Identification Number:
NL 00720 TN 27
Intended Audience:See Transmittal Sheet
Originating Office:Systems
Title:Manual Adjustment, Credit and Award Process (MADCAP) Beneficiary Notice Print Program
Type:POMS Full Transmittals
Program:All Programs
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 20 – Manual Adjustment, Credit and Award Process (MADCAP) Beneficiary Notice Print Program
Transmittal No. 27, 01/09/2023

Audience

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

Originating Component

OEIS

Effective Date

Upon Receipt

Background

We are updating Program Operations Manual System (POMS) sections in NL 00720 effective with Manual Adjustment Credit and Award Process (MADCAP) October 2022 release. Language changes for notices in the attached sections are a direct result of updates requested by Policy and the Centers for Medicare and Medicaid Services (CMS) for the Consolidated Appropriations Act .

Summary of Changes

NL 00720.007 List of Captions for MADCAP

We introduced new MADCAP captions that assist with incorporating the new language updates for claimants entitled or potentially entitled to Supplemental Medical Insurance Premium Beneficiary Immunosuppressive Drug (SMI-PBID) Medicare coverage.

NL 00720.065 BRR Beneficiary Reporting Responsibility

We introduced a new MADCAP (Universal Text Identifier) UTI BRR084 to inform beneficiaries of their reporting responsibilities when entitled to SMI-PBID

NL 00720.145 ENT Entitlement

We introduced a new MADCAP UTI ENT082 to inform beneficiaries of their entitlement to SMI-PBID Medicare coverage.

NL 00720.180 HIB Health Insurance Benefits

We introduced new MADCAP UTIs and revised several existing UTIs incorporate the new SMI-PBID provisions. We revised HIB183, HIB184, HIB186, HIB193, HIB194 and HIB220 to incorporate the new SMI- PBID provisions.

NL 00720.007 List of Captions for MADCAP

CAPTION TEXT

TNA/ AURORA UTI

A PENALTY WILL BE DEDUCTED FROM PAYMENTS

PENC02

ABOUT THE APPEALS

ALSC26

APPLY FOR MEDICARE

HIBC20

BENEFIT OFFSET NATIONAL DEMONSTRATION (BOND)

DIBC12

DO YOU THINK THAT YOU DO NOT OWE THIS MONEY?

RCYC02

DO YOU THINK WE ARE WRONG ABOUT THE OVERPAYMENT?

ALSC06

DO YOU THINK WE ARE WRONG?

ALSC01

HEALTH INSURANCE FOR CHILDREN

HIBC02

HOW THE HEARING PROCESS WORKS

ALSC05

HOW TO APPLY FOR IMMUNOSUPPRESSIVE DRUG COVERAGE

HIBC14

HOW TO ASK US TO REVIEW THE DETERMINATION ON THE FEE AGREEMENT

ATYC02

HOW TO ASK US TO REVIEW THE FEE

ATYC05

HOW TO PAY US BACK

RCYC01

HOW TO PAY US BACK

OPTC05

IF YOU ASK FOR A RECONSIDERATION AND A HEARING

ALSC28

IF YOU DISAGREE WITH THE COURT ORDER

GARC01

IF YOU DISAGREE WITH THE DECISIONS

ALSC04

IF YOU HAVE ANY QUESTIONS

REFC01

IF YOU HAVE QUESTIONS ABOUT THE BOND PROJECT

REFC05

IF YOU HAVE QUESTIONS THAT ARE NOT ABOUT THE BOND PROJECT

REFC06

IF YOU NEED COVERAGE FOR IMMUNOSUPPRESSIVE DRUGS ONLY

HIBC16

IF YOU NEED HEALTH COVERAGE THROUGH MARKETPLACE OR MEDICAID

HIBC21

IF YOU NEED HELP WITH COSTS FOR THE IMMUNOSUPPRESSIVE DRUG COVERAGE

HIBC18

IF YOU NEED IMMUNOSUPPRESSIVE DRUG COVERAGE IN THE FUTURE

HIBC17

IF YOU SAVE ANY MONEY

CFDC02

IF YOU THINK YOU SHOULD NOT HAVE TO PAY US BACK

WAVC01

IF YOU WANT HELP WITH YOUR APPEAL

REPC01

IF YOU WANT TO APPEAL

ALSC27

INFORMATION ABOUT HEALTH PLAN AND PRESCRIPTION DRUG PLAN COSTS

MHPC04

INFORMATION ABOUT HEALTH PLAN PREMIUMS

MHPC02

INFORMATION ABOUT REPRESENTATIVES FEES

ATYC01

INFORMATION ABOUT MEDICARE

HIBC01

INFORMATION ABOUT MEDICARE PRESCRIPTION DRUG PLAN COSTS

MHPC03

INFORMATION ABOUT MILITARY SERVICE

MSVC01

INFORMATION ABOUT OTHER DISABILITY BENEFITS

DIBC09

INFORMATION ABOUT PAST-DUE BENEFITS WITHHELD TO PAY A REPRESENTATIVE

ATYC03

INFORMATION ABOUT THE CLARK COURT CASE

FUGC06

INFORMATION ABOUT THE MARTINEZ SETTLEMENT

FUGC05

INFORMATION ABOUT THE PRESCRIPTION DRUG COVERAGE INCOME-RELATED MONTHLY ADJUSTMENT AMOUNT

MPDC31

INFORMATION ABOUT WORK AND EARNINGS

ERNC09

INFORMATION ABOUT YOUR INSTALLMENT PAYMENT

ASTC02

INFORMATION WE NEED FROM YOU

SUSC04

IT IS IMPORTANT TO GO TO THE HEARING

ALSC08

OTHER INFORMATION

COPC01

OTHER SOCIAL SECURITY BENEFITS

CLOC01

PRESCRIPTION DRUG PLAN ENROLLMENT

MPDC19

REDUCTION TO COLLECT YOUR SSI OVERPAYMENT

RCYC05

RULES FOR LAWFUL PRESENCE IN THE U.S.

INFC09

RULES UNDER THE NEW LAW

RNSC02

THE BASIS FOR OUR DECISION

DIBC02

THE DATE YOU BECAME DISABLED

DIBC01

THINGS TO REMEMBER

INFC08

WE CONSIDERED FOREIGN CREDITS

TOTC01

WHAT HAPPENS WHEN THE SPECIAL RULES FOR BOND NO LONGER APPLY

INFC50

WHAT WE WILL PAY

PAYC38

WHAT WE WILL PAY AND WHEN

PAYC01

WHAT YOU NEED TO DO

INFC06

WHEN PROVISIONAL BENEFITS END

XRPC01

WHEN WE BEGIN YOUR PAYMENTS

CHKC11

WHY WE ARE DELAYING YOUR PAYMENTS

CHKC03

WHY WE BEGIN YOUR PAYMENTS

PAYC39

WHY WE CANNOT PAY YOU

CHKC01

WHY YOUR BENEFITS ENDED

BENC17

WHY YOUR PROVISIONAL BENEFITS ENDED

XRPC02

YOU MAY BE DUE MORE BENEFITS

AETC02

YOUR BENEFITS

CHKC09

YOUR RESPONSIBILITIES

INFC02

YOUR SSI PAYMENTS MAY CHANGE

ATYC04

NL 00720.065 BRR Beneficiary Reporting Responsibility

BRR004 RIGHTS AND RESPONSIBILITIES RSI, DOMESTIC OR FOREIGN (G34)

(System Generated)

Caption: Your Responsibilities

 (1)  benefits are based on the information  (2)  gave us. If this information changes, it could affect  (3)  benefits. For this reason, it is important that you report changes to us right away.

We have enclosed a pamphlet,  (4)  . It tells you what must be reported and how to report.  (5) 


Fill-in values:
Fill-in (1)
Choice 1: Mr. Beneficiary's Name possessive
Choice 2: Ms. Beneficiary's Name possessive
Choice 3: Beneficiary's Name possessive
Choice 4: Your
Fill-in (2)
Choice 1: he
Choice 2: she
Choice 3: you
Fill-in (3)
Choice 1: his
Choice 2: her
Choice 3: you
Fill-in (4)
Choice 1: "Your Payments While You Are Outside the United States"
Choice 2: "What You Need To Know When You Get Retirement Or Survivors Benefits"
Choice 3: "What You Need To Know When You Get Social Security Disability Benefits"
Fill-in (5)
Choice 1: NULL

BRR006 DISABILITY IMPROVEMENT INFORMATION (G12)

(System Generated)

Caption: Things To Remember

If  (1)  health gets worse and you think  (2)  disabled before  (3)  full retirement age,  (4)   (5)   (6)   (7)  , you should contact us about applying again for disability benefits. Also, please get in touch with us three months before  (8)  age 62 to find out whether  (9)  for retirement benefits.


Fill-in values:
Fill-in (1)
Choice 1: Beneficiary's Last Name
Choice 2: you
Fill-in (2)
Choice 1: she is
Choice 2: he is
Choice 3: you are
Fill-in (3)
Choice 1: she reaches
Choice 2: he reaches
Choice 3: you reach
Fill-in (4)
Choice 1: full retirement age at which FRA is effective (without additional months, if applicable) in the format: 65
Fill-in (5)
Choice 1: and
Choice 2: null
Fill-in (6)
Choice 1: If present, show additional FRA months in the format: 2
Choice 2: null
Fill-in (7)
Choice 1: months
Choice 2: null
Fill-in (8)
Choice 1: she reaches
Choice 2: he reaches
Choice 3: you reach
Fill-in (9)
Choice 1: she qualifies
Choice 2: you qualify
Choice 3: he qualifies

BRRO06 INDIVIDUAL AGE 62-65 (NO RIB CLAIM FILED) (T26)

(Requested)

Caption: Things To Remember

If  (1)  health gets worse and you think  (2)  disabled before  (3)  full retirement age,  (4)   (5)   (6)   (7)  , you should contact us about applying again for disability benefits. Also, please get in touch with us three months before  (8)  age 62 to find out whether  (9)  for retirement benefits.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary's Last name
Choice 2: you
Fill-in (2) - Systems Generated
Choice 1: she is
Choice 2: he is
Choice 3: you are
Fill-in (3) - Systems Generated
Choice 1: she reaches
Choice 2: he reaches
Choice 3: you reach
Fill-in (4) - Systems Generated
Choice 1: full retirement age at which FRA is effective (without additional months, if applicable) in the format: 65
Fill-in (5) - Systems Generated
Choice 1: and
Choice 2: null
Fill-in (6) - Systems Generated
Choice 1: If present, show additional FRA months in the format: 2
Choice 2: null
Fill-in (7) - Systems Generated
Choice 1: months
Choice 2: null
Fill-in (8) - Systems Generated
Choice 1: she reaches
Choice 2: he reaches
Choice 3: you reach
Fill-in (9) - Systems Generated
Choice 1: she qualifies
Choice 2: you qualify
Choice 3: he qualifies

BRR016 RIGHTS AND RESPONSIBILITIES NON-DIB, RRB DOM. OR FOR (G35)

(System Generated)

Caption: Your Responsibilities

The decisions we made on your claim are based on information you gave us. If this information changes, it could affect your benefits. For this reason, it is important that you report changes to us or to the Railroad Retirement Board right away. We have enclosed a pamphlet which tells you what must be reported and how to report.


Fill-in values:

 

NONE

BRR026 REPORTING RESPONSIBILITIES - PROVISIONAL BENEFITS (P11)

(Requested)

Caption: Your Responsibilities

You must tell us right away about any changes that may affect  (1)  benefits. You should tell us if:

  •  (2)  mailing address;

  •  (3)  to work or  (4)  work hours;

  •  (5)  doctor says  (6)  condition has improved;

  •  (7)  to leave the United States for 30 days or more;

  •  (8)  been convicted of a criminal offense; or

  •  (9)  benefits have been reinstated as either a disabled widow/widower or a disabled adult child.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Choice 4: null
Fill-in (2) - Systems Generated
Choice 1: You change your
Choice 2: He changes his
Choice 3: She changes her
Fill-in (3) - Systems Generated
Choice 1: You return
Choice 2: He returns
Choice 3: She returns
Fill-in (4) - Systems Generated
Choice 1: you increase your
Choice 2: he increases his
Choice 3: she increases her
Fill-in (5) - Systems Generated
Choice 1:Your
Choice 2: His
Choice 3: Her
Fill-in (6) - Systems Generated
Choice 1:Your
Choice 2: His
Choice 3: Her
Fill-in (7) - Systems Generated
Choice 1: You plan
Choice 2: He plans
Choice 3: She plans
Fill-in (8) - Systems Generated
Choice 1: You have
Choice 2: He has
Choice 3: She has
Fill-in (9) - Systems Generated
Choice 1: You marry and your
Choice 2: He marries and his
Choice 3: She marries and her

BRR040 FACILITY OF PAYMENT WORKER'S RESPONSIBILITIES (G36)

(System Generated)

Caption: Your Responsibilities

Please let us know if any of the following things happen:

  • The amount of money  (1)   (2)  to make changes; or

  • Another family member starts working; or

  • A family member moves out of the household.

The way we pay benefits could change if any of these things happen.


Fill-in values:
Fill-in (1)
Choice 1: you
Choice 2: she
Choice 3: he
Fill-in (2)
Choice 1: expects
Choice 2: expects

BRR057 RIB BENEFITS AT 62 MAY BE HIGHER FOR FAMILY THAN DIB (J72)

(Requested)

Caption: Things To Remember

You should get in touch with us about 3 months before  (1)   (2)  age 62. At that time, you can find out whether  (3)  family would receive higher benefits if  (4)  for retirement benefits.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary's Name
Choice 2: you
Fill-in (2) - Systems Generated
Choice 1: reach
Choice 2: reaches
Fill-in (3) - Systems Generated
Choice 1: your
Choice 2: her
Choice 3: his
Fill-in (4) - Systems Generated
Choice 1: you file
Choice 2: he files
Choice 3: she files

BRR075 REMINDER TO INCLUDE CLAIM NUMBER ON CORRESPONDENCE (G80)

(System Generated)

Caption: If You Disagree With The Decision

Always give  (1)  Social Security claim number on any letter or notice you send about  (2)  claim.


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

BRR076 REMINDER TO KEEP LETTER AS PERMANENT RECORD (G81)

(System Generated)

Caption: If You Disagree With The Decision

KEEP AS A PERMANENT RECORD – DO NOT DESTROY


Fill-in values:

 

NONE

BRR078 (WB6) BOND

Caption:

(System Generated)

Because of  (1)  work and earnings, no benefits are payable to you at this time under the rules of the Benefit Offset National Demonstration (BOND) project. If  (2)  work or earnings change, we may be able to pay some benefits in the future.


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

BRR079 (WB7) BOND

Caption:

(System Generated)

Because of  (1)  work and earnings, benefits are payable to you at this time under the rules of the Benefit Offset National Demonstration (BOND) project. If  (2)  work or earnings change, some benefits may not be payable in the future.


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

BRR080 REMINDER TO REPORT CHANGES IN WORK OR EARNINGS (W67)

(Requested)

Caption: Your Responsibilities

Please be sure to let us know right away if  (1)  work or earnings change, because changes could affect the amount of  (2)  benefits.


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

BRR084 REPORTING RESPONSIBILITIES FOR SUPPLEMENTAL MEDICAL INSURANCE PREMIUM IMMUNOSUPPRESSIVE DRUG BENEFICIARIES

(Systems Generated)

Caption: Your Responsibilities

Call Social Security at 1-877-465-0355 between 8:30 a.m. – 6:00 p.m. EST, Monday through Friday, within 60 days of signing up for certain other health insurance coverage. You can’t keep the immunosuppressive drug benefit once your other coverage starts.

BRRR13 CURRENT YEAR S.E.I. USED PENDING RECEIPT OF TAX RETURN (C06)

(Requested)

Caption: Your responsibility

 (1)  benefits are partly based on self-employment income for  (2)  . As soon as the taxable year is over,  (3)  should report this income on a Federal tax return.

Then, you must send us a copy of the return. Also, send us a cancelled check or other proof to show that  (4)  filed the return. Otherwise, we will stop  (5)  benefits and ask you to return any money we have sent you.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Your
Choice 2: Her
Choice 3: His
Fill-in (2) - Requested As A Year In Format CCYY
Choice 1: Year
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (5) - Systems Generated
Choice 1: your
Choice 2: her
Choice 3: his

NL 00720.145 ENT Entitlement

ENT001 STUDENT ENFORCEMENT (B22)

(System Generated)

Caption: Your Responsibility

We are writing to let you know that  (1)   (2)  for child's payments as a student. Based on the information we have,  (3)  benefits will continue through  (4)  . We will send another letter when we stop  (5)  benefits.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name possessive
Fill-in (2) - Systems Generated
Choice 1: qualify
Choice 2: qualifies
Fill-in (3) - Systems Generated
Choice 1: your
Choice 2: her
Choice 3: his
Fill-in (4) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (5) - Systems Generated
Choice 1: your
Choice 2: her
Choice 3: his

ENT015 RIB ALLOWANCE SUBSEQUENT DIB DENIAL (J17)

(Requested)

Caption: Other Social Security Benefits

Although  (1)  cannot receive disability benefits,  (2)  still entitled to retirement benefits.


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

ENT027 DUAL ENTITLEMENT AWARD — PRIMARY AND AUXILIARY/SURVIVOR BENEFITS AWARDED SIMULTANEOUSLY — ONE NOTICE SENT (A38)

(Requested)

Caption: None

 (1)  entitled to monthly  (2)  benefits beginning  (3)  .  (4)  also entitled to  (5)  benefits on the record of  (6)  beginning  (7)  .


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: You are
Choice 2: He is
Choice 3: She is
Fill-in (2) - Systems Generated
Choice 1: disability
Choice 2: retirement
Fill-in (3) - Systems Generated
Choice 1: MM/CCYY
Fill-in (4) - Systems Generated
Choice 1: You are
Choice 2: He is
Choice 3: She is
Fill-in (5) - Requested As A One Position Alpha Character
Choice 1: (A) wife's
Choice 2: (B) husband's
Choice 3: (C) widow's
Choice 4: (D) widower's
Choice 5: (E) mother's
Choice 6: (F) father's
Choice 7: (G) disabled widow's
Choice 8: (H) disabled widower's
Choice 9: (I) disabled divorced widow's
Choice 10: (J) disabled divorced widower's
Choice 11: (K) Child's
Fill-in (6) - Requested
Choice 1: Number holder's name on the other record
Fill-in (7) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY

ENT028 DUAL ENTITLEMENT - PRIMARY AWARD - SIMULTANEOUS ENTITLEMENT TO AUXILIARY/SURVIVOR BENEFITS - SEPARATE PAYMENTS (A40)

(Requested)

Caption: Your Benefits

 (1)  also entitled to  (2)  benefits on the record of  (3)  beginning  (4)  . We are sending  (5)  another letter about these benefits.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: You are
Choice 2: He is
Choice 3: She is
Fill-in (2) - Requested As A One Position Alpha Character
Choice 1: (A) wife's
Choice 2: (B) husband's
Choice 3: (C) widow's
Choice 4: (D) widower's
Choice 5: (E) mother's
Choice 6: (F) father's
Choice 7: (G) disabled widow's
Choice 8: (H) disabled widower's
Choice 9: (I) disabled divorce widow's
Choice 10: (J) disabled divorced widower's
Choice 11: (K) Child's
Fill-in (3) - Requested
Choice 1: Number holder on the other record
Fill-in (4) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (5) - Systems Generated
Choice 1: you
Choice 2: her
Choice 3: him

ENT029 DUAL ENTITLEMENT AUXILIARY/SURVIVOR AWARD - SIMULTANEOUS ENTITLEMENT ON PRIMARY RECORD - SEPARATE PAYMENTS (A41)

(Requested)

Caption: Your Benefits

 (1)  also entitled to benefits on  (2)  own earnings record beginning  (3)  . We are sending  (4)  another letter about these benefits.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: You are
Choice 2: He is
Choice 3: She is
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: her
Choice 3: his
Fill-in (3) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (4) - Systems Generated
Choice 1: you
Choice 2: her
Choice 3: him

ENT038 BENEFITS REDUCED TO ZERO UNDER DIB FAMILY MAXIMUM PROVISIONS (J74)

(Requested/Generated)

Caption: Your Benefits

We have approved  (1)  application for  (2)  benefits.  (3)  entitlement date is  (4)  . However, we cannot pay  (5)  any benefits because all of the money we can pay on this record is already being paid to  (6)  .


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Your
Choice 2: Full name possessive
Fill-in (2) - Requested As A One Position Alpha Character
Choice 1: (A) spouse's
Choice 2: (B) child's
Choice 3: (C) parent's
Fill-in (3) - Systems Generated
Choice 1: His
Choice 2: Her
Choice 3: Your
Fill-in (4) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY (DOEC)
Fill-in (5) - Systems Generated
Choice 1: you
Choice 2: her
Choice 3: him
Fill-in (6) - Requested As A Language
Choice 1: Number holders full name

ENT048 ACCRUED BENEFITS TEMPORARILY WITHHELD PENDING FINAL RECOMMENDATION (B23)

(Requested)

Caption: Your Benefits

We are withholding payment for  (1)  until we decide the best way

to make payments.


Fill-in values:
Fill-in (1) - Requested As A Date In Format Shown Below
Choice 1: MM/YYYY
Choice 2: MM/YYYY and MM/YYYY
Choice 3: MM/YYYY through MM/YYYY

ENT051 HI DATE OF ENTITLEMENT (H10)

(Requested/Generated)

Caption: Information About Medicare

You are entitled to hospital insurance under Medicare beginning  (1)  .


Fill-in values:
Fill-in (1) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY

ENT052 SMI DATE OF ENTITLEMENT (H12)

(Requested/Generated))

Caption: Information About Medicare

You are entitled to medical insurance under Medicare beginning  (1)  .


Fill-in values:
Fill-in (1) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY

ENT056 NO PAYMENT AWARD ENTITLED TO AN EQUAL OR LARGER BENEFIT ON ANOTHER RECORD (B41)

(Requested)

Caption: Your Benefits

We approved  (1)  claim for  (2)  benefits. However, we cannot pay  (3)  on  (4)  record because  (5)  entitled to an equal or larger benefit on another Social Security record.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Fill-in (2) - Requested As A One Position Alpha Character
Choice 1: (A) wife's
Choice 2: (B) husband's
Choice 3: (C) widow's
Choice 4: (D) widower's
Choice 5: (E) mother's
Choice 6: (F) father's
Choice 7: (G) disabled widow's
Choice 8: (H) disabled widower's
Choice 9: (I) disabled divorced widow's
Choice 10: (J) disabled divorced widower's
Choice 11: (K) child's
Fill-in (3) - Systems Generated
Choice 1: him
Choice 2: you
Choice 3: her
Fill-in (4) - Requested As A Language
Choice 1: Number holder's name possessive
Fill-in (5) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is

ENT062 MONTH OF ENTITLEMENT CONFIRMED (A52)

(Requested)

Caption: Your Benefits

We reviewed  (1)  record. When  (2)  applied,  (3)  asked us to start  (4)  benefits in  (5)  . We found that  (6)  is still the month when benefits should start.


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

ENT063 BENEFICIARY ENTITLED ON TWO ACCOUNTS A BENEFITS (PREVIOUSLY AWARDED) TO BE COMBINED WITH WIDOW(ER)'S BENEFITS AND PAYMENT OF LUMP-SUM (B07)

(Requested)

Caption: What We Will Pay

The check, which includes the money  (1)  due through  (2)  , will also include a lump-sum payment of  (3)  . This is a one-time payment we make because of a worker's death.

After that, we will send  (4)  benefits in one check each month. The check will include  (5)  which  (6)  due on  (7)  own Social Security record and  (8)  which  (9)  due on the other record.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you are
Choice 2: Beneficiary Name is
Fill-in (2) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Amount of lump-sum
Fill-in (4) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (5) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Amount MBP
Fill-in (6) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (7) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (8) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Amount MBP
Fill-in (9) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is

ENT064 UNDERPAYMENT PAID TO OTHER BENEFICIARY (B08)

(Requested)

Caption: What We Will Pay

Your  (1)  check includes  (2)  which we owed  (3)  .


Fill-in values:
Fill-in (1) - Requested As A One Position Alpha Character
Choice 1: (A) next
Choice 2: (B) first
Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Amount of underpayment
Fill-in (3) - Requested As A One Position Alpha Character or language
Choice 1: (A) your wife
Choice 2: (B) your husband
Choice 3: (C) your father
Choice 4: (D) your mother
Choice 5: name of beneficiary

ENT065 SIMULTANEOUS A AND AB AWARDS (B17)

(Requested)

Caption: Other Social Security Benefits

We are still working on  (1)   (2)  claim for spouse's benefits. When we decide whether or not  (3)  is entitled to benefits, we will send  (4)  a letter.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your
Choice 2: Beneficiary name possessive
Fill-in (2) - Requested As A One Position Alpha Character
Choice 1: (A) wife's
Choice 2: (B) husband's
Fill-in (3) - Systems Generated
Choice 1: he
Choice 2: she
Fill-in (4) - Systems Generated
Choice 1: him
Choice 2: her

ENT066 AUXILIARY CLAIM PENDING (C07)

(Requested)

Caption: Things To Remember

We are still working on  (1)  claim. When we decide whether or not  (2)  entitled to benefits, we will send another letter to give our decision.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary's Name possessive
Choice 2: your
Fill-in (2) - Systems Generated
Choice 1: he is
Choice 2: she is
Choice 3: you are

ENT067 UNDERPAYMENT DUE TO DEATH OF BENEFICIARY SHARED WITH INDIVIDUAL(S) OF EQUAL ENTITLEMENT (C09)

(Requested)

Caption: What We Will Pay

This check includes  (1)  , which is part of the money which was due  (2)  . Each person who is eligible for part of this money will get an equal share. The amount shown above is  (3)  share.


Fill-in values:
Fill-in (1) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Amount
Fill-in (2) - Requested As A Language
Choice 1: Name of deceased individual
Fill-in (3) - Systems Generated
Choice 1: your
Choice 2: Beneficiary name possessive

ENT068 RIGHTS AND RESPONSIBILITIES DOMESTIC CONVERSION FROM DIB (G14)

(System Generated)

Caption: Your Responsibilities

It is important that you report changes that could affect  (1)  benefits to us right away. To explain these changes, we have enclosed a pamphlet, When You Get Social Security Retirement or Survivor Benefits. What You Need To Know. It will tell you what must be reported and how to report. Please be sure to read the part of the pamphlet which explains how earnings from work could change  (2)  payments.


Fill-in values:
Fill-in (1)
Choice 1: your
Choice 2: Beneficiary name possessive
Fill-in (2)
Choice 1: your
Choice 2: Beneficiary name possessive

ENT069 RIGHTS AND RESPONSIBILITIES FOREIGN CONVERSION FROM DIB (G15)

(System Generated)

Caption: Your Responsibilities

It is important that you report changes that could affect  (1)  benefits to us right away. To explain these changes, we have enclosed a pamphlet, Your Social Security Checks While You Are Outside the United States. It will tell you what must be reported and how to report. The pamphlet explains that we may not pay  (2)  if  (3)  more than 45 hours in a month.


Fill-in values:
Fill-in (1)
Choice 1: your
Choice 2: Beneficiary name possessive
Fill-in (2)
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (3)
Choice 1: you work
Choice 2: he works
Choice 3: she works

ENT070 DATE OF BIRTH ESTABLISHED DIFFERENT FROM THAT ALLEGED OR DATE ESTABLISHED BEFORE ATTAINMENT OF RETIREMENT AGE (C08)

(Requested/Generated)

Caption: The Basis For Our Decision

Based on the information given to us,  (1)  born on  (2)  .


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary's name + was
Choice 2: you were
Fill-in (2) - Requested As A Date In Format Shown Below
MM/DD/CCYY

ENT071 DIB TO RIB CONVERSION (GA3)

(System Generated)

Caption: Your Benefits

We are changing the type of benefit  (1)  from Social Security. Beginning  (2)  ,  (3)  entitled to retirement benefits.  (4)  no longer entitled to disability benefits because  (5)  reached full retirement age.


Fill-in values:
Fill-in (1)
Choice 1: Name + receives
Choice 2: you receive
Fill-in (2)
Choice 1: MM/CCYY
Fill-in (3)
Choice 1: he is
Choice 2: she is
Choice 3: you are
Fill-in (4)
Choice 1: He is
Choice 2: She is
Choice 3: You are
Fill-in (5)
Choice 1: he has
Choice 2: she has
Choice 3: you have

ENT075 NEW BENEFICIARY ENTITLED TO BENEFITS (J79)

(Requested)

Caption: Your Benefits

Since  (1)  now entitled to benefits, we changed the amount we can pay  (2)  beginning  (3)  . We will continue to pay this new monthly amount as long as  (4)   (5)  payments.


Fill-in values:
Fill-in (1) - Requested As A One Position Alpha Character
Choice 1: (A) name of terminated beneficiary is
Choice 2: (B) names of terminated beneficiaries are
Choice 3: (C) you are
Fill-in (2) - Systems Generated
Name (or names) of previously entitled beneficiary (or beneficiaries)
Fill-in (3) - Requested As A Date In Format Shown Below
MM/CCYY (date of adjustment)
Fill-in (4) - Systems Generated
Choice 1: Beneficiary's Name + receives
Choice 2: you receive
Fill-in (5) - Requested As A One Position Alpha Character
Choice 1: (A) workers' compensation
Choice 2: (B) public disability
Choice 3: (C) workers' compensation and public disability

ENT082 SMI-PBID DATE OF ENTITLEMENT

(Systems Generated)

Caption: Information about Medicare

 (1)  Medicare Part B Immunosuppressive Drug coverage starts  (2) .


Fill-in Values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary's Name (possessive)
Choice 2: Your
Fill-in (2) - Systems Generated
Choice 1: MM/CCYY

NL 00720.180 HIB Health Insurance Benefits

 


NL 00720 TN 27 - Manual Adjustment, Credit and Award Process (MADCAP) Beneficiary Notice Print Program - 1/09/2023