

Show the HI-NONEQRELST date in MMCCYY

Choice 2

Show the SMI-NONEQRELST date in MMCCYY

Fill-in (9)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (10)

 

Choice 1

Show the total amount for HI premiums calculated

Choice 2

Show the total amount for SMI premiums calculated

Choice 3

Show the combined total amount for HI and SMI premiums calculated

Fill-in (11)

 

Choice 1

Show the HI-NONEQRELST date in MMCCYY

Choice 2

Show the SMI-NONEQRELST date in MMCCYY

Fill-in (12)

Show the COM month in MMCCYY

Fill-in (13)

 

Choice 1

tell us we can withhold this amount from the check.

Choice 2

tell us to bill you for this amount.

HIB069 – HI/SMI TERMINATION FOR NON-PAYMENT OF PREMIUMS

(1) Medicare premium amount of (2) for (3) insurance was not paid within the time limit. Therefore, (4) (5) insurance coverage has stopped. (6) last month of coverage (7) (8). Benefits will not be paid for any (9) services (10) after (11) last month of coverage.

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN possessive

Choice 2

Your

Fill-in (2)

Show money amount for HI/SMI premiums due in 99999.99

Fill-in (3)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (6)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (7)

 

Choice 1

is

Choice 2

was

Fill-in (8)

 

Choice 1

Show the HI TERM date minus 1 month in MMCCYY

Choice 2

Show the SMI TERM date minus 1 month in MMCCYY

Fill-in (9)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (10)

 

Choice 1

he receives

Choice 2

she receives

Choice 3

you receive

Fill-in (11)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB070 – PREMIUM HI DWI CONTINUES SMI TERMINATES NON-PAYMENT

This decision does not affect (1) (2) insurance coverage. (3) should continue to pay (4) insurance premiums to keep this coverage.

Fill-in values:

 

Fill-in (1)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (2)

 

Choice 1

medical

Choice 2

hospital

Fill-in (3)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (4)

 

Choice 1

medical

Choice 2

hospital

HIB071 – RRB JURIS STARTS AND COLLECTS MEDICARE PREMIUMS

The Social Security Administration is no longer responsible for deducting Medicare premiums from Social Security payments. The Railroad Retirement Board (RRB) is now responsible for collecting medical insurance premiums for all railroad beneficiaries and their families. This includes beneficiaries who are also entitled to Social Security benefits.

HIB072 – RRB JURIS STARTS AND COLLECTS MEDICARE PREMIUMS

Since (1) (2) a railroad beneficiary, the RRB will start to withhold medical insurance premiums from (3) Railroad Retirement annuity. If (4) not currently receiving a Railroad Retirement annuity, the Social Security Administration will let the RRB know when (5) next premium is due. The RRB will send (6) a bill for premiums.

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN

Choice 2

You

Fill-in (2)

 

Choice 1

is

Choice 2

are

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (6)

 

Choice 1

him

Choice 2

her

Choice 3

you

HIB073 – RRB SENDS NEW MEDICARE CARD

(1) protection under Medicare will continue without any change in coverage.

The RRB will send (2) a new Medicare card. Until then, (3) may use (4) old card.

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN possessive

Choice 2

Your

Fill-in (2)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB074 – NEW MEDICARE CARD

We will send (1) a new health insurance card. It will show that (2) entitled to (3) insurance.

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN

Choice 2

BGN

Choice 3

you

Fill-in (2)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (3)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

HIB075 – EQUITABLE RELIEF/HARDSHIP

If (1) benefits beginning (2) but (3) 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)

 

Choice 1

he wants

Choice 2

she wants

Choice 3

you want

Fill-in (2)

 

Choice 1

Show the HI NONEQRELST date in MMCCYY

Choice 2

Show the SMI NONEQRELST date in MMCCYY

Fill-in (3)

 

Choice 1

find

Choice 2

finds

HIB076 – HI/SMI TERMINATION INFORMATIONAL

If (1) not sign up for Part B when (2) first eligible, (3) may have to pay a late enrollment penalty for as long as (4) Part B. (5) monthly premium may go up 10 percent for each full 12-month period that (6) could have had Part B coverage, but did not sign up for it. Usually, (7) will not have to pay a late enrollment penalty if (8) up during a special enrollment period.

 If (9) to sign up for (10) later, (11) 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 (12) up in the general enrollment period, (13) Part B coverage will start July 1 of the year (14) up.

Fill-in values:

 

Fill-in (1)

 

Choice 1

you do

Choice 2

he does

Choice 3

she does

Fill-in (2)

 

Choice 1

you are

Choice 2

he is

Choice 3

she is

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

you have

Choice 2

he has

Choice 3

she has

Fill-in (5)

 

Choice 1

Your

Choice 2

His

Choice 3

Her

Fill-in (6)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (7)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (8)

 

Choice 1

you sign

Choice 2

he signs

Choice 3

she signs

Fill-in (9)

 

Choice 1

you want

Choice 2

BGN plus BLN plus “wants”

Fill-in (10)

 

Choice 1

Part A

Choice 2

Part B

Choice 3

Part A and Part B

Fill-in (11)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (12)

 

Choice 1

you sign

Choice 2

he signs

Choice 3

she signs

Fill-in (13)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (14)

 

Choice 1

you sign

Choice 2

he signs

Choice 3

she signs

HIB077 – SMI TERMINATION INFORMATIONAL

People who have Medicare Part B (medical insurance) pay a monthly premium. If (1) not sign up for Part B when (2) first eligible, (3) may have to pay a late enrollment penalty for as long as (4) Part B. (5) monthly premium may go up 10 percent for each full 12-month period that (6) could have had Part B coverage, but did not sign up for it. Usually, (7) will not have to pay a late enrollment penalty if (8) up during a special enrollment period.

Fill-in values:

 

Fill-in (1)

 

Choice 1

you do

Choice 2

he does

Choice 3

she does

Fill-in (2)

 

Choice 1

you are

Choice 2

he is

Choice 3

she is

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

you have

Choice 2

he has

Choice 3

she has

Fill-in (5)

 

Choice 1

Your

Choice 2

His

Choice 3

Her

Fill-in (6)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (7)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (8)

 

Choice 1

you sign

Choice 2

he signs

Choice 3

she signs

HIB078 – HI TERMINATION INFORMATIONAL

(1) monthly premium for hospital insurance may be 10 percent higher when (2).

Fill-in values:

 

Fill-in (1)

 

Choice 1

His

Choice 2

Her

Choice 3

Your

Fill-in (2)

 

Choice 1

he re-enrolls

Choice 2

she re-enrolls

Choice 3

you re-enroll

HIB079 – VOLUNTARY TERMINATION FOR PREMIUM HI OR SMI

Because (10) canceling (2) (3) insurance coverage, (4) no longer entitled to (5) insurance coverage. (6) hospital and medical insurance coverage ends on the last day of (7).

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN plus the word “is”

Choice 2

BGN plus the word “is”

Choice 3

you are

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

medical

Choice 2

hospital

Fill-in (4)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (5)

 

Choice 1

hospital

Choice 2

medical

Fill-in (6)

 

Choice 1

His

Choice 2

Her

Choice 3

Your

Fill-in (7)

Show the HI TERM date minus 1 month in MMCCYY format

HIB080 – VOLUNTARY SMI TERMINATION CIVIL SERVICE INVOLVED

The Office of Personnel Management will no longer deduct the medical insurance premiums from (1) annuity checks. They will let (2) know when the deductions will stop.

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN possessive

Choice 2

BGN possessive

Choice 3

your

Fill-in (2)

 

Choice 1

him

Choice 2

her

Choice 3

you

HIB082 – HI AND/OR SMI VOLUNTARY TERMINATION

(1) asked that we stop (2) (3) insurance coverage under Medicare. This coverage ends the last day of (4).

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN

Choice 2

You

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (4)

 

Choice 1

Show the HI TERM date minus 1 month in MMCCYY format

Choice 2

Show the SMI TERM date minus 1 month in MMCCYY format

HIB083 – SPECIAL ENROLLMENT PERIOD DISABILITY

(1) may also be able to enroll during a special enrollment period. (2) can do this if (3) (4) one of the conditions listed below:

  • (5) covered under a group health plan through (6) current work or (7) spouse's current work, or

  • (8) covered under a large group health plan through (9) current work or any family member's current work.

(10) may enroll for Medicare (11) insurance at any time (12) covered under the group health plan. However, (13) may wait and enroll during the 8-month period that begins when the work ends or (14) coverage under the plan ends, whichever occurs first. (15) may also enroll if the type of plan (16) changes.

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN

Choice 2

BGN

Choice 3

You

Fill-in (2)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

meets

Choice 2

meet

Fill-in (5)

 

Choice 1

He is

Choice 2

She is

Choice 3

You are

Fill-in (6)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (7)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (8)

 

Choice 1

He is

Choice 2

She is

Choice 3

You are

Fill-in (9)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (10)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (11)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (12)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (13)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (14)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (15)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (16)

 

Choice 1

he has

Choice 2

she has

Choice 3

you have

HIB084 – SPECIAL ENROLLMENT PERIOD AGED

(1) may also be able to enroll during a special enrollment period. (2) can do this if (3) all of the conditions listed below:

  • (4) health insurance coverage is under an employer's plan because (5) or (6) spouse is working, and

  • (7) had health insurance coverage under that plan since (8) became age 65.

(9) may enroll for Medicare (10) insurance at any time (11) covered under the group health plan. However, (12) may wait and enroll during the 8-month period that begins when the work ends or (13) coverage under the plan ends, whichever occurs first.

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN

Choice 2

BGN

Choice 3

You

Fill-in (2)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (3)

 

Choice 1

he meets

Choice 2

she meets

Choice 3

you meet

Fill-in (4)

 

Choice 1

His

Choice 2

Her

Choice 3

Your

Fill-in (5)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (6)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (7)

 

Choice 1

He has

Choice 2

She has

Choice 3

You have

Fill-in (8)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (9)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (10)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (11)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (12)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (13)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB085 – VOLUNTARY SMI TERMINATION CURRENT PAY

We will stop taking premiums for medical insurance out of (1) checks.

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN possessive

Choice 2

BGN possessive

Choice 3

your

HIB086 – VOLUNTARY HI/SMI TERMINATION PREMIUMS DUE

(1) should send us (2) to pay for the premiums (3) through (4). Please make

(5) check or money order payable to the “Centers for Medicare & Medicaid Services” and mail it to us in the enclosed envelope. Include (6) claim number (shown above) on the check or money order.

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN

Choice 2

BGN

Choice 3

BGN plus BLN

Choice 4

You

Fill-in (2)

 

Choice 1

Show total Part A and Part B past due premiums due in $9999.99 format

Choice 2

Show total Part A or Part B past due premiums due in $9999.99 format

Fill-in (3)

 

Choice 1

he owes

Choice 2

she owes

Choice 3

you owe

Fill-in (4)

 

Choice 1

Show the HI TERM date minus 1 month in the format May 1999

Choice 2

Show the SMI TERM date minus 1 month in the format May 1999

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (6)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB087 – VOLUNTARY SMI TERMINATION HI CONTINUES

(1) hospital insurance coverage will continue.

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN possessive

Choice 2

BGN possessive

Choice 3

your

HIB088 – HI/SMI FOREIGN ADDRESS

Normally, Medicare will only pay for (1) services which (2) (3) in the United States. Since (4) living outside the U.S., Medicare will not pay for (5) services unless (6) to the U.S. for services.

Fill-in values:

 

Fill-in (1)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (2)

 

Choice 1

BGN plus BLN

Choice 2

BGN

Choice 3

you

Fill-in (3)

 

Choice 1

receives

Choice 2

receive

Fill-in (4)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (5)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (6)

 

Choice 1

he returns

Choice 2

she returns

Choice 3

you return

HIB089 – BENE AT FRA PROVISION PAYMENTS END HI/SMI ENDS

Since (1) no longer receiving provisional monthly Social Security benefits, we are stopping (2) (3) insurance coverage. This coverage ends the last day of (4). Please destroy (5) Medicare card after coverage ends.

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN plus the word “is”

Choice 2

you are

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

hospital

Choice 2

hospital and medical

Fill-in (4)

Show HI-TERM date in MMCCYY format

Fill-in (5)

 

Choice 1

BGN plus BLN possessive

Choice 2

your

HIB090 – TERMINATION ALL MEDICARE COVERAGE

(1) Medicare card will not be valid when (2) (3) coverage ends. Please destroy (4) card after (5) coverage ends.

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN possessive

Choice 2

Your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

Medicare Part A (hospital insurance) and Part B (medical insurance)

Choice 2

Medicare Part B (medical insurance)

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB092 – STATE/LOCAL GOVT CONTINUES TO PAY SMI PREMIUM

(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)

 

Choice 1

BGN plus BLN possessive

Choice 2

Your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

He

Choice 2

She

Choice 3

You

HIB093 – STATE OR GROUP CONTINUES TO PAY SMI PREMIUMS

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

the State

Choice 2

an organization

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

hospital and medical

Choice 2

medical

HIB101 – MEDICARE STATE BUY-IN

(1) (2) will pay (3) Medicare (4) insurance premium beginning (5). (6)

Fill-in values:

 

Fill-in (1)

 

Choice 1

Leave blank

Choice 2

The State of

Fill-in (2)

show state corresponding to the HITP-CODE or the SMTP-CODE

Fill-in (3)

 

Choice 1

BGN plus BLN possessive

Choice 2

your

Fill-in (4)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (5)

TP START date in MMCCYY format

Fill-in (6)

 

Choice 1

This also means that he is entitled to this Medicare coverage for an earlier period than shown on his current Medicare card.

Choice 2

This also means that she is entitled to this Medicare coverage for an earlier period than shown on her current Medicare card.

Choice 3

This also means that you are entitled to this Medicare coverage for an earlier period than shown on your current Medicare card.

Choice 4

NULL

HIB102 – STATE BUY-OUT

(1) (2) will no longer pay (3) Medicare (4) insurance premiums after (5). (6) must pay the premiums beginning (7).

Fill-in values:

 

Fill-in (1)

 

Choice 1

Leave blank

Choice 2

The State of

Fill-in (2)

show state corresponding to the HITP-CODE or the SMTP-CODE

Fill-in (3)

 

Choice 1

BGN plus BLN possessive

Choice 2

your

Fill-in (4)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (5)

Show the TP STOP date in MMCCYY format

Fill-in (6)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (7)

Show the TP STOP date plus 1 month in MMCCYY format

HIB103 – LIMITED BUY-IN AND BUY-OUT

(1) (2) paid (3) Medicare (4) insurance premium for (5).

Fill-in values:

 

Fill-in (1)

 

Choice 1

Leave blank

Choice 2

The State of

Fill-in (2)

Show state corresponding to the HITP-CODE or the SMTP-CODE

Fill-in (3)

 

Choice 1

BGN plus BLN possessive

Choice 2

your

Fill-in (4)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (5)

 

Choice 1

MMCCYY

Choice 2

MMCCYY and MMCCYY

Choice 3

MMCCYY through MMCCYY

HIB104 – LIMITED ST BUY-IN/BUY-OUT NO CHANGE IN COVERAGE

This does not change our records, which show that (1) Medicare (2) insurance coverage.

Fill-in values:

 

Fill-in (1)

 

Choice 1

he currently has

Choice 2

she currently has

Choice 3

you currently have

Choice 4

he does not currently have

Choice 5

she does not currently have

Choice 6

you do not currently have

Fill-in (2)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

HIB105 – RETRO BUYIN/BUYOUT PAST DUE PREMIUMS

Our records also show that (1) premiums through (2).

Fill-in values:

 

Fill-in (1)

 

Choice 1

he still owes

Choice 2

she still owes

Choice 3

you still owe

Fill-in (2)

MMCCYY

HIB106 – STATE BUYIN FOR SMI PREMIUM PENALTY ONLY

We must charge a premium penalty on (1) Medicare medical insurance because (2) enrolled later than (3) could have. (4) State or local government retirement system will pay (5) medical insurance late enrollment premium penalty beginning (6). However, (7) must pay the basic Medicare medical insurance premium.

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN possessive

Choice 2

your

Fill-in (2)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

His

Choice 2

Her

Choice 3

Your

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (6)

MM/YYYY

Fill-in (7)

 

Choice 1

he

Choice 2

she

Choice 3

you

HIB107 – STATE STOPS PAYING SMI PREMIUM PENALTY

(1) State or local government retirement system will no longer pay (2) Medicare medical insurance late enrollment premium penalty after (3). (4) must pay the basic premium and the penalty beginning (5).

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN possessive

Choice 2

Your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

show date in MMCCYY format

Fill-in (5)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (6)

show date in MMCCYY format

HIB108 – GROUP PAYER BUY-OUT

The organization that was paying (1) Medicare (2) insurance premium will no longer pay it after (3). (4) must pay the premium beginning (5).

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN possessive

Choice 2

your

Fill-in (2)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (3)

show date in MMCCYY format

Fill-in (4)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (5)

Show date in MMCCYY format

HIB109 – 3RD Party SMI PREMIUM DEDUCTED FROM MBA

We will deduct the (1) of (2) from (3) monthly payment. Later in this letter, we tell (4) what to do if (5) with this change in the amount of (6) monthly payment.

Fill-in values:

 

Fill-in (1)

Medicare medical insurance premium

Fill-in (2)

SMI premium amount in $9999.99 format

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (5)

 

Choice 1

he disagrees

Choice 2

she disagrees

Choice 3

you disagree

Fill-in (6)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB110 – SMI PREMIUM DEDUCTED FROM MBA PAST DUE PREMIUMS

We will deduct the (1) of (2) from (3) monthly payment. We will also deduct the past due premiums, which total (4). Later in this letter, we tell (5) what to do if (6) with this change in the amount of (7) monthly payment.

Fill-in values:

 

Fill-in (1)

Medicare medical insurance premium

Fill-in (2)

SMI premium amount in $9999.99 format

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

premium amount due in 99999.99 format

Fill-in (5)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (6)

 

Choice 1

he disagrees

Choice 2

she disagrees

Choice 3

you disagree

Fill-in (7)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB111 – BUY-IN AND REFUND OF MEDICARE PREMIUMS

This is the money due (1) for the Medicare insurance premiums that (2) already paid.

Fill-in values:

 

Fill-in (1)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (2)

 

Choice 1

he

Choice 2

she

Choice 3

you

HIB112 – BUYIN PREMIUM NO LONGER DEDUCTED FROM MBA

We will no longer deduct the premium from (1) monthly payment. Later in this letter, we tell (2) what to do if (3) with this change in the amount of (4) monthly payment.

Fill-in values:

 

Fill-in (1)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (2)

 

Choice 1

you

Fill-in (3)

 

Choice 1

you disagree

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB113 – BUY-OUT NOT IN PAY STATUS PREMIUM BILLING

We will send (1) first bill for the (2) within a month. The monthly (3) (4). (5) Please contact us if (6) not receive the first bill within a month.

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN possessive

Choice 2

BGN possessive

Choice 3

your

Fill-in (2)

 

Choice 1

Medicare hospital insurance premium

Choice 2

Medicare medical insurance premium

Choice 3

Medicare hospital and medical insurance premiums

Fill-in (3)

 

Choice 1

premium is

Choice 2

premiums total

Fill-in (4)

money amount in format 999,999.99

Fill-in (5)

 

Choice 1

After that, we will bill him each month for this premium. (Use in Medicare Part A and combined Part A and Part B billing.)

Choice 2

After that, we will bill her each month for this premium. (Use in Medicare Part A and combined Part A and Part B billing.)

Choice 3

After that, we will bill you each month for this premium. (Use in Medicare Part A and combined Part A and Part B billing.)

Choice 4

Each bill after that will be for a 3-month period. (Use in Medicare Part B billing situations including those which include a premium penalty.)

Fill-in (6)

 

Choice 1

he does

Choice 2

she does

Choice 3

you do

HIB114 – BENEFITS TERM PROFRA MEDICARE CONTINUES

(1) Medicare coverage will continue because (2) age 65 or older.

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN possessive

Choice 2

Your

Fill-in (2)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

HIB115 – HI/SMI BUY-OUT

If (1) to cancel this insurance, please contact the local Social Security office at the telephone number and address shown below. Remember that the date (2) insurance coverage ends depends on when (3) it:

If (4) it within 30 days from the date of this notice, (5) coverage will end at the same time the State stopped paying the premiums.

If (6) it after 30 days but within six months of when the State stopped paying the premiums, coverage will stop at the end of the same month in which (7) us.

If (8) more than 6 months to contact us, coverage will stop at the end of the month after the month in which (9) us.

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN plus “wants”

Choice 2

you want

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

he cancels

Choice 2

she cancels

Choice 3

you cancel

Fill-in (4)

 

Choice 1

he cancels

Choice 2

she cancels

Choice 3

you cancel

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (6)

 

Choice 1

he cancels

Choice 2

she cancels

Choice 3

you cancel

Fill-in (7)

 

Choice 1

he contacts

Choice 2

she contacts

Choice 3

you contact

Fill-in (8)

 

Choice 1

he waits

Choice 2

she waits

Choice 3

you wait

Fill-in (9)

 

Choice 1

he contacts

Choice 2

she contacts

Choice 3

you contact

HIB118 – HI/SMI ENTITLEMENT RECEIPT OF CARD IN 4 WEEKS

If (1) not receive (2) health insurance card within 4 weeks after the receipt of this notice, please get in touch with us. If (3) medical care before (4) the card, use this letter as proof that (5) covered by Medicare (6) insurance.

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN plus “does”

Choice 2

BGN plus “does”

Choice 3

you do

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

he needs

Choice 2

she needs

Choice 3

you need

Fill-in (4)

 

Choice 1

he receives

Choice 2

she receives

Choice 3

you receive

Fill-in (5)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (6)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

HIB119 – BILLING TO CONFIRM GROUP PAYER

(1) recently arranged for an organization to pay (2) Medicare (3) insurance premium. Although we will send the bills to this organization, (4) responsible for seeing that they are paid.

If this organization decides to stop paying (5) premium, we will again send the bills to (6).

If there is any other change in (7) Medicare premium, we will let (8) know.

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN

Choice 2

You

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (4)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (5)

Choice 1

Choice 2

Choice 3

his

her

your

Fill-in (6)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (7)

 

Choice 1

BGN plus BLN possessive

Choice 2

your

Fill-in (8)

 

Choice 1

him

Choice 2

her

Choice 3

you

HIB120 – BUY-OUT FOR HI AND SMI

(1) can cancel hospital insurance coverage and keep medical insurance coverage, or cancel both. However, (2) cannot keep hospital insurance coverage without medical insurance coverage. So if (3) medical insurance coverage, hospital insurance coverage will end at the same time.

Fill-in values:

 

Fill-in (1)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (2)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (3)

 

Choice 1

he cancels

Choice 2

she cancels

Choice 3

you cancel

HIB131 – MEDICARE CONTINUES BASED ON AGE, DIB, OR ESRD

However, Medicare coverage will continue because (1) (2).

Fill-in values:

 

Fill-in (1)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Choice 4

he has

Choice 5

she has

Choice 6

you have

Fill-in (2)

 

Choice 1

disabled

Choice 2

over age 65

Choice 3

end stage renal disease

HIB132 – ESRD TERMINATES AND RRB JURISDICTION

However, since the Railroad Retirement Board (RRB) handles (1) hospital and medical insurance (2) Medicare coverage will continue unless the RRB tells (3) they are stopping (4) coverage.

Fill-in values:

 

Fill-in (1)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB133 – ESRD TERMINATION - SAME HI/SMI TERMINATION DATES

We are writing to tell (1) that Medicare coverage based on (2) kidney condition ends with the last day of (3).

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN

Choice 2

you

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

Show HI-TERM date minus 1 month in MMCCYY format

HIB134 – ESRD TERM HI TERM DATE EARLIER THAN SMI TERM DATE

We are writing to tell (1) that (2) hospital insurance coverage ended on the last day of (3). (4) medical insurance coverage will end on the last day of (5).

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN

Choice 2

you

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

Show HI-TERM date minus 1 month in MMCCYY format

Fill-in (4)

 

Choice 1

His

Choice 2

Her

Choice 3

Your

Fill-in (5)

Show SMI-TERM date minus 1 month in MMCCYY format

HIB135 – ESRD TERM HI TERM DATE EARLIER THAN SMI TERM DATE

Medicare coverage based on a kidney condition usually ends the last day of the (1) month after the month (2) unless before then (3) again:

  • (4) regular dialysis, or

  • (5) a kidney transplant

Since (6) in (7), (8) Medicare coverage should have ended the last day of (9). (10) hospital insurance did end on that date. But, because we didn't take action in time, we must continue (11) medical insurance coverage until the date shown above.

Fill-in values:

 

Fill-in (1)

 

Choice 1

12th

Choice 2

36th

Fill-in (2)

 

Choice 1

he gets a transplant

Choice 2

she gets a transplant

Choice 3

you get a transplant

Choice 4

regular dialysis stops

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

begins

Choice 2

begin

Fill-in (5)

 

Choice 1

gets

Choice 2

get

Fill-in (6)

 

Choice 1

he got a kidney transplant

Choice 2

she got a kidney transplant

Choice 3

you got a kidney transplant

Choice 4

his dialysis stopped

Choice 5

her dialysis stopped

Choice 6

your dialysis stops

Fill-in (7)

 

Choice 1

Show KDNY-TRNSDATE date in MMCCYY format

Choice 2

Show DLYS-STOP date in MMCCYY format

Fill-in (8)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (9)

Show HI-TERM date minus 1 month in format MMCCYY

Fill-in (10)

 

Choice 1

His

Choice 2

Her

Choice 3

Your

Fill-in (11)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB136 – TERMINATION OF ESRD COVERAGE

Let us know right away if (1) regular dialysis again or (2) a kidney transplant so (3) can file a new claim for Medicare coverage based on (4) kidney condition.

Fill-in values:

 

Fill-in (1)

 

Choice 1

he resumes

Choice 2

she resumes

Choice 3

you resume

Fill-in (2)

 

Choice 1

gets

Choice 2

get

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB137 – ESRD TERMINATES SAME HI/SMI TERMINATION DATES

Medicare coverage based on a kidney condition ends the last day of the (1) month after (2), unless before then (3):

  • a kidney transplant, or

  • resume regular dialysis.

Our records show that (4) (5) (6).

Fill-in values:

 

Fill-in (1)

 

Choice 1

12th

Choice 2

36th

Fill-in (2)

 

Choice 1

regular dialysis stops

Choice 2

a kidney transplant

Fill-in (3)

 

Choice 1

he gets

Choice 2

she gets

Choice 3

you get

Fill-in (4)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (5)

 

Choice 1

stopped regular dialysis

Choice 2

received a kidney transplant

Fill-in (6)

 

Choice 1

Show DLYS-STOP date for the latest DLYS occurrence on the POST-MBR in format MMCCYY

Choice 2

Show KDNY-TRNSDATE date for the latest KDNY occurrence on the POST-MBR in format MMCCYY

HIB142 – CURRENT PAY TO SUSPENSE OR DEFERRED STATUS

We will continue to charge a monthly premium for (1) medical insurance under Medicare.

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN possessive

Choice 2

your

HIB143 – SMI PENALTY RATE TO BASE RATE AT AGE 65

Under a special provision of the Social Security Act, now that (1) (2) for Medicare medical insurance based on (3) age, (4) monthly medical insurance premium amount has been reduced from (5) to (6).

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN

Choice 2

you

Fill-in (2)

 

Choice 1

qualifies

Choice 2

qualify

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

Show the SMI premium penalty rate

Fill-in (6)

Show the SMI premium base rate

HIB151 – LIMITED BUY-IN/BUY-OUT - COVERAGE CONTINUES

(1) must pay the premium beginning (2).

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

He

Choice 3

She

Fill-in (2)

MMCCYY

HIB154 – EXPLANATION OF BENFITS WHEN MEDICARE IS THE SECONDARY PAYER WHEN THE BENEFICARY IS WORKING AND COVERED BY HIS OR HER EMPLOYER

(1) working for an employer who has 20 or more employees? (2) covered under this employer's group health plan? If so, the employer's plan will pay first for health care services. Medicare will pay secondary benefits when the employer's plan doesn't cover all of the expenses.

Contact your nearest Social Security office for more information about Part B Medicare special enrollment.

Fill-in values:

 

Fill-in (1)

 

Choice 1

The word 'Is' BGN plus BLN

Choice 2

Are you

Fill-in (2)

 

Choice 1

Is he

Choice 2

Is she

Choice 3

Are you

HIB157 – PIC C'S NOTICE WHEN CHILD < AGE 19 AND NO OPEN HI

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)

www.insurekidsnow.gov

HIB160 – HI/SMI REVERSAL - NOT TIMELY BUT IN GEP

We received (1) cancellation of (2) earlier request that (3) Medicare (4) insurance coverage be terminated. Although this cancellation request was filed too late for the coverage to be reinstated without interruption, it was filed during a period in which (5) could reenroll. This difference is important because there are months for which (6) not have Medicare (7) insurance coverage.

Fill-in values:

 

Fill-in (1)

   

Choice 1

Choice 2

   

BGN plus BLN possessive

your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (5)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (6)

 

Choice 1

he does

Choice 2

she does

Choice 3

you do

Fill-in (7)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

HIB161 – HI/SMI REVERSAL NOT FILED TIMELY NOT IN GEP

We stopped (1) Medicare (2) insurance at (3) request. Then (4) decided that (5) still wanted it. (6) decided too late for us to start (7) Medicare (8) insurance again at this time.

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN possessive

Choice 2

your

Fill-in (2)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (5)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (6)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (7)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (8)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

HIB162 – REFUSAL OVER AUTOMATIC ENROLLMENT

(1) told us that (2) not want (3) insurance under Medicare.

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN

Choice 2

You

Fill-in (2)

 

Choice 1

he does

Choice 2

she does

Choice 3

you do

Fill-in (3)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

HIB163 – SMI REFUSAL CURRENT PAY REFUND OF PREMIUMS

(1) not have to pay a premium for any months (2) not entitled to Medicare Part B (medical insurance). If we took out premiums for any of these months, we will return the money to (3).

Fill-in values:

 

Fill-in (1)

 

Choice 1

You do

Choice 2

BGN plus BLN plus does

Fill-in (2)

 

Choice 1

you were

Choice 2

he was

Choice 3

she was

Fill-in (3)

 

Choice 1

you

Choice 2

him

Choice 3

her

HIB164 – SMI REFUSAL PREMIUM BILLING AND NO OPEN THIRD PARTY

Since our records were previously annotated to show that (1) enrolled for Medicare (2) insurance, a premium billing notice may have been prepared for mailing to (3). If (4) a billing notice, (5) should destroy it.

Fill-in values:

 

Fill-in (1)

 

Choice 1

he was

Choice 2

she was

Choice 3

you were

Fill-in (2)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (3)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (4)

 

Choice 1

he receives

Choice 2

she receives

Choice 3

you receive

Fill-in (5)

 

Choice 1

he

Choice 2

she

Choice 3

you

HIB165 – REFUSAL/WITHDRAWAL STATE BUY-IN ESTABLISHED

Our records show that (1) State has agreed to pay the premiums for (2) Medicare (3) insurance coverage. Therefore, (4) will continue to be enrolled.

Fill-in values:

 

Fill-in (1)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (4)

 

Choice 1

he

Choice 2

she

Choice 3

you

HIB175 – SMI PREMIUMS/ARREARAGE DEDUCTED FROM PMA OR CMA

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

Beneficiary's full name possessive

Choice 2

your

HIB176 – SMI PREMIUMS/ARREARAGE DEDUCTED FROM PMA OR CMA WHEN BENEFITS ARE RESUMED

Since benefits are again payable we will resume withholding (1) medical premiums due to date.

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN possessive

Choice 2

your

HIB182 – IRMAA AMOUNT STARTS, IRMAA AMOUNT CHANGES OR IRMAA AMOUNT NO LONGER APPLIED TO SMI PREMIUM (PART B)

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)

 

Choice 1

your

Choice 2

BGN plus BLN possessive

Fill-in (2)

 

Choice 1

you have

Choice 2

she has

Choice 3

he has

Fill-in (3)

 

Choice 1

you

Choice 2

she

Choice 3

he

Fill-in (4)

 

Choice 1

your

Choice 2

her

Choice 3

his

Fill-in (5)

 

Choice 1

your

Choice 2

her

Choice 3

his

Fill-in (6)

 

Choice 1

your

Choice 2

her

Choice 3

his

Fill-in (7)

 

Choice 1

you pay your

Choice 2

he pays his

Choice 3

she pays her

HIB183 – USE WITH HIB182 WHEN IRMAA AFFECTS PART B RATE

We sent (1) another letter that explained how we determined the amount of (2) premium.

Fill-in values:

 

Fill-in (1)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB184 – USE WITH HIB182 WHEN BENEFICIARY WILL CONTINUE TO BE BILLED FOR PART B SMI PREMIUMS

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB185 – USE WHEN HIB182 IS GENERATED AS THE INTRODUCTORY UTI AND BENEFICIARY'S LAF IS CURRENT PAY OR DEFERRED

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)

 

Choice 1

using the PCI show the calendar date of the COM check

Choice 2

using the PCI show the calendar date of the DPD check

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB186 – SMI MATURITY AND NO IRMAA DATA ON POST MBR

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). 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)

Show the IRMAA level 1 yearly amount for singles

Fill-in (2)

Show the IRMAA level 1 yearly amount for couples

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

he has

Choice 2

she has

Choice 3

you have

Fill-in (5)

show the SMI START date

HIB215 – T2 BENEFITS TERMINATE HI/SMI TERMINATES

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)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

hospital

Choice 2

hospital and medical

Fill-in (4)

 

Choice 1

His

Choice 2

Her

Choice 3

Your

Fill-in (5)

 

Choice 1

hospital

Choice 2

hospital and medical

Fill-in (6)

Show HI-TERM date in format MMCCYY

Fill-in (7)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB225 – HRFST LESSDO MBA LESS THAN SMI PREMIUM

(1) monthly medical insurance premium is (2). The monthly benefit that (3) should get is less than (4) medical insurance premiums. We are stopping (5) monthly benefits starting (6) to pay for part of this premium. After adjusting for (7) monthly benefits, we find that we must bill (8) for (9).

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN possessive

Choice 2

Your

Fill-in (2)

Show the current SMI premium amount

Fill-in (3)

 

Choice 1

BGN plus BLN

Choice 2

you

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (6)

Show the first EFD in HIST Data that corresponds to LESSDO

Fill-in (7)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (8)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (9)

Show money amount for the remaining premiums

HIB226 – HRFST LESSDO MBA > SMI BUT LESS THAN A DOLLAR

We are stopping (1) monthly benefit starting (2). When we take (3) monthly medical insurance premium of (4) from (5) monthly benefit, the amount left is less than a dollar. At the end of the year, we will adjust (6) record and pay all money (7) due.

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN possessive

Choice 2

your

Fill-in (2)

Show the first EFD in HIST Data that corresponds to LESSDO

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

Show current SMI premium amount

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (6)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (7)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

HIB248 – PREMIUM HI REDUCTION WHEN 30 QUARTERS ATTAINED NO OPEN ENTITLEMENT TO PREMIUM HI

Currently, (1) not eligible for free Medicare hospital insurance. However, (2) may be eligible to buy hospital insurance for the reduced premium of (3) per month. You can get more information about this hospital insurance by contacting any Social Security office.

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN plus the word “is”

Choice 2

you are

Fill-in (2)

he / she / you

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (3)

Show the premium HI amount that pertains to the HIRE-30QTR date in HIRE data in the format $$$$¢¢

HIB249 – OFFER RELIEF FOR SMI PREMIUMS (VSMI RATES)

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);

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)

Show the SMI-NONEQRELST date

Fill-in (2)

Show the SMI-NONEQRELST date

Fill-in (3)

Show the total amount of the SMI premiums

Fill-in (4)

Show the SMI-NONEQRELST date

Fill-in (5)

Show the current operating month date

Fill-in (6)

Show the SMI-NONEQRELST date

Fill-in (7)

Show the current VSMI rate

Fill-in (8)

Show the current Part B premium rate

HIB260 – PREMIUM RELIEF ESTABLISHED DUE TO IRMAA B AND/OR IRMAA D

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)

 

Choice 1

BGN plus BLN possessive

Choice 2

your

HIB261 – PREMIUM RELIEF ESTABLISHED DUE TO IRMAA B

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

Fill-in values:

 

Fill-in (1)

Show the total amount of the SMI arrearages for IRMAA B in the format $$$$$$¢¢

Fill-in (2)

Show the RLF-START date in the first occurrence of Premium Relief data in the format November 2009

Fill-in (3)

 

Choice 1

null

Choice 2

and

Choice 3

through

Fill-in (4)

 

Choice 1

Null

Choice 2

Show the RLF-STOP date in the last occurrence of Premium Relief data in the format November 2009

HIB262 – PREMIUM RELIEF ESTABLISHED DUE TO IRMAA D

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

Fill-in values:

 

Fill-in (1)

Show the total amount of IRMAA D equitable relief arrearages in the format $$$$$$¢¢

Fill-in (2)

Show the RLF-START date in the first occurrence of Premium Relief data in the format November 2009

Fill-in (3)

 

Choice 1

null

Choice 2

and

Choice 3

through

Fill-in (4)

 

Choice 1

Null

Choice 2

Show the RLF-STOP date in the last occurrence of Premium Relief data in the format November 2009

HIB263 – PREMIUM RELIEF ESTABLISHED DUE TO IRMAA B AND ALSO IRMAA D

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

Fill-in values:

 

Fill-in (1)

Show the sum of the total amount of the IRMAA B equitable relief arrearages plus the total amount of the IRMAA D equitable relief arrearages in the format $$$$$$¢¢

HIB264 – PREMIUM RELIEF ESTABLISHED - ALTERNATIVES TO FULL WITHHOLDING OF BENEFITS

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)

 

Choice 1

he owes

Choice 2

she owes

Choice 3

you owe

Fill-in (2)

 

Choice 1

he owes

Choice 2

she owes

Choice 3

you owe

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

Show the current operating month (COM) plus 2 months in the format July 2009

HIB265 – DEDUCTION OF CURRENT SMI PREMIUMS

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)

 

Choice 1

BGN plus BLN possessive

Choice 2

your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

Show the current operating month (COM) plus 2 months in the format July 2009

HIB266 – FULL WITHHOLDING OF PART B RELIEF PREMIUMS WHEN CURRENT SMI PREMIUMS ARE ALSO DEDUCTED

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

Fill-in values:

 

Fill-in (1)

Show the sum of the RCVBL-TOTAMT for current PART B only arrearages in the format $$$$$$¢¢

HIB267 – FULL WITHHOLDING OF IRMAA D RELIEF PREMIUMS WHEN CURRENT SMI PREMIUMS ARE BEING DEDUCTED

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

Fill-in values:

 

Fill-in (1)

Show the sum of the RCVBL-TOTAMT for current IRMAA D only arrearages in the format $$$$$$¢¢

HIB268 – FULL WITHHOLDING OF IRMAA D RELIEF PREMIUMS WHEN NO CURRENT SMI PREMIUMS BEING DEDUCTED

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)

Show the current operating month (COM) in the format July 2009

Fill-in (2)

Show the sum of the IRMAA D arrearages in the format $$$$$$¢¢

HIB269 – FULL WITHHOLDING CONTINUES UNTIL PREMIUMS PAID IN FULL

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN possessive

Choice 2

your

Fill-in (2)

 

Choice 1

he owes

Choice 2

she owes

Choice 3

you owe

HIB270 – FULL WITHHOLDING OF PART B RELIEF PREMIUMS WHEN NO CURRENT SMI PREMIUMS BEING DEDUCTED

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)

Show the current operating month (COM) in the format July 2009

Fill-in (2)

Show the sum of the IRMAA B arrearages in the format $$$$$$¢¢

HIB271 – PARTIAL RECOVERY OF PART B OR IRMAA D RELIEF PREMIUMS

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)

Add the RCVBL-PARTAMT for each occurrence and show this sum in the format $$$$$$¢¢

Fill-in (2)

 

Choice 1

BGN plus BLN possessive

Choice 2

your

Fill-in (3)

Show the current operating month (COM) in the format July 2009

Fill-in (4)

Add the RCVBL-PARTAMT for each occurrence and show this sum in the format $$$$$$¢¢


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900730116
NL 00730.116 - "H" Paragraphs and Captions - 08/01/2017
Batch run: 08/01/2017
Rev:08/01/2017