Identification Number:
NL 00703 TN 77
Intended Audience:See Transmittal Sheet
Originating Office:ORDP OISP
Title:Exhibit and Dictated Letters
Type:POMS Transmittals
Program:Title II (RSI)
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part NL – Notices, Letters and Paragraphs
Chapter 007 – Letters and Paragraphs for Title II, Title XVI, and Title XVIII
Subchapter 03 – Exhibit and Dictated Letters
Transmittal No. 77, 01/03/2019

Audience

PSC: BA, CA, CCRE, CS, DS, ICDS, IES, ILPDS, IPDS, ISRA, NPR, PETE, RECONR, SCPS, TSA, TST;
OCO-OEIO: BET, BIES, BTE, CC, CDT, CR, CTE, EIE, ERE, FDE, PETL, RECONR, RECOVR;
OCO-ODO: BET, BTE, CCE, CR, CST, CT, CTE, CTE TE, DE, DEC, DS, DSE, PAS, PETE, PETL, RCOVTA, RECONE, RECOVR;
FO/TSC: CS, CS TII, CS TXVI, CSR, DRT, FR, OA, OS, RR, TA, TSC-CSR;

Originating Component

OISP

Effective Date

Upon Receipt

Background

The November 2017 BRI run generated approximately 118,000 LESSDO actions. LESSDO notices must be prepared for these receipted actions. Historically PCs have developed local notices for their own AURORA libraries. While these notices are quite similar, slight variations exist. As part of the Processing Center (PC) Automation Initiative, PCs assisted OEST with the development of 6 new exhibit letters that provide standard language to address common LESSDO scenarios. On 08/25/2018, MSS 18-080 OTH announced the new LESSDO exhibit notices were released into AURORA production. These LESSDO notice enhancements create standardized notice language and support our Agency’s effort to improve the way we do business and deliver services. This transmittal aims to ensure technicians receive uniform requesting instructions and publishes the 6 new LESSDO exhibit letters into POMS.

Summary of Changes

NL 00703.012 Usage Chart for HI/SMI Exhibit Letters

Inserted row titled "Premium Collections" between rows titled "Withdrawal" and "Miscellaneous." Added the following 6 new LESSDO exhibit letter to the chart (Document Identifiers: E4030, E4031, E4032, E4033, E4034, E4035).

 

NL 00703.631 Initial LESSDO Notice (MBA Less than SMI Premium)

Added new POMS section to include PC standardized LESSDO exhibit letter (Document Identifier : E4030).

 

NL 00703.632 MBA Less than SMI Premium (LESSDO) - No Prior Year Premium Balance

Added new POMS section to include PC standardized LESSDO exhibit letter (Document Identifier : E4031).

 

NL 00703.633 MBA Less than SMI Premium (LESSDO) - Prior Year Premium Balance Less than 3 Months

Added new POMS section to include PC standardized LESSDO exhibit letter (Document Identifier : E4032).

 

NL 00703.634 MBA Less than SMI Premium (LESSDO) - Prior Year Premium Balance Equals 3 (or more) Months

Added new POMS section to include PC standardized LESSDO exhibit letter (Document Identifier : E4033).

 

NL 00703.635 MBA Less than SMI Premium (LESSDO) - Failure to Bill - More than 6 Months Past Due Premiums

Added new POMS section to include PC standardized LESSDO exhibit letter (Document Identifier : E4034).

 

NL 00703.636 MBA Less than SMI Premium (LESSDO) - Failure to Bill - Equitable Relief Period Ends

Added new POMS section to include PC standardized LESSDO exhibit letter (Document Identifier : E4035).

NL 00703.012 Usage Chart for HI/SMI Exhibit Letters

Type Situation/Exhibit Manual
Section
Document
Identifier For Word Processor
DECLINATION SMI - Processed Declination of Coverage -Beneficiary in Current Pay Status - Refund Due NL 00703.616 E3616
SMI - Processed Declination of Coverage - Beneficiary in Suspense Status - Discard Any Bill For Premiums NL 00703.617 E3617
Beneficiary's Refusal of SMI Coverage Not Acceptable - State is Paying Premiums NL 00703.618 E3618
ENROLLMENT SMI - Reenrollment During the GEP After Prior Enrollment Terminated NL 00703.602 E3602
Enrollment Beyond the Initial Enrollment Period NL 00703.603 E3603
Applied Prior to Beginning of Initial Enrollment Period NL 00703.604 E3604
SMI Denial - Not in GEP or SEP NL 00703.605 E3605
ENTITLEMENT HI/SMI - Reduced HI Premium NL 00703.600 E3600
SMI Only - Eligible for Reduced Premium NL 00703.601 NONE
HI/SMI - Entitled to Mother's or Widow's Benefits - Coverage Based on Disability - Coverage Begins Within 2 Months After COM NL 00703.619 E3619
HI/SMI - Entitled to Mother's or Widow's Benefit - Coverage Based On Disability - Coverage Begins More Than 2 Months After COM NL 00703.620 E3620
HI/SMI - Based on Chronic Renal Provisions NL 00703.621 E3621
INELIGIBLE Ineligible For HI/SMI Coverage Due to DIB Termination NL 00703.622 E3622
Ineligible For HI/SMI Coverage Because DIB Ceased NL 00703.623 E3623
WITHDRAWAL SMI Reversal Request Treated as GEP Enrollment NL 00703.606 E3606
Withdrawal From SMI - Entitlement to CHAMPUS or CHAMPVA NL 00703.625 E3625
PREMIUM COLLECTIONS Initial LESSDO Notice (MBA Less than SMI Premium) NL 00703.631 E4030
MBA Less than SMI Premium (LESSDO) - No Prior Year Premium Balance NL 00703.632 E4031
MBA Less than SMI Premium (LESSDO) - Prior Year Premium Balance Less than 3 Months NL 00703.633 E4032
MBA Less than SMI Premium (LESSDO) - Prior Year Premium Balance Equals 3 (or more) Months NL 00703.634 E4033
MBA Less than SMI Premium (LESSDO) - Failure to Bill - More than 6 Months Past Due Premiums NL 00703.635 E4034
MBA Less than SMI Premium (LESSDO) - Failure to Bill - Equitable Relief Period Ends NL 00703.636 E4035
MISCELLANEOUS New Health Insurance Card - As a Result of Requested Changes NL 00703.609 E3609
Address Change - Returning HI Card NL 00703.610 E3610
DIB to RIB Conversion - Full retirement age PAC Reduction NL 00703.624 E3624
Notice When Claimant Protests Amount of Premium NL 00703.626 E3626
Notice When Claimant's Correspondence Contains an Incorrect Claim Number NL 00703.627 E3627
Notice When Claimant Protests Termination NL 00703.628 E3628
General “Check Box” Notice NL 00703.629 E3629
Government Medicare - Coverage Based on Disability - Coverage Begins More Than 2 Months After COM NL 00703.630 E3630

NL 00703.631 Initial LESSDO Notice (MBA Less than SMI Premium)

Document Identifier for Word Processor: E4030

A. Requesting instructions

This letter is used when the SMI premium deduction reduces the monthly benefit payable (MBP) to less than zero on an initial cash award, at the start of SMI entitlement, or when there is a change in the SMI premium amount. Benefit payments may be suspended S9/LESSDO in single entitlement or dual entitlement cases where payments are separate, see SM 00850.475.

B. Exhibit letter

LIS004

We are writing to give you new information about the (1) benefits which (2) on this Social Security record.

CHKC09

Your Benefits
CHK083

We charge a monthly premium for (1) Medicare medical insurance. The current premium is $(2).

(3) entitled to a monthly benefit of $(4). (5) monthly benefit amount is less than (6) Medicare premium. Starting (7), we will withhold (8) full monthly benefit to pay part of (9) Medicare premium.

HIBC01

Information About Medicare

HIB702

The total premiums due for (1) through (2) are $(3).

After adjusting (4) benefits, (5) will owe $(6) in Medicare premiums. We have enclosed the bill for that amount.

We will continue to bill (7) on a yearly basis as long as (8) monthly benefit is lower than the monthly Medicare medical insurance premium.

CTDO Suspect Social Security Fraud?

Please visit http://oig.ssa.gov/r or call the Inspector General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).

If You Have Questions

We invite you to visit our website at www.socialsecurity.gov on the Internet to find general information about Social Security. If you have any specific questions, you may call us toll-free at 1-800-772-1213, or call your local Social Security office at 1-(3)-(4)-(5). We can answer most questions over the phone. If you are deaf or hard of hearing, you may call our TTY number, 1-800-325-0778. You can also write or visit any Social Security office. The office that serves your area is located at:

(6)

(7)

(8)

(9) (10)-(11)

If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

HBN001 MEDICARE PREMIUM BILL CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)

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. Include your Medicare 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 have any questions concerning this Medicare Premium Bill, please write or visit any Social Security Office.

 

PLEASE DETACH AT DOTTED LINE

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

CMS-500A

 

Medicare Number: (5) Amount Due: $(6)

Name: (7)

 

Make Checks Payable To:

CMS MEDICARE INSURANCE

 

Send To:

Medicare Premium Collection Center

P.O. Box 790355

St. Louis, MO 63179-0355

 

( ) Check here if your address has changed.

Show new address below.

________________________________________

________________________________________

 

PAYMENTS BY CHECK

When you provide a check as a payment, you authorize the Medicare Premium Collection Center (MPCC) to use the information from your check to make a one-time electronic funds transfer from your bank account. When the MPCC uses information from your check to make an electronic funds transfer, they may withdraw funds from your bank account as soon as the same day they receive your payment. You will not get your check back from your bank. If the MPCC cannot process your payment electronically, they will process it as a check transaction. Your bank statement will show the transaction as "CMS Medicare" and this is your proof of payment.

C. Exhibit fill-ins

LIS004

1. Case Number

CHK083

  1. 1. 

    Amended court order

  2. 2. 

    Beneficiary's full Name (possessive)

  3. 3. 

    Month YYYY

  4. 4. 

    Amount

HIB702

  1. 1. 

    Percentage amount/amount of withholding

  2. 2. 

    Percent/Null

  3. 3. 

    Beneficiary's full name

  4. 4. 

    his/her

  5. 5. 

    Amount

  6. 6. 

    Beneficiary's full name

  7. 7. 

    Month DD, YYYY

  8. 8. 

    Name of person/agency

CTDO

  1. 1. 

    Zipcode

  2. 2. 

    Zip+4 or DO Code

  3. 3. 

    Telephone Area Code

  4. 4. 

    Phone Exchange

  5. 5. 

    Phone Number

  6. 6. 

    Local Office Address Line #1

  7. 7. 

    Local Office Address Line #2

  8. 8. 

    Local Office Address Line #3

  9. 9. 

    City & State of Local Office

  10. 10. 

    Local Office Zipcode

  11. 11. 

    Zip+4 of Local Office

HBN001

  1. 1. 

    Billing Date (Equal to the Date of the Notice)

  2. 2. 

    Month YYYY

  3. 3. 

    SMI premiums due

  4. 4. 

    Month DD, YYYY

  5. 5. 

    Medicare Beneficiary Identifier

  6. 6. 

    SMI premiums due

  7. 7. 

    Beneficiary’s Full Name

NL 00703.632 MBA Less than SMI Premium (LESSDO) - No Prior Year Premium Balance

Document Identifier for Word Processor: E4031

A. Requesting instructions

This letter is used when COLA or No COLA applies and there is no premium balance remaining from the previous year (prior year arrearage is paid in full.) See HI 01001.041B.3.a.

B. Exhibit letter

LIS004

We are writing to give you new information about the (1) benefits which (2) on this Social Security record.

 

CHKC09

 

Your Benefits
CHK084

(1) monthly benefit amount is $(2) effective (3) and (4) monthly Medicare medical insurance premium is $(5).

 

HIBC01

Information About Medicare

 

HIB703

Since (1) monthly benefit amount is less than (2) Medicare premium, we will continue to withhold (3) monthly benefits to pay part of (4) Medicare premium. The difference between the premiums (5) for (6) and (7) monthly benefit amount for (8) is $(9).

After adjusting (10) benefits, (11) $(12) in Medicare premiums. We enclosed a bill for that amount and a return envelope.

We will continue to bill (13) on a yearly basis as long as (14) monthly benefit is lower than the monthly Medicare medical insurance premium.

 

CTDO

Suspect Social Security Fraud?

Please visit http://oig.ssa.gov/r or call the Inspector General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).

If You Have Questions

We invite you to visit our website at www.socialsecurity.gov on the Internet to find general information about Social Security. If you have any specific questions, you may call us toll-free at 1-800-772-1213, or call your local Social Security office at 1-(3)-(4)-(5). We can answer most questions over the phone. If you are deaf or hard of hearing, you may call our TTY number, 1-800-325-0778. You can also write or visit any Social Security office. The office that serves your area is located at:

(6)

(7)

(8)

(9) (10)-(11)

If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

 

HBN001 MEDICARE PREMIUM BILL CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)

 

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. Include your Medicare 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 have any questions concerning this Medicare Premium Bill, please write or visit any Social Security Office.

 

PLEASE DETACH AT DOTTED LINE

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

CMS-500A

Medicare Number: (5) Amount Due: $(6)

Name: (7)

 

Make Checks Payable To:

CMS MEDICARE INSURANCE

 

Send To:

Medicare Premium Collection Center

P.O. Box 790355

St. Louis, MO 63179-0355

 

( ) Check here if your address has changed.

Show new address below.

________________________________________

________________________________________

 

PAYMENTS BY CHECK

When you provide a check as a payment, you authorize the Medicare Premium Collection Center (MPCC) to use the information from your check to make a one-time electronic funds transfer from your bank account. When the MPCC uses information from your check to make an electronic funds transfer, they may withdraw funds from your bank account as soon as the same day they receive your payment. You will not get your check back from your bank. If the MPCC cannot process your payment electronically, they will process it as a check transaction. Your bank statement will show the transaction as "CMS Medicare" and this is your proof of payment.

C. Exhibit fill-ins

LIS004

1. Case Number

CHK084
  1. 1. 

    Your, His or Her

  2. 2. 

    Monthly benefit amount

  3. 3. 

    Month YYYY

  4. 4. 

    your, his or her

  5. 5. 

    Current SMI premium amount

HIB703

  1. 1. 

    your, his or her

  2. 2. 

    your, his or her

  3. 3. 

    your, his or her

  4. 4. 

    your, his or her

  5. 5. 

    you owe, he owes or she owes

  6. 6. 

    Month YYYY through Month YYYY

  7. 7. 

    your, his or her

  8. 8. 

    Month YYYY through Month YYYY

  9. 9. 

    Money amount difference

  10. 10. 

    your, his or her

  11. 11. 

    you owe, he owes or she owes

  12. 12. 

    Billing amount

  13. 13. 

    you, him or her

  14. 14. 

    your, his or her

CTDO
  1. 1. 

    Zipcode

  2. 2. 

    Zip+4 or DO Code

  3. 3. 

    Telephone Area Code

  4. 4. 

    Phone Exchange

  5. 5. 

    Phone Number

  6. 6. 

    Local Office Address Line #1

  7. 7. 

    Local Office Address Line #2

  8. 8. 

    Local Office Address Line #3

  9. 9. 

    City & State of Local Office

  10. 10. 

    Local Office Zipcode

  11. 11. 

    Zip+4 of Local Office

HBN001

  1. 1. 

    Billing Date (Equal to the Date of the Notice)

  2. 2. 

    Month YYYY

  3. 3. 

    SMI premiums due

  4. 4. 

    Month DD, YYYY

  5. 5. 

    Medicare Beneficiary Identifier

  6. 6. 

    SMI premiums due

  7. 7. 

    Beneficiary’s Full Name

NL 00703.633 MBA Less than SMI Premium (LESSDO) - Prior Year Premium Balance Less than 3 Months

Document Identifier for Word Processor: E4032

A. Requesting instructions

This letter is used when COLA or No COLA applies, a premium arrearage balance from the prior year(s) exists, and the prior year(s) balance is less than three months premiums at the standard rate. See HI 01001.041B.3.b.

B. Exhibit letter

LIS004

 

We are writing to give you new information about the (1) benefits which (2) on this Social Security record.

 

CHKC09

Your Benefits

 

CHK084 (1) monthly benefit amount is $(2) effective (3) and (4) monthly Medicare medical insurance premium is $(5).

HIBC01

 

Information About Medicare

 

HIB704

Since (1) monthly benefit amount is less than (2) Medicare premium, we will withhold (3) monthly benefits to pay part of (4) Medicare premium. The difference between the premiums (5) for (6) and (7) monthly benefit amount for (8) is $(9).

In addition, our records show that (10) $(11) in past due premiums for (12).

Enclosed is a bill for the total amount due of $(13), and a return envelope. We will continue to bill (14) on a yearly basis as long as (15) monthly benefit is lower than the monthly Medicare medical insurance premium.

 

CTDO

 

Suspect Social Security Fraud?

Please visit http://oig.ssa.gov/r or call the Inspector General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).

If You Have Questions

We invite you to visit our website at www.socialsecurity.gov on the Internet to find general information about Social Security. If you have any specific questions, you may call us toll-free at 1-800-772-1213, or call your local Social Security office at 1-(3)-(4)-(5). We can answer most questions over the phone. If you are deaf or hard of hearing, you may call our TTY number, 1-800-325-0778. You can also write or visit any Social Security office. The office that serves your area is located at:

(6)

(7)

(8)

(9) (10)-(11)

If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

 

HBN001

MEDICARE PREMIUM BILL

CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)

 

 

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. Include your Medicare 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 have any questions concerning this Medicare Premium Bill, please write or visit any Social Security Office.

 

PLEASE DETACH AT DOTTED LINE

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

CMS-500A

 

Medicare Number: (5) Amount Due: $(6)

Name: (7)

 

Make Checks Payable To:

CMS MEDICARE INSURANCE

 

Send To:

Medicare Premium Collection Center

P.O. Box 790355

St. Louis, MO 63179-0355

 

 

( ) Check here if your address has changed.

Show new address below.

________________________________________

________________________________________

 

PAYMENTS BY CHECK

 

When you provide a check as a payment, you authorize the Medicare Premium Collection Center (MPCC) to use the information from your check to make a one-time electronic funds transfer from your bank account. When the MPCC uses information from your check to make an electronic funds transfer, they may withdraw funds from your bank account as soon as the same day they receive your payment. You will not get your check back from your bank. If the MPCC cannot process your payment electronically, they will process it as a check transaction. Your bank statement will show the transaction as "CMS Medicare" and this is your proof of payment.

 

C. Exhibit fill-ins

LIS004

1. Case Number

CHK084

  1. 1. 

    Your, His or Her

  2. 2. 

    Monthly benefit amount

  3. 3. 

    Month YYYY

  4. 4. 

    your, his or her

  5. 5. 

    Current SMI premium amount

HIB704

  1. 1. 

    your, his or her

  2. 2. 

    your, his or her

  3. 3. 

    your, his or her

  4. 4. 

    your, his or her

  5. 5. 

    you owe, he owes or she owes

  6. 6. 

    Month YYYY through Month YYYY

  7. 7. 

    your, his or her

  8. 8. 

    Month YYYY through Month YYYY

  9. 9. 

    Money amount difference

  10. 10. 

    you owe, he owes or she owes

  11. 11. 

    Billing Amount for arrearage

  12. 12. 

    Month YYYY through Month YYYY

  13. 13. 

    Total Billing Amount

  14. 14. 

    you, him or her

  15. 15. 

    your, his or her

 

CTDO

  1. 1. 

    Zipcode

  2. 2. 

    Zip+4 or DO Code

  3. 3. 

    Telephone Area Code

  4. 4. 

    Phone Exchange

  5. 5. 

    Phone Number

  6. 6. 

    Local Office Address Line #1

  7. 7. 

    Local Office Address Line #2

  8. 8. 

    Local Office Address Line #3

  9. 9. 

    City & State of Local Office

  10. 10. 

    Local Office Zipcode

  11. 11. 

    Zip+4 of Local Office

HBN001

  1. 1. 

    Billing Date (Equal to the Date of the Notice)

  2. 2. 

    Month YYYY

  3. 3. 

    SMI premiums due

  4. 4. 

    Month DD, YYYY

  5. 5. 

    Medicare Beneficiary Identifier

  6. 6. 

    SMI premiums due

  7. 7. 

    Beneficiary’s Full Name

NL 00703.634 MBA Less than SMI Premium (LESSDO) - Prior Year Premium Balance Equals 3 (or more) Months

Document Identifier for Word Processor: E4033

A. Requesting instructions

This letter is used when COLA or No COLA applies, a premium arrearage balance from the prior year(s) exists, and the prior year(s) balance is equal to or more than three months premiums at the standard rate. See HI 01001.041B.3.c.

B. Exhibit letter

LIS004

 

We are writing to give you new information about the (1) benefits which (2) on this Social Security record.

 

CHKC09

 

Your Benefits

 

CHK084 (1) monthly benefit amount is $(2) effective (3) and (4) monthly Medicare medical insurance premium is $(5).

 

HIBC01

 

Information About Medicare

 

HIB705

Since (1) monthly benefit amount is less than (2) Medicare premium, we will withhold (3) monthly benefits to pay part of (4) medical insurance premium. The difference between the premiums (5) for (6) and (7) monthly benefit amount for (8) is $(9).

After adjusting benefits, (11) $(12) in Medicare premiums. We enclosed a bill for that amount and a return envelope.

In addition, our records show (13) past due medical insurance premiums of $(14) for (15). (16) must pay this medical insurance premium balance within 3 months of the date of this notice. A separate bill is enclosed for these past-due premiums. If the premium balance is not paid in full, (17) Medicare Part B coverage will stop the last day of (18).

 

CTDO

Suspect Social Security Fraud?

Please visit http://oig.ssa.gov/r or call the Inspector General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).

If You Have Questions

We invite you to visit our website at www.socialsecurity.gov on the Internet to find general information about Social Security. If you have any specific questions, you may call us toll-free at 1-800-772-1213, or call your local Social Security office at 1-(3)-(4)-(5). We can answer most questions over the phone. If you are deaf or hard of hearing, you may call our TTY number, 1-800-325-0778. You can also write or visit any Social Security office. The office that serves your area is located at:

(6)

(7)

(8)

(9) (10)-(11)

If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

 

HBN001

MEDICARE PREMIUM BILL

CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)

 

 

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. Include your Medicare 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 have any questions concerning this Medicare Premium Bill, please write or visit any Social Security Office.

 

PLEASE DETACH AT DOTTED LINE

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

CMS-500A

 

Medicare Number: (5) Amount Due: $(6)

Name: (7)

 

Make Checks Payable To:

CMS MEDICARE INSURANCE

 

Send To:

Medicare Premium Collection Center

P.O. Box 790355

St. Louis, MO 63179-0355

 

 

( ) Check here if your address has changed.

Show new address below.

________________________________________

________________________________________

 

PAYMENTS BY CHECK

When you provide a check as a payment, you authorize the Medicare Premium Collection Center (MPCC) to use the information from your check to make a one-time electronic funds transfer from your bank account. When the MPCC uses information from your check to make an electronic funds transfer, they may withdraw funds from your bank account as soon as the same day they receive your payment. You will not get your check back from your bank. If the MPCC cannot process your payment electronically, they will process it as a check transaction. Your bank statement will show the transaction as "CMS Medicare" and this is your proof of payment.

 

HBN001

MEDICARE PREMIUM BILL

CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)

 

 

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. Include your Medicare 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 have any questions concerning this Medicare Premium Bill, please write or visit any Social Security Office.

 

PLEASE DETACH AT DOTTED LINE

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

CMS-500A

 

Medicare Number: (5) Amount Due: $(6)

Name: (7)

 

Make Checks Payable To:

CMS MEDICARE INSURANCE

 

Send To:

Medicare Premium Collection Center

P.O. Box 790355

St. Louis, MO 63179-0355

 

( ) Check here if your address has changed.

Show new address below.

________________________________________

________________________________________

 

PAYMENTS BY CHECK

When you provide a check as a payment, you authorize the Medicare Premium Collection Center (MPCC) to use the information from your check to make a one-time electronic funds transfer from your bank account. When the MPCC uses information from your check to make an electronic funds transfer, they may withdraw funds from your bank account as soon as the same day they receive your payment. You will not get your check back from your bank. If the MPCC cannot process your payment electronically, they will process it as a check transaction. Your bank statement will show the transaction as "CMS Medicare" and this is your proof of payment.

C. Exhibit fill-ins

LIS004

1. Case Number

CHK084

  1. 1. 

    Your, His or Her

  2. 2. 

    Monthly benefit amount

  3. 3. 

    Month YYYY

  4. 4. 

    your, his or her

  5. 5. 

    Current SMI premium amount

HIB705

  1. 1. 

    your, his or her

  2. 2. 

    your, his or her

  3. 3. 

    your, his or her

  4. 4. 

    your, his or her

  5. 5. 

    you owe, he owes or she owes

  6. 6. 

    Month YYYY through Month YYYY

  7. 7. 

    your, his or her

  8. 8. 

    Month YYYY through Month YYYY

  9. 9. 

    Money amount difference

  10. 10. 

    your, his or her

  11. 11. 

    you owe, he owes or she owes

  12. 12. 

    Billing Amount

  13. 13. 

    you owe, he owes or she owes

  14. 14. 

    Past due premiums amount

  15. 15. 

    Month YYYY through Month YYYY

  16. 16. 

    You, He or She

  17. 17. 

    your, his or her

  18. 18. 

    Third Month from Date of Notice

CTDO

  1. 1. 

    Zipcode

  2. 2. 

    Zip+4 or DO Code

  3. 3. 

    Telephone Area Code

  4. 4. 

    Phone Exchange

  5. 5. 

    Phone Number

  6. 6. 

    Local Office Address Line #1

  7. 7. 

    Local Office Address Line #2

  8. 8. 

    Local Office Address Line #3

  9. 9. 

    City & State of Local Office

  10. 10. 

    Local Office Zipcode

  11. 11. 

    Zip+4 of Local Office

HBN001

  1. 1. 

    Billing Date (Equal to the Date of the Notice)

  2. 2. 

    Month YYYY

  3. 3. 

    SMI premiums due

  4. 4. 

    Month DD, YYYY

  5. 5. 

    Medicare Beneficiary Identifier

  6. 6. 

    SMI premiums due

  7. 7. 

    Beneficiary’s Full Name

NL 00703.635 MBA Less than SMI Premium (LESSDO) - Failure to Bill - More than 6 Months Past Due Premiums

Document Identifier for Word Processor: E4034

A. Requesting instructions

This letter is used when a claimant has been awarded SMI coverage and has received notification of entitlement but SSA failed to send a billing notice.

B. Exhibit letter

LIS004

 

We are writing to give you new information about the (1) benefits which (2) on this Social Security record.

 

CHKC09

 

Your Benefits

CHK084

(1) monthly benefit amount is $(2) effective (3) and (4)

monthly Medicare medical insurance premium is $(5).

 

HIBC01

 

Information About Medicare

 

HIB706

 

Since (#1) monthly benefit amount is less than (#2) Medicare premium, we will withhold (#3) monthly benefits to pay part of (#4) medical insurance premium. The difference between the premiums (#5) for (#6) and (#7) monthly benefit amount for (#8) is $(#9).

After adjusting (#10) benefits, (#11) $(#12) in Medicare

premiums. We enclosed a bill for that amount and a return envelope.

In addition, our records show (#13) not been billed for several months of past Medicare coverage. This error has now been corrected. (#14) $(#15) for unpaid past premiums. Within 30 days, we will bill (#16) for these past premiums. If paying the past due amount will create a severe hardship for (#17), contact the local Social Security office. (#18) may be able to request relief from this payment or arrange an alternate method of payment.

 

CTDO Suspect Social Security Fraud?

Please visit http://oig.ssa.gov/r or call the Inspector General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).

If You Have Questions

We invite you to visit our website at www.socialsecurity.gov on the Internet to find general information about Social Security. If you have any specific questions, you may call us toll-free at 1-800-772-1213, or call your local Social Security office at 1-(3)-(4)-(5). We can answer most questions over the phone. If you are deaf or hard of hearing, you may call our TTY number, 1-800-325-0778. You can also write or visit any Social Security office. The office that serves your area is located at:

(6)

(7)

(8)

(9) (10)-(11)

If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

 

HBN001

MEDICARE PREMIUM BILL

CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)

 

 

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. Include your Medicare 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 have any questions concerning this Medicare Premium Bill, please write or visit any Social Security Office.

 

PLEASE DETACH AT DOTTED LINE

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

CMS-500A

 

Medicare Number: (5) Amount Due: $(6)

Name: (7)

 

Make Checks Payable To:

CMS MEDICARE INSURANCE

 

Send To:

Medicare Premium Collection Center

P.O. Box 790355

St. Louis, MO 63179-0355

 

( ) Check here if your address has changed.

Show new address below.

________________________________________

________________________________________

 

PAYMENTS BY CHECK

When you provide a check as a payment, you authorize the Medicare Premium Collection Center (MPCC) to use the information from your check to make a one-time electronic funds transfer from your bank account. When the MPCC uses information from your check to make an electronic funds transfer, they may withdraw funds from your bank account as soon as the same day they receive your payment. You will not get your check back from your bank. If the MPCC cannot process your payment electronically, they will process it as a check transaction. Your bank statement will show the transaction as "CMS Medicare" and this is your proof of payment.

 

C. Exhibit fill-ins

LIS004

1. Case Number

CHK084

  1. 1. 

    Your, His or Her

  2. 2. 

    Monthly benefit amount

  3. 3. 

    Month YYYY

  4. 4. 

    your, his or her

  5. 5. 

    Current SMI premium amount

HIB706

  1. 1. 

    your, his or her

  2. 2. 

    your, his or her

  3. 3. 

    your, his or her

  4. 4. 

    your, his or her

  5. 5. 

    you owe, he owes or she owes

  6. 6. 

    Month YYYY through Month YYYY

  7. 7. 

    your, his or her

  8. 8. 

    Month YYYY through Month YYYY

  9. 9. 

    Money amount difference

  10. 10. 

    your, his or her

  11. 11. 

    you owe, he owes or she owes

  12. 12. 

    Billing Amount

  13. 13. 

    you have, he has or she has

  14. 14. 

    You owe, He owes or She owes

  15. 15. 

    Billing Amount

  16. 16. 

    you, him or her

  17. 17. 

    you, him or her

  18. 18. 

    You, He or She

CTDO

  1. 1. 

    Zipcode

  2. 2. 

    Zip+4 or DO Code

  3. 3. 

    Telephone Area Code

  4. 4. 

    Phone Exchange

  5. 5. 

    Phone Number

  6. 6. 

    Local Office Address Line #1

  7. 7. 

    Local Office Address Line #2

  8. 8. 

    Local Office Address Line #3

  9. 9. 

    City & State of Local Office

  10. 10. 

    Local Office Zipcode

  11. 11. 

    Zip+4 of Local Office

HBN001

  1. 1. 

    Billing Date (Equal to the Date of the Notice)

  2. 2. 

    Month YYYY

  3. 3. 

    SMI premiums due

  4. 4. 

    Month DD, YYYY

  5. 5. 

    Medicare Beneficiary Identifier

  6. 6. 

    SMI premiums due

  7. 7. 

    Beneficiary’s Full Name

NL 00703.636 MBA Less than SMI Premium (LESSDO) - Failure to Bill - Equitable Relief Period Ends

Document Identifier for Word Processor: E4035

A. Requesting instructions

This letter is used when no past-due premium remittance is received and the equitable relief period ends.

B. Exhibit letter

LIS004

 

We are writing to give you new information about the (1) benefits which (2) on this Social Security record.

 

HIBC01

 

Information About Medicare

 

HIB707

We told you in our letter dated (1), our records show you did not receive a bill for Medicare medical insurance premiums owed for (2). In our previous letter, we explained you could contact your local Social Security office if paying the past due amount would create a severe hardship for (3).

We have not received a request for relief or a request for an alternate method of payment. Therefore, we must bill (4) for $(5) in past due Medicare medical insurance premiums and $(6) for (7). We are enclosing a bill for $(8), which represents all premiums due for (9).

If the full payment of $(10) for premiums owed through (11) is not received by (12), (13) Medicare Part B will end on (14) which is the last day of the third month following the month of this notice.

 

CTDO

Suspect Social Security Fraud?

Please visit http://oig.ssa.gov/r or call the Inspector General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).

If You Have Questions

We invite you to visit our website at www.socialsecurity.gov on the Internet to find general information about Social Security. If you have any specific questions, you may call us toll-free at 1-800-772-1213, or call your local Social Security office at 1-(3)-(4)-(5). We can answer most questions over the phone. If you are deaf or hard of hearing, you may call our TTY number, 1-800-325-0778. You can also write or visit any Social Security office. The office that serves your area is located at:

(6)

(7)

(8)

(9) (10)-(11)

If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

 

HBN001

MEDICARE PREMIUM BILL

CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)

 

 

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. Include your Medicare 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 have any questions concerning this Medicare Premium Bill, please write or visit any Social Security Office.

 

PLEASE DETACH AT DOTTED LINE

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

CMS-500A

 

Medicare Number: (5) Amount Due: $(6)

Name: (7)

 

Make Checks Payable To:

CMS MEDICARE INSURANCE

 

Send To:

Medicare Premium Collection Center

P.O. Box 790355

St. Louis, MO 63179-0355

 

( ) Check here if your address has changed.

Show new address below.

________________________________________

________________________________________

 

PAYMENTS BY CHECK

When you provide a check as a payment, you authorize the Medicare Premium Collection Center (MPCC) to use the information from your check to make a one-time electronic funds transfer from your bank account. When the MPCC uses information from your check to make an electronic funds transfer, they may withdraw funds from your bank account as soon as the same day they receive your payment. You will not get your check back from your bank. If the MPCC cannot process your payment electronically, they will process it as a check transaction. Your bank statement will show the transaction as "CMS Medicare" and this is your proof of payment.

 

C. Exhibit fill-ins

LIS004

1. Case Number

HIB707

  1. 1. 

    Month DD, YYYY

  2. 2. 

    Month YYYY through Month YYYY

  3. 3. 

    you or Beneficiary’s name

  4. 4. 

    you, him or her

  5. 5. 

    Past due arrearage

  6. 6. 

    Current premium due

  7. 7. 

    Month YYYY through Month YYYY

  8. 8. 

    Total billing amount

  9. 9. 

    Month YYYY through Month YYYY

  10. 10. 

    Total billing amount

  11. 11. 

    last month of the past due premium arrearage

  12. 12. 

    Last day of third month after date of notice

  13. 13. 

    your, his or her

  14. 14. 

    Last day of third month after date of notice

CTDO

  1. 1. 

    Zipcode

  2. 2. 

    Zip+4 or DO Code

  3. 3. 

    Telephone Area Code

  4. 4. 

    Phone Exchange

  5. 5. 

    Phone Number

  6. 6. 

    Local Office Address Line #1

  7. 7. 

    Local Office Address Line #2

  8. 8. 

    Local Office Address Line #3

  9. 9. 

    City & State of Local Office

  10. 10. 

    Local Office Zipcode

  11. 11. 

    Zip+4 of Local Office

HBN001

  1. 1. 

    Billing Date (Equal to the Date of the Notice)

  2. 2. 

    Month YYYY

  3. 3. 

    SMI premiums due

  4. 4. 

    Month DD, YYYY

  5. 5. 

    Medicare Beneficiary Identifier

  6. 6. 

    SMI premiums due

  7. 7. 

    Beneficiary’s Full Name


NL 00703 TN 77 - Exhibit and Dictated Letters - 1/03/2019