TN 19 (08-14)

NL 00730.126 “M” Paragraphs and Captions

List of “M” Paragraphs and Captions

A. “MAN” Universal Text Identifier - Manual

MAN001 – MANUAL NOTICE NEEDED TO EXPLAIN TITLE II REDESIGN ACTION(S)

MANUAL NOTICE NEEDED – (1)

Fill-in values:

Fill-in (1)

 

Choice 1

LIMITED GROUP PAYER

Choice 2

THIRD-PARTY WIPEOUT PROCESSED

Choice 3

MEDICARE CLAIM WITHDRAWAL PROCESSED

Choice 4

MBA LESS SMI PAST PREMIUMS

Choice 5

MULTIPLE 3RD PARTY CLOSED PERIODS

Choice 6

SPA OPA POSTED TO BOUD TERM TO TERM

Choice 7

SUSPENSION FOR WITHDRAWAL CLAIM

Choice 8

NEW OPA AND PRIOR OPA UNDER PROTEST

Choice 9

MULTIPLE FFEL CHANGED OCCURRENCES

Choice 10

WARRANT ISSUING AGENCY IS BLANK

Choice 11

MBR ORI AND WARRANTDT NO MATCH ON FFSCF

Choice 12

WC/PDB STOPS AND NO AMOF DATA PRESENT

Choice 13

FFEL SUSP NO CHANGE IN FFEL OCCURRENCES

Choice 14

ICF INPUT WC DATA DELETED ON POST-MBR

Choice 15

MULTIPLE ARD DATA LINES FOR SAME YEAR (YOER)

B. “MAR” Universal Text Identifiers - Marriage

MAR008 – MARRIAGE DOES NOT AFFECT SOCIAL SECURITY ADMINISTRATION BENEFITS

Thank you for telling us that (1) married. However, this marriage will not affect (2) benefits.

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

you

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

MAR009 – DIVORCE DOES NOT AFFECT SOCIALSECURITY ADMINISTRATION BENEFITS

Thank you for telling us about (1) divorce. However, the divorce will not affect (2) benefits.

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

C. “MHP” Universal Text Identifiers – Medicare Health Plan

MHPC02 – CAPTION

Information About (1) Health Plan Premiums

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

Your

MHPC03 – CAPTION

Information About (1) Medicare Prescription Drug Plan Costs

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

Your

MHPC04 – CAPTION

Information About (1) Health Plan Premiums and Medicare Prescription Drug Plan Costs

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

Your

MHP008 – MEDICARE ADVANTAGE PART B PREMIUM REDUCED

MONTH CCYY    MONTH CCYY    $$$$$$¢¢    $$$$$$¢¢

NOTE: The fill-ins for MHP008 will be repeated for each occurrence of MARD data that needs to be displayed in the notice.

Fill-in values:

Fill-in (1)

Medicare Advantage Reduction Start Date (MARD-START-REL) for the first occurrence of MARD data that has changed when comparing the pre- and post-MBRs

NOTE: for Fill-in (1), the date will be displayed in the numeric format showing the slash after the month and before the year (e.g., 01/2006)

Fill-in (2)

Medicare Advantage Reduction Stop Date (MARD-STOP-REL) that corresponds to the MARD start date

NOTE: the MARD stop date may not have a value if there is no stop date on the post-MBR

Fill-in (3)

Medicare Advantage Reduction Amount (MARD-AMOUNT) that corresponds to the start/stop occurrence

NOTE: If an MARD occurrence on the pre-MBR is wiped-out, then the value for this fill-in will be zero and displayed as 0.00

Fill-in (4)

Show the Part B premium after the Medicare Advantage Reduction Amount (MARD-AMOUNT) is applied.

NOTE: if the MARD occurrence displayed is for a wiped-out occurrence on the pre-MBR, the value for this fill-in will be the Part B SMI rate

NOTE: The decision to display MARD occurrence from the pre-MBR that is wiped-out was made by CMS notice policy when creating the revised language to use for Medicare Advantage reduction of Part B premium amount.

MHP009 – PART C HEALTH PLAN PREMIUMS DEDUCTION FROM SSA BENEFITS STARTS

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

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

you

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

MHP012 – PART C HEALTH PLAN PREMIUMS DEDUCTED FROM A PRIOR MONTHLY ACCRUAL (PMA) OR CURRENT MONTHLY ACCRUAL (CMA)

This represents all health plan premiums due to date.

MHP013 – SUPPLEMENTAL MEDICAL INSURANCE (SMI) PART B PREMIUM REDUCED

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

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

your

MHP014 – MEDICARE ADVANTAGE PART B PREMIUM REDUCED

Below we show the changes to the monthly deduction to (1) medical insurance (Part B) premium:

Start Date

Stop Date

Amount of Reduction

Amount of Premium After the Reduction

(2)

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

a blank line is required for Fill-in (2) for formatting purposes

MHP015 – PART C HEALTH PLAN PREMIUM DEDUCTED FROM MONTHLY BENEFIT PAYABLE (MBP) > $0.00

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

Fill-in values:

Fill-in (1)

For every Deductions Additions History (DAH) occurrence on the post-MBR with the Deductions Additions History Update Date (DAH-UPDDT) equal to the Run Date that has a Deductions Additions History Type of Payment Code (DAH-TOP) = MBP (M) and has a Deductions Additions History Item Code (DAH-ITEM) = 445, 450, 455 and/or 460, add the Deductions Additions History Amount (DAH-AMOUNT) for each of these occurrences together and show this total as the fill-in value

Fill-in (2)

 

Choice 1

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

Choice 2

your

MHP016 – PART C HEALTH PLAN PREMIUM DEDUCTION AMOUNT CHANGES

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

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

your

MHP017 – PART C HEALTH PLAN PREMIUMS NO LONGER DEDUCTED FROM SSA BENEFITS

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

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

MHP018 – ADVISES BENEFICIARY TO CONTACT THEIR HEALTH PLAN ABOUT PART C HEALTH PLAN OR ABOUT THE REDUCTION OF PART B PREMIUM AMOUNT

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

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

MHP027 – REFUND FOR PART C HEALTH PLAN PREMIUMS ONLY PAID IN THE PRIOR MONTH ACCRUAL AMOUNT (PAMT) OR CURRENT MONTH ACCRUAL AMOUNT (CAMT)

This payment includes a refund of (1) health plan premiums.

Fill-in values:

Fill-in (1)

 

Choice 1

his

Choice 2

her

Choice 3

your

MHP028 – REFUND FOR PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS PAID IN A PRIOR MONTH ACCRUAL AMOUNT (PAMT) OR CURRENT MONTH ACCRUAL AMOUNT (CAMT)

This payment includes a refund of (1) Medicare prescription drug plan costs.

Fill-in values:

Fill-in (1)

 

Choice 1

his

Choice 2

her

Choice 3

your

MHP029 – REFUND FOR PART C HEALTH PLAN PREMIUMS AND ALSO PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS

This payment includes a refund of (1) health plan premiums and (2) Medicare prescription drug plan costs.

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

MHP030 – REFUND FOR PART D ONLY MEDICARE PRESCRIPTION DRUG PLAN COSTS AND NO OTHER TITLE II REDESIGN PARAGRAPH GENERATED AS INTRODUCTORY PARAGRAPH

Based on the information we have (1) (2) due a refund for Medicare prescription drug plan costs.

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

you

Fill-in (2)

 

Choice 1

is

Choice 2

are

MHP031 – REFUND FOR PART C ONLY HEALTH PLAN PREMIUMS AND NO OTHER TITLE II REDESIGN PARAGRAPH GENERATED AS INTRODUCTORY PARAGRAPH

Based on the information, we have (1) (2) due a refund for health plan premiums.

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

you

Fill-in (2)

 

Choice 1

is

Choice 2

are

MHP032 – REFUND FOR PART C HEALTH PLAN PREMIUMS AND ALSO REFUND FOR PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS AND NO OTHER TITLE II REDESIGN PARAGRAPH GENERATED AS INTRODUCTORY PARAGRAPH

Based on the information, we have (1) (2) due a refund for (3) health plan premiums and (4) Medicare prescription drug plan costs.

Fill-in values:

Fill-in (1)

 

Choice 1

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

his

Choice 2

her

Choice 3

your

MHP033 – BENEFICIARY REQUESTS THAT ONLY PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS DEDUCTED FROM SOCIAL SECURITY ADMINISTRATION BENEFITS

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

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

you

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

MHP034 – BENEFICIARY REQUESTS THAT PART C HEALTH PLAN PREMIUMS AND ALSO PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS DEDUCTED FROM SOCIAL SECURITY ADMINISTRATION BENEFITS

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

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

you

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

MHP035 – PART C ONLY HEALTH PLAN PREMIUMS DEDUCTED FROM PRIOR MONTH ACCRUAL AMOUNT (PAMT) CHECK

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

Fill-in values:

Fill-in (1)

Total amount of the Part C health plan premiums deducted from the Prior Month Accrual Amount (PAMT) check; this amount includes any Part C arrearages show in Deductions Additions History (DAH) data from the PAMT

Fill-in (2)

 

Choice 1

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

Choice 2

your

Fill-in (3)

Run date plus 15 days as the date in the format Month DD, CCYY

MHP036 – PART D ONLY MEDICARE PRESCRIPTION DRUG PLAN COSTS DEDUCTED FROM PRIOR MONTH ACCRUAL AMOUNT (PAMT) CHECK

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)

Total amount of the Part D Medicare prescription drug plan costs deducted from the Prior Month Accrual Amount (PAMT) check; this amount includes any Part D arrearages show in Deductions Additions History (DAH) data from the PAMT

Fill-in (2)

 

Choice 1

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

Choice 2

your

Fill-in (3)

Run date plus 15 days as the date in the format Month DD, CCYY

MHP037 – PART C HEALTH PLAN PREMIUMS AND ALSO PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS DEDUCTED FROM PRIOR MONTH ACCRUAL AMOUNT (PAMT) CHECK

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)

Total amount of the Part C health plan premiums deducted from the Prior Month Accrual Amount (PAMT) check; this amount includes any Part C arrearages show in Deductions Additions History (DAH) data from the PAMT

Fill-in (2)

 

Choice 1

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

Choice 2

your

Fill-in (3)

Total amount of the Part D Medicare prescription drug plan costs deducted from the Prior Month Accrual Amount (PAMT) check; this amount includes any Part D arrearages show in Deductions Additions History (DAH) data from the PAMT

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

Run date plus 15 days as the date in the format Month DD, CCYY

MHP038 – PART C ONLY HEALTH PLAN PREMIUMS DEDUCTED FROM CURRENT AMOUNT (CAMT) CHECK

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)

Total amount of the Part C health plan premiums deducted from the Current Amount (CAMT) check; this amount includes any Part C arrearages show in Deductions Additions History (DAH) data from the CAMT

Fill-in (2)

 

Choice 1

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

Choice 2

your

Fill-in (3)

Current Operating Month (COM) in the format Month CCYY

Fill-in (4)

Using the PCI (Payment Cycle Indicator) show the calendar date in which the Current Operating Month (COM) check will be paid in the format Month DD, CCYY

MHP039 – PART D ONLY MEDICARE PRESCRIPTION DRUG PLAN COSTS DEDUCTED FROM CURRENT AMOUNT (CAMT) CHECK

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)

Total amount of the Part D Medicare prescription drug plan costs deducted from the Current Amount (CAMT) check; this amount includes any Part C arrearages show in Deductions Additions History (DAH) data from the CAMT

Fill-in (2)

 

Choice 1

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

Choice 2

your

Fill-in (3)

Current Operating Month (COM) in the format Month CCYY

Fill-in (4)

Using the Payment Cycle Indicator (PCI), show the calendar date in which the Current Operating Month (COM) check will be paid in the format Month DD, CCYY

MHP040 – PART C HEALTH PLAN PREMIUMS AND ALSO PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS DEDUCTED FROM THE CURRENT MONTHLY ACCRUAL (CMA) CHECK

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)

Total amount of the Part C health plan premiums deducted from the Current Monthly Accrual (CMA) check; this amount includes any Part C arrearages show in Deductions Additions History (DAH) data from the CMA

Fill-in (2)

 

Choice 1

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

Choice 2

your

Fill-in (3)

Total amount of the Part D Medicare prescription drug plan costs deducted from the Current Amount (CAMT) check; this amount includes any Part C arrearages shown in Deductions Additions History (DAH) data from the Current Monthly Accrual (CMA)

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)

Current Operating Month (COM) in the format Month CCYY

Fill-in (7)

Using the Payment Cycle Indicator (PCI) show the calendar date in which the Current Operating Month (COM) check will be paid in the format Month DD, CCYY

MHP041 – PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS FROM THE PRIOR MONTH ACCRUAL AMOUNT (PAMT) AND/OR CURRENT AMOUNT (CAMT)

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

MHP042 – PART C HEALTH PLAN PREMIUMS AND ALSO PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS FROM THE PRIOR MONTH ACCRUAL AMOUNT (PAMT) AND/OR CURRENT AMOUNT (CAMT)

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

MHP043 – PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS ONLY DEDUCTED FROM MONTHLY BENEFIT PAYABLE (MBP)

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

Fill-in values:

Fill-in (1)

Amount of the Part D Medicare prescription drug plan costs deducted from the Monthly Benefit Payable (MBP)

Fill-in (2)

 

Choice 1

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

Choice 2

your

MHP044 – PART C HEALTH PLAN PREMIUM AND PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS DEDUCTED FROM THE MONTHLY BENEFIT PAYABLE (MBP)

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)

Amount of the Part C health plan premium deducted from the Monthly Benefit Payable (MBP)

Fill-in (2)

 

Choice 1

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

Choice 2

your

Fill-in (3)

Amount of the Part D Medicare prescription drug plan costs deducted from the Monthly Benefit Payable (MBP)

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

MHP045 – CHANGE IN THE DEDUCTION AMOUNT FOR PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS FROM SOCIAL SECURITY ADMINISTRATION BENEFITS

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

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

your

MHP046 – CHANGE IN THE DEDUCTION AMOUNT FOR PART C HEALTH PLAN PREMIUM AND ALSO A CHANGE IN THE DEDUCTION AMOUNT FOR PART D MEDICARE 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)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

MHP047 – PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS ONLY NO LONGER DEDUCTED FROM SOCIAL SECURITY ADMINISTRATION BENEFITS

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

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

MHP048 – PART C HEALTH PLAN PREMIUMS AND ALSO PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS NO LONGER DEDUCTED FROM SOCIAL SECURITY ADMINISTRATION BENEFITS

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)

 

Choice 1

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

Choice 2

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

MHP049 – REFERRAL LANGUAGE USED WHEN PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS ONLY ARE INVOLVED FOR ANY REASON

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)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

MHP050 – REFERRAL LANGUAGE USED WHEN PART C HEALTH PLAN PREMIUMS AND ALSO PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS ARE BOTH INVOLVED FOR ANY REASON

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)

 

Choice 1

your

Choice 2

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

Fill-in (2)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (3)

 

Choice 1

you have

Choice 2

he has

Choice 3

she has

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

MHP053 – INITIAL ENTITLEMENT TO HOSPITAL INSURANCE (HI)/SUPPLEMENTAL MEDICAL INSURANCE (SMI) WITH NO CURRENT DEDUCTION FOR MEDICARE PART D OR INCOME RELATED MONTHLY ADJUSTMENT AMOUNT (IRMAA) 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)

 

Choice 1

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

Choice 2

you

Fill-in (2)

 

Choice 1

is

Choice 2

are

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (5)

www.medicare.gov

Fill-in (6)

 

Choice 1

him

Choice 2

her

Choice 3

you

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)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (10)

 

Choice 1

he has

Choice 2

she has

Choice 3

you have

Fill-in (11)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (12)

www.socialsecurity.gov

D. “MIS” Universal Text Identifier - Miscellaneous

MIS050 – BENEFICIARY DIES IN OR BEFORE THEIR CURRENT DATE OF ENTITLEMENT (DOEC)

We are sorry to learn of your recent loss. Please accept our sincere sympathy.

We are not processing the application for Social Security benefits for (1). This is because (2) could not have been entitled to benefits for any month before (3) death on (4).

Fill-in values:

Fill-in (1)

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

Fill-in (2)

 

Choice 1

he

Choice 2

she

Fill-in (3)

 

Choice 1

his

Choice 2

her

Fill-in (4)

Beneficiary Date of Death (BDOD) in format Month CCYY

E. “MOE” Universal Text Identifiers – Month Of Entitlement

MOE003 – SINGLE ENTITLEMENT RECORD AND MONTH OF ENTITLEMENT (MOE) DATE CHANGE DUE TO WORK AND EARNINGS

We reviewed (1) record. When (2) applied for benefits, (3) asked us to start (4) benefits in (5). We changed the month (6) benefits start to (7) because of (8) (9) work and earnings.

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

you

Choice 2

he

Choice 3

she

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (5)

Date of Entitlement (DOE) start date from the pre-MBR in the format Month CCYY

Fill-in (6)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (7)

Date of Entitlement (DOE) new start date from the post-MBR in the format Month CCYY

Fill-in (8)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (9)

 

Choice 1

Year prior to the Date of Entitlement (DOE) start in the format CCYY

Choice 2

Full Retirement Age (FRA) year in the format CCYY

Choice 3

Year prior to the Full Retirement Age (FRA) year in the format CCYY

Choice 4

Date of Entitlement (DOE) start year in the format CCYY

MOE004 – DUAL ENTITLEMENT RECORD AND THE MONTH OF ENTITLEMENT (MOE) DATES CHANGES DUE TO WORK AND EARNINGS FOR A CLOSED YEAR

We reviewed (1) record. When (2) applied, (3) asked us to start (4) benefits in (5). We changed the month (6) benefits start to (7) because of (8) (9) work and earnings.

(10) also receiving (11) benefits on claim number (12). We will send you another letter about (13) (14) benefits.

Fill-in values:

Fill-in (1)

 

Choice 1

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

Date of Entitlement (DOE) start date in the format Month CCYY

Fill-in (6)

 

Choice 1

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

Choice 2

your

Fill-in (7)

Date of Entitlement (DOE) new start date

Fill-in (8)

 

Choice 1

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

Choice 2

Number Holder First Name plus Number Holder Last Name

Choice 3

your

Fill-in (9)

 

Choice 1

Year prior to the Date of Entitlement (DOE) start in the format CCYY

Choice 2

Full Retirement Age (FRA) year in the format CCYY

Choice 3

Year prior to the Full Retirement Age (FRA) year in the format CCYY

Choice 4

Date of Entitlement (DOE) start year in the format CCYY

Fill-in (10)

 

Choice 1

He is

Choice 2

She is

Choice 3

You are

Fill-in (11)

 

Choice 1

his own

Choice 2

her own

Choice 3

your own

Choice 4

spouse

Choice 5

child

Choice 6

widow(er)

Choice 7

mother

Choice 8

father

Choice 9

parent

Choice 10

disabled widow (er)

Fill-in (12)

Other account number and Beneficiary Identification Code (BIC)

Fill-in (13)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (14)

 

Choice 1

own

Choice 2

spouse

Choice 3

child

Choice 4

widow(er)

Choice 5

mother

Choice 6

father

Choice 7

parent

Choice 8

disabled widow (er)

MOE005 – DUAL ENTITLEMENT RECORD AND MONTH OF ENTITLEMENT (MOE) CHANGES DUE TO WORK AND EARNINGS FOR A CLOSED YEAR FOR A BENEFICIARY WHO CHOSE AN EARLY MOE WITHOUT REDUCTION

We reviewed (1) record. When (2) applied, (3) asked us to start (4) benefits in (5). We changed the month (6) benefits start to (7) because of (8) (9) work and earnings. The change lets (10) get payments without permanently reducing (11) monthly benefits.

(12) also, receiving (13) benefits on claim number (14). We will send you another letter about (15) (16) benefits.

Fill-in values:

Fill-in (1)

 

Choice 1

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

Original Date of Entitlement (DOE) start date in the format Month CCYY

Fill-in (6)

 

Choice 1

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

Choice 2

your

Fill-in (7)

New Month of Entitlement (MOE) start date

Fill-in (8)

 

Choice 1

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

Choice 2

NH First Name plus NH Last Name

Choice 3

your

Fill-in (9)

Enforcement year in the format CCYY

Fill-in (10)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (11)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (12)

 

Choice 1

He is

Choice 2

She is

Choice 3

You are

Fill-in (13)

 

Choice 1

his own

Choice 2

her own

Choice 3

your own

Choice 4

spouse

Choice 5

child

Choice 6

widow(er)

Choice 7

mother

Choice 8

father

Choice 9

parent

Choice 10

disabled widow (er)

Fill-in (14)

Other account number and Beneficiary Identification Code (BIC)

Fill-in (15)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (16)

 

Choice 1

own

Choice 2

spouse

Choice 3

child

Choice 4

widow(er)

Choice 5

mother

Choice 6

father

Choice 7

parent

Choice 8

disabled widow(er)

MOE006 – NEW MONTH OF ENTITLEMENT (MOE) TO AN AUXILIARY WHEN THE MOE CHANGED BASED ON THE NUMBER HOLDER'S MOE CHANGING

We changed the month (1) benefits start on (2) record from (3) to (4). We changed the month because of (5) (6) work and earnings. (7) is the earliest month (8) can get benefits on (9) record. (10) benefits must start before (11) benefits can start.

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

NH First Name plus NH Last Name (possessive)

Fill-in (3)

Date of Entitlement (DOE) start date

Fill-in (4)

New Date of Entitlement (DOE) start date

Fill-in (5)

NH First Name plus NH Last Name

Fill-in (6)

Year of enforcement in the format CCYY

Fill-in (7)

Date of Entitlement (DOE) start date

Fill-in (8)

 

Choice 1

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

Choice 2

you

Fill-in (9)

NH First Name plus NH Last Name

Fill-in (10)

NH First Name plus NH Last Name

Fill-in (11)

 

Choice 1

NH First Name plus NH Last Name

Choice 2

your

MOE007 – SINGLE ENTITLEMENT RECORD AND THE MONTH OF ENTITLEMENT (MOE) DATE CHANGES DUE TO WORK AND EARNINGS FOR A CLOSED YEAR FOR A BENEFICIARY WHO CHOSE AN EARLY MOE WITHOUT REDUCTION

We reviewed (1) record. When (2) applied, (3) asked us to start (4) benefits in (5). We changed the month (6) benefits start to (7) because of (8) (9) work and earnings. This change lets (10) get payments without permanently reducing (11) monthly benefits.

Fill-in values:

Fill-in (1)

 

Choice 1

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

Original Month of Entitlement (MOE) in the format Month CCYY

Fill-in (6)

 

Choice 1

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

Choice 2

your

Fill-in (7)

New Month of Entitlement (MOE) in the format Month CCYY

Fill-in (8)

 

Choice 1

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

Choice 2

First name of NH plus Last name of NH

Choice 3

your

Fill-in (9)

Year of enforcement in the format CCYY

Fill-in (10)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (11)

 

Choice 1

his

Choice 2

her

Choice 3

your

F. “MPD” Universal Text Identifiers – Medicare Prescription Drug Plan

MPDC19 – Caption

Medicare Prescription Drug Plan Enrollment

MPDC31 – Caption

Information About The Prescription Drug Coverage Income-Related Monthly

Adjustment Amount

MPD346 – INCOME-RELATED MONTHLY ADJUSTMENT AMOUNT (IRMAA) D PREMIUMS REFUND IN PRIOR MONTH ACCRUAL AMOUNT (PAMT) OR CURRENT AMOUNT (CAMT) - NO OTHER INTRODUCTORY UTI APPLIES

Based on the information, we have (1) (2) due a refund for prescription drug coverage income-related monthly adjustment amounts.

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

you

Fill-in (2)

 

Choice 1

is

Choice 2

are

MPD347 – INCOME-RELATED MONTHLY ADJUSTMENT AMOUNT (IRMAA) D PREMIUMS REFUND IN PRIOR MONTH ACCRUAL AMOUNT (PAMT) OR CURRENT AMOUNT (CAMT)

This payment includes a refund of (1) prescription drug coverage income-related monthly adjustment amount.

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

your

MPD348 – INCOME-RELATED MONTHLY ADJUSTMENT AMOUNT (IRMAA) D PREMIUM DEDUCTED FROM CURRENT AMOUNT (CAMT)

We deducted (1) for (2) prescription drug coverage income-related monthly adjustment amount from the check (3) will receive for (4) on or about (5).

Fill-in values:

Fill-in (1)

Total Income Related Monthly Adjustment Amount (IRMAA) D amounts deducted from Current Amount (CAMT)

Fill-in (2)

 

Choice 1

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

Choice 2

your

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

Current Operating Month (COM)

Fill-in (5)

Using the Payment Cycle Indicator (PCI), show the calendar date in which the Current Operating Month (COM) check will be paid

MPD349 - INCOME-RELATED MONTHLY ADJUSTMENT AMOUNT (IRMAA) D CONTINUES TO BE DEDUCTED FROM THE MONTHLY BENEFIT PAYABLE (MBP)

The monthly deduction for (1) prescription drug coverage income-related monthly adjustment amount is (2).

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

Total Income Related Monthly Adjustment Amount (IRMAA) D amounts deducted from Monthly Benefit Payable (MBP)

MPD350 – INCOME-RELATED MONTHLY ADJUSTMENT AMOUNT (IRMAA) D PREMIUM DEDUCTED FROM PRIOR MONTH ACCRUAL AMOUNT (PAMT)

We deducted (1) for (2) prescription drug coverage income-related monthly adjustment amount from the check you will receive on or about (3).

Fill-in values:

Fill-in (1)

Total Income-Related Monthly Adjustment Amount (IRMAA) D amounts deducted from Prior Month Accrual Amount (PAMT)

Fill-in (2)

 

Choice 1

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

Choice 2

your

Fill-in (3)

Run date plus 15 days

MPD351 – INCOME-RELATED MONTHLY ADJUSTMENT AMOUNT (IRMAA) D NO LONGER DEDUCTED FROM BENEFITS

We will no longer deduct (1) prescription drug coverage income-related monthly adjustment amount from (2) monthly benefits.

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

MPD352 – INCOME-RELATED MONTHLY ADJUSTMENT AMOUNT (IRMAA) D ARREARAGES DEDUCTED FROM PRIOR MONTH ACCRUAL AMOUNT (PAMT) OR CURRENT AMOUNT (CAMT)

We are deducting past-due prescription drug coverage income-related monthly adjustment amounts from (1) check.

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

your


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900730126
NL 00730.126 - "M" Paragraphs and Captions - 04/15/2015
Batch run: 04/15/2015
Rev:04/15/2015