Identification Number:
NL 00730 TN 33
Intended Audience:See Transmittal Sheet
Originating Office:Systems OITEBS
Title:Title II Redesign (T2R) Notices Title II Postentitlement (PE) Actions
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 30 – Title II Redesign (T2R) Notices Title II Postentitlement (PE) Actions
Transmittal No. 33, 02/06/2020

Audience

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

Originating Component

OITBS

Effective Date

Upon Receipt

Background

 

We are updating Program Operations Manual System (POMS) sections in NL 00730 effective with Title II Redesign’s (T2R) August 23, 2019 release.

The language changes for notices in the attached sections are a direct result of updates requested by the Office of Income Security Programs (OISP), Office of Public Service and Operation Support (OPSOS), Office of Disability Policy (ODP) and Office of General Counsel (OGC). These changes were in support of the Unprocessed Medical Cessation Initiative's goal to automate additional cases and a routine maintenance request.

 

Summary of Changes

NL 00730.020 Title II Redesign (T2R) Notice Documentation

We updated the criteria for the I029 notice completion code, as we are now able to generate a complete notice for up to three SMI premium rate and effective date changes instead of two. The I029 will now generate when there are more than three SMI premium rate and effective date changes. We placed bold formatting on the word "Instructions" for the notice completion code I034 for consistency.

 

NL 00730.106 “C” Paragraphs and Captions

We added the new Universal Text Identifier (UTI) CDR083 to acknowledge the beneficiary's request for Medicare only continuation during a disability cessation appeal when the disability cessation date is in the future. We also added the new UTI CDR084 to advise a beneficiary who did not have payment continuation during an appeal of a disability cessation decision that a favorable reversal occurred. We also added the missing bullet point in the UTI CFD003 and corrected the bullet typed to dots instead of numbers. We added the missing Choice 1 and Choice 2 labels to Fill-in 1 of the UTI CLO002.

 

NL 00730.116 “H” Paragraphs and Captions

We updated the title and language in the UTI HIB087 to include the type of Medicare coverage that will continue now that we added both Part A (hospital insurance) and Part B (medical insurance) as fill-in choices. We also updated the UTIs HIB170 and HIB171 by adding a fill-in for Medicare coverage types to allow usage when Part A only is continuing for the UTI HIB170, removing the second sentence to make it a fill-in for both UTIs, and making the last two sentences a fill-in for the UTI HIB170. The word "checks" was changed to "payments" throughout the text in HIB170 and HIB171 also.

 

NL 00730.126 “M” Paragraphs and Captions

We corrected the language shown for MHP053 because it was missing the first paragraph that contained fill-ins one through three.

 

NL 00730.130 “O” Paragraphs and Captions

We updated the language in the first sentence of the UTI OPT217 and reduced the number of fill-ins from four to three per OGC's request. We also updated the language in the UTI OPT226 to reflect "a crime" instead of "crimes" per OGC's request.

 

NL 00730.132 “P” Paragraphs and Captions

We updated the fill-ins in the UTI PAY148 to explain the two general reasons for recovering part or all of the monthly benefit payment.

 

NL 00730.138 “S” Paragraphs and Captions

We updated the title of the UTI SUS035, as it will also advise auxiliaries of benefit suspension while the disabled number holder's (NH) appeal of a disability cessation decision with Medicare continuation only is pending. We also removed the unnecessary word "his" beside Fill-in 3 for the UTI SUS070.

NL 00730.020 Title II Redesign (T2R) Notice Documentation

A. Introduction

Target Notice Architecture (TNA) does not produce a folder copy of the T2R notice. We store T2R notice information in the Online Retrieval System (ORS).

B. Description of Universal Text Identifier (UTI)

TNA uses UTIs to compose, format, and sequence the T2R notices. The notice consists of a heading, captions, paragraphs, a signature, addresses, and enclosures. The UTI is a six-part alphanumeric code that identifies the specific paragraphs or captions T2R selects for various parts of the notice.

C. Completion codes

T2R notice process generates the following completion codes, which are on the first page of the notice in the lower left corner:

Completion Code

Code

Informational Code Description

Complete (C)

 

Notice is complete and requires no further action.

Systems Bad (S)

001

T2R cannot complete a notice in a fully automated fashion and manual intervention is required. Asterisks appear for fill-in values that cannot be determined or T2R did not generate an introductory UTI.

Instructions:

The technician needs to

  • complete the fill-in values, and

  • include an appropriate introductory paragraph.

Review (R)

Notice is complete but needs additional information.

 

002

The Post-MBR shows a change in payee, the Person Information database or Pre-MBR does not contain a valid address for the beneficiary, and the Representative Payee Data (REPD) line shows:

  • Type of Payee (TOP) is not equal to A (Self-SEL),

  • Custody Code (CC) is not equal to V (in payee’s custody),

  • Competency Code (CMC) = Y, and

  • The beneficiary is age 18 or older.

Instructions:

  • The technician reviews and sends the notice to the beneficiary to inform him or her of the new payee.

  • The technician can obtain the beneficiary’s address from the Representative Payee System (RPS) or Supplemental Security Income Record (SSR).

 

020

There is a new hospital insurance (HI) occurrence with HI-TYPE = P (PREMIUM), a new Supplementary Medical Insurance (SMI) occurrence and no Hospital Insurance Premium (HIPR), or Supplementary Medical Insurance Premium (SMPR).

Instructions:

The technician reviews the action as well as the notice. If HI/SMI is open, there should be an HIPR or SMPR occurrence on the Post-MBR.

Incomplete (I)

 

The notice needs additional language added. The code is generated if the following conditions are met:

 

003

A HI/SMI occurrence based on Disability Insurance Benefits (DIB) is established. The T2R enrollment process establishes the DIB HI (free) and SMI granting equitable relief based on the time limitation for CMS payment of Part B (SMI) bills for medical claim services.

Instructions:

The technician needs to add the AURORA (manual notice system) paragraph “Supplementary Medical Insurance based on Disability” (SMID) to the notice.

 

004

A beneficiary requests waiver of equitable relief for SMI (meaning the beneficiary wants the earlier SMI coverage).

Instructions:

The technician needs to add the AURORA (manual notice system) paragraph “Supplementary Medical Insurance based on Disability” (SMID) to the notice.

 

007

This is used for three scenarios:

The Post-MBR History Reason for Suspension or Termination (HRFST) = OTHTRM.

The HRFST = CHDTRM and there is a changed Child in Care (CIC) occurrence with the CIC-ENDRSN = Other Child Termination Reason (O).

The HRFST = Disability Insurance Benefits Cessation (DIBCES) and there is a changed CIC occurrence with the CIC-ENDRSN = Other Child Termination Reason (O).

Instructions:

The technician needs to determine the specific termination reason and add dictated language to the notice.

 

008

The Post-MBR History Reason for Suspension or Termination (HRFST) = CHDTRM and there is a change in more than one occurrence of Child in Care (CIC) Data. All the occurrences of changed CIC Data show the same CIC-END date with the CIC-ENDRSN = Death (D) and there is more than one deceased beneficiary.

Instructions:

The technician needs to add a paragraph using the names of all deceased beneficiaries (PIC C’s). This paragraph explains to the BIC B or BIC E that SSA terminated benefits because named C’s were the last children in their care.

 

009

The Post-MBR History Reason for Suspension or Termination (HRFST) = Miscellaneous (MISCEL) for any effective date that the pre-MBR does not show with the HRFST = MISCEL.

Instructions:

The technician needs to review the case to determine the reason SSA suspended the beneficiary and add dictated language to the notice.

 

011

On the Post-MBR, if a Prior Month Accrual Amount (PAMT) is present and is > $0.00, the PAMT-PAID date equals the Run Date and no UTIs generate under Caption INFC17. If ADJ048 or HIB111 generates, process as a complete notice.

Instructions:

The technician needs to determine why we are paying the Prior Monthly Accrual (PMA) and add language to the notice.

 

012

A new overpayment was established and The Historical Date of Entitlement Termination (BCLM-DOETERM) on the Post-MBR is earlier than the BCLM-DOETERM date on the Pre-MBR for the same occurrence of Beneficiary Claim Data (BCLM). We cannot use the language in UTI OPT122 when the termination changes to an earlier date.

Instructions:

The technician needs to review the case and include information about the termination date changing to an earlier date.

 

013

The Payee Name and Address Legend (PNAL) data does not contain the word “FOR”, "GDN OF" or "CONS OF". T2R uses the RPY073 to tell the beneficiary the name of the new payee. The RPY073 UTI value for Fill-in 1 is the new payee’s name.

Instructions:

The technician needs to fill-in the new payee’s name.

 

014

The Payee Name and Address Legend (PNAL) data does not contain the word “FOR”, "GDN OF" or "CONS OF". T2R uses PAY084 when the beneficiary has a new payee and a Current Amount (CAMT) check is paid. The PAY084 UTI value for Fill-in 2 is the new payee’s name.

Instructions:

The technician needs to fill in the new payee’s name.

 

015

The Payee Name and Address Legend (PNAL) data does not contain the word “FOR”, "GDN OF" or "CONS OF". T2R uses the PAY085 UTI when a beneficiary has a new payee and a Prior Month Accrual Amount (PAMT) and a Current Amount (CAMT) check are paid. The PAY085 value for Fill-in 2 is the new payee’s name.

Instructions:

The technician needs to fill in the new payee’s name.

 

016

The Payee Name and Address Legend (PNAL) data does not contain the word “FOR”, "GDN OF" or "CONS OF". T2R generates PAY126 when a beneficiary has a new payee, we paid a Current Amount (CAMT) check, and benefits are terminating Current Operating Month (COM) + 1. The PAY126 value for Fill-in 2 is the New Payee’s Name.

Instructions:

The technician needs to fill in the new payee’s name.

 

018

T2R terminated benefits for History Reason for Suspension or Termination (HRFST) = CHDTRM and the CIC-END date is not equal to Historical Date of Entitlement Termination (BCLM-DOETERM). The T2Redesign Enrollment and Eligibility process will use the HRFST = CHDTRM. In certain situations, the BCLM-DOETERM date does not equal the CIC-END date.

Instructions:

The technician needs to explain why the termination date does not equal the CIC-END date.

EXAMPLE: In Current Operating Month (COM) 05/04, HA dies 04/04.

Pre-MBR shows HC1 terminated HRFST = CMARRY.

Pre-MBR shows HB2 suspended HRFST = CERTEL (B2 is age 62) with CIC-END date.

Post-MBR shows HB2 terminated 04/04 HRFST = CHDTRM with CIC-END date.

 

019

Benefits are suspended with History Reason for Suspension or Termination (HRFST) = LEGIS2. The HRFST is used for interim processing until full automation is implemented.

Instructions:

The technician needs to review the notice to include appropriate Legislative language.

 

021

More than one beneficiary dies and the Beneficiary Dates of Death (BDOD) are not equal; or there are more than three dead beneficiaries and their BDODs are equal. T2R suppresses the UTI OPT133 under Caption INFC17.

Instructions:

The technician needs to fill-in the deceased beneficiaries names and dates of death when either of these situations occur.

 

022

Reverse Jurisdiction Start is present and the Monthly Benefit Amount (MBA) is still reduced; however, no Amount of Offset Stop Date (AMOF-STOP) is on the post-MBR.

Instructions:

The technician needs to explain why the MBA is still in offset.

 

025

There are more than 20 Medicare Advantage Reduction Data (MARD) occurrences from the first point of change on.

Instructions:

The technician must determine the correct MARD occurrences. Add UTIs MHP013, MHP014, MHP008 and MHP018 to the notice to explain the reduction of Part B premium due to Medicare Advantage.

NOTE: When the T2R notice process generates a complete automated notice with MHP013, MHP014 and MHP008, if there are MARD occurrences on the pre-MBR that are now wiped out, the T2R notice attempts to include the wiped out occurrences in MHP008. For a wipe out, MHP008 shows the reduction amount as $0.00 and the Supplementary Medical Insurance (SMI) amount after reduction reflects the beneficiary’s full SMI rate.

 

026

The History Reason for Suspension or Termination (HRFST) = TWPFRD for an ongoing or embedded period of suspension.

Instructions:

The Fraudulent Unit in the Processing Centers needs to add special language to the T2R notice.

 

028

The Master Beneficiary Record (MBR) is updated with a new open Hospital Insurance (HI) occurrence with the HI-TYPE = P, a new open Supplementary Medical Insurance (SMI), a new open SMI Third-Party (SMTP) occurrence, and the SMI Start date is earlier than the SMTP Start date.

Instructions:

The technician needs to determine if the beneficiary owes SMI premiums in addition to the HI premiums for months prior to the third-party start date.

 

029

The Income-Related Monthly Adjustment Amount (IRMAA) affects the Supplementary Medical Insurance (SMI) premium amount and there are more than three SMI premium rates and effective dates. UTI HIB005 currently only allows for three rates and dates.

Instructions:

The technician needs to provide all SMI rates and corresponding effective dates.

 

030

The T2R notice process determines that Income-Related Monthly Adjustment Amount (IRMAA) affects the Supplementary Medical Insurance (SMI) premium amount but after comparing the IRMAA amounts there is no change and Deductions and Additions History (DAH) data shows DAH-ITEM 175 or 180 (Part B refund).

Instructions:

The technician needs to determine if the Medicare Part B refund indicated in DAH data is due to IRMAA since there is no change in the Part B premium amount.

 

031

Premium Relief data is present on the Post-MBR and the Relief Establish date equals the Post-Entitlement (PE) run date. The Relief Reason is not equal to Income-Related Monthly Adjustment Amount (IRMAA) or IRMAA D.

Instructions:

The technician needs to explain the reason(s) we are offering relief for the Supplementary Medical Insurance (SMI) premiums due.

 

032

Going from a Variable Supplementary Medical Insurance (VSMI) rate to a non-VSMI rate and T2R does not generate the UTI HIB005. In addition, VSMI data is deleted or a VSMI-TERM date updates to the post-MBR.

Instructions:

The technician needs to review the notice to include information about the change in rate.

 

033

There is more than one occurrence with the History Reason for Suspension or Termination (HRFST) = WINFAL.

Instructions:

The technician needs to explain the Start and Stop dates of each WINFAL occurrence.

 

034

There are more than four Annual Earnings Limit amounts.

Instructions:

The technician needs to provide all the Annual Earnings amounts and date changes.

 

036

More than four Annual Earnings (AORE) amounts that change to zero ($0.00) exist.

Instructions:

The technician needs to provide all the years that change to zero ($0.00).

Appointed Representative (L)

 

We issue a copy of the beneficiary’s notice to an appointed representative. This code is generated when:

  • Supplemental Security Income (SSI) Windfall is processed and,

  • An appointed representative is present and,

  • The Registration, Appointment and Services for Representatives (RASR) system does not show the representative as the active principal representative who is approved for direct payment.

NOTE: T2R produced and released a complete notice to the beneficiary. A copy of that notice is in AURORA.

Instructions:

The technician should review the notice and process through Aurora. A cover letter addressed to the appointed representative on the notice should be the only change to the notice.

If the beneficiary has more than one representative, the technician sends only one copy to the principal representative per GN 03910.040D.

NOTE: Due to the Print Mail Cost-Savings project, implemented in May 2013, do not generate ENC003 (enclosures) on the attorney copies of notices.

Manual (M)

 

You must prepare a manual notice because the T2R notice program cannot explain the processing situation. In most situations, you need to use dictated language to explain the T2R action. We list the conditions that require preparation of a manual notice below.

 

101

Limited group payer

When a group payer pays for a limited period of Medicare, prepare a manual notice. The notice needs to explain the group payer buy-in and buy-out period and the effect this period has on the beneficiary’s HI/SMI coverage.

 

102

Third-party wipe out processed

When a third-party wipe out action is processed, the technician needs to prepare a manual notice. Prepare a notice to explain that the third-party data is being deleted because it was erroneously established (refer to wipeout processing in SM 03040.245B.3).

 

103

Medicare application withdrawal processed

When the pre-MBR has an open HI/SMI occurrence and the post-MBR is updated with an HI-NONCOVRSN = X and the HI-BASIS is not End-Stage Renal-Disease (E); or an SMI-NONCOVRSN = X and the SMI-BASIS is not E. Prepare a manual notice when the HI/SMI BASIS is not E. The notice needs to explain that a withdrawal of a Medicare application was processed.

 

104

Monthly Benefit Amount is less than the Supplementary Medical Insurance premium amount (LESSDO) and the beneficiary is in LAF S9 with past premiums due

When the beneficiary goes from current pay status (LAF C) to suspended (LAF S9) with History Reason for Suspension or Termination (HRFST) of LESSDO (Monthly Benefit Amount is less than the Supplementary Medical Insurance premium amount), and owes past SMI premiums. Prepare a manual notice to explain the S9 suspension and the amount of any premiums due. T2R can only address the S9 suspension when it is effective with the current operation month. For instruction on processing LESSDO cases refer to SM 00850.475.

NOTE: If BENH01 is included on the manual notice, review to determine if BEN125 should be added to the notice.

 

105

Multiple third-party closed periods posted

If multiple third-party actions are processed and the updated MBR shows two or more closed third-party periods either being established or changed for the same coverage type, prepare a manual notice to explain the closed periods of coverage. In addition, provide the beneficiary with information regarding medical expenses for the closed periods.

 

106

Special Payment Amount Overpayment Disposition Amount (OPA) posted to Beneficiary Over/Underpayment Data (BOUD) – Termination status to termination status

When the pre-MBR has a Special Payment Amount (SPA) overpayment and the beneficiary is in terminated status (LAF = T (any except T1)) with post-MBR Beneficiary Over/Underpayment Data (BOUD) where the Due Process Overpayment (DPO) is equal to the pre-MBR DPO plus SPA and there is no change in the Historical Date of Entitlement Termination (BCLM-DOETERM) on the pre- and post-MBR, prepare a manual notice to advise the beneficiary of the overpayment posted to BOUD. In these situations, the SPA overpayment was incorrect and the technician should have posted the overpayment to BOUD. The T2R Summary Business Function recognizes this and is now posting the overpayment to BOUD. The T2R notice process has to assume that we never advised the beneficiary of the SPA overpayment.

 

107

Suspension for withdrawal claim

If benefits are suspended with History Reason for Suspension or Termination (HRFST) = WITHDR and the Beneficiary’s Date of Death (BDOD) = zeroes on the post-MBR, prepare a manual notice to send Exhibit 3700 to the beneficiary.

 

108

New Overpayment Disposition Amount (OPA) and prior OPA under protest

If T2R is establishing a new overpayment and the post-MBR Beneficiary Over/Underpayment Data (BOUD) has a Protest Indicator not equal to blank, prepare a manual notice. The data needed to explain when the new overpayment adjustment would start is not on the updated MBR. Due Process Recovery Date (DPRD) should not be posted with a Protest code.

 

109

Multiple fugitive felon occurrences changed

If there is more than one changed fugitive felon (FFEL) occurrence when comparing pre-MBRs and post-MBRs, the technician needs to determine the changed occurrences and prepare a manual notice that addresses the particular warrant date(s). The T2R notice process only has language for one changed occurrence.

 

110

Warrant issuing agency name is blank

If the warrant-issuing agency name is blank or not available to the T2R notice process, the technician needs to determine the agency’s name and prepare a manual notice.

 

111

Master Beneficiary Record Originating Agency Identifier (ORI) and warrant data do not match on Fugitive Felon SSA Control File (FFSCF)

If the Fugitive Felon (FFEL) data and the Fugitive Felon SSA Control File (FFSCF) data do not match, the technician in the Program Service Center needs to determine the FFSCF data that corresponds to the FFEL occurrence. Prepare a manual notice based on the FFEL update.

 

112

Workers’ Compensation/Public Disability Benefits stop and no Amount of Offset (AMOF) data present

If the T2R notice process has determined that we are no longer reducing or withholding the Monthly Benefit Amount (MBA) because of WC/PDB and the post-MBR does not contain Amount of Offset (AMOF) data (the AMOF data should be present on the MBR when WC/PDB stops), the technician needs to review the MBR and prepare a manual notice that contains dictated language to explain the action.

 

113

Fugitive Felon (FFEL) suspension – no change in FFEL occurrences

If The T2R system suspends benefits based on the History Reason for Suspension or Termination (HRFST) of Fugitive Felon (FUGFEL), and the FFEL data was previously updated to the MBR when the beneficiary was placed in suspense for PRISON then the T2R notice process cannot determine what FFEL occurrence the suspension corresponds to because there is no change in pre-FFEL and post-FFEL data. The technician needs to determine the appropriate FFEL occurrence that corresponds to the fugitive felon suspension and prepare a manual notice.

 

114

Title II Interactive Computation Facility (ICF) input – Workers’ Compensation data deleted on post-MBR

If Injury or Illness (INIL) Data is present on the Pre-MBR and all INIL occurrences are deleted on the Post-MBR, the technician needs to review the case to determine why Workers’ Compensation (WC) data was deleted. Prepare a manual notice to advise the beneficiary of the findings. If payments have not changed, do not send a manual notice, see DI 52165.015B.6.

 

115

Multiple Annual Report Data (ARD) lines for the same Year of Earnings Report (YOER)

T2R cannot process foreign work and domestic work for the same year. Since there are no UTIs to explain foreign work, the technician will review the case and prepare a manual notice explaining all changes to the beneficiary.

NL 00730.106 “C” Paragraphs and Captions

List of “C” Paragraphs and Captions

A. “CDB” Universal Text Identifier – Childhood Disability Benefits

CDB003 – USED ON CHILDHOOD DISABILITY BENEFIT (CDB) AWARDS TO EXPLAIN TRIAL WORK PERIOD

If (1) (2) while (3) (4) still disabled, (5) may qualify for a trial work period to test (6) ability to work. During this period, (7) may work 9 months, sometimes more, and not lose Social Security disability payments because of the work, no matter how much (8).

To end the trial work period, the 9 months of work must take place in a 60-month period. The months do not have to be in a row. After the trial work period has ended, we will look at the work (9) did and decide if (10) (11) still disabled. The pamphlet described below has more information about the trial work period and other rules that may help (12) return to work.

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

works

Choice 2

work

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

is

Choice 2

are

Fill-in (5)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (6)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (7)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (8)

 

Choice 1

he earns

Choice 2

she earns

Choice 3

you earn

Fill-in (9)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (10)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (11)

 

Choice 1

is

Choice 2

are

Fill-in (12)

 

Choice 1

him

Choice 2

her

Choice 3

your

B. “CDR” Universal Text Identifiers – Childhood Disability Review

CDR001 – CHILDHOOD DISABILITY BENEFIT (CDB) AWARD - MEDICAL EXAM IN 3 YEARS

Doctors and other trained staff decided that (1) (2) disabled under our rules.

But, this decision must be reviewed at least once every 3 years. We will send you a letter before we start the review. Based on that review, (3) benefits will continue if (4) still disabled, but will end if (5) no longer disabled.

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

he is

Choice 2

she is

Choice 3

you are

Fill-in (5)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

CDR002 – CHILDHOOD DISABILITY BENEFIT (CDB) AWARD - MEDICAL EXAM IN 5–7 YEARS

Doctors and other trained staff decided that (1) (2) disabled under our rules.

However, we must review all disability cases. Therefore, we will review (3) case in 5 to 7 years. We will send you a letter before we start the review.

Based on that review, (4) benefits will continue if (5) still disabled, but will end if (6) no longer disabled.

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

Fill-in (5)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (6)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

CDR004 – CHILDHOOD DISABILITY BENEFIT (CDB) AWARD – DISABILITY NOT PERMANENT

The doctors and other trained personnel who decided that (1) (2) disabled expect (3) health to improve. Therefore, we will review (4) case in the future.

We will send you a letter before we start the review. Based on that review, (5) benefits will continue if (6) (7) still disabled, but will end if (8) (9) no longer disabled.

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

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (6)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (7)

 

Choice 1

is

Choice 2

are

Fill-in (8)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (9)

 

Choice 1

is

Choice 2

are

CDR063 – NUMBER HOLDER (NH) OR CHILDHOOD DISABILITY BENEFITS (CDB) OR DISABLED WIDOW(ER) BENEFITS (DWB) SUSPENDED - FAILURE TO COOPERATE

We cannot pay (1) benefits because our records show that (2) did not return information we asked for concerning (3) disability.

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

he

Choice 2

she

Choice 3

you

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

CDR065 – NUMBER HOLDER (NH) OR CHILDHOOD DISABILITY BENEFITS (CDB) OR DISABLED WIDOW(ER) BENEFITS (DWB) SUSPENDED - FAILURE TO COOPERATE

If we stop (1) Social Security disability benefits and you do not give us the information we asked for before (2), (3) will have to file a new application to get Social Security disability benefits again. If we do not hear from you by this date, we will send you another letter which will give you the information about (4) appeal rights.

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)

Add 12 months to the first effective date in History data that corresponds to the
ongoing Continuing Disability Review (CDR) Failure to Cooperate (FTC) suspension
and display in the format Month CCYY

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

CDR066 – NUMBER HOLDER (NH) OR CHILDHOOD DISABILITY BENEFITS (CDB) OR DISABLED WIDOW(ER) BENEFITS (DWB) TERMINATED FOR FAILURE TO COOPERATE

(1) no longer (2) for Social Security disability benefits beginning (3) because our records show that (4) did not return information we asked for during (5) continuing disability review.

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

qualifies

Choice 2

qualify

Fill-in (3)

Historical Date of Entitlement Termination (BCLM-DOETERM-REL) - this date
corresponds to the first effective date in History (HIST) data on the
post-MBR of the Continuing Disability Review (CDR) Failure to Cooperate (FTC) for
PIC A or W or the CDR FTC for PIC C in the format Month CCYY)

Fill-in (4)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

CDR067 – BENEFITS ARE TERMINATED DUE TO THE NUMBER HOLDER'S FAILURE TO COOPERATE OR DISABILITY CESSATION

We can no longer pay (1) benefits because (2) no longer qualifies for Social Security disability benefits beginning (3).

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)

NH-NAME

Fill-in (3)

Historical Date of Entitlement Termination (BCLM-DOETERM-REL) that
corresponds to the first effective date in History (HIST) data for the Disability
Insurance Benefits Cessation (DIBCES) termination which is used for an
auxiliary when the Number Holder fails to cooperate

CDR083 – REQUEST FOR MEDICARE ONLY STATUTORY BENEFIT CONTINUATION FOR A BENEFICIARY WITH A FUTURE DATED DISABILITY CESSATION DATE (DBC)

In an earlier letter, we told (1) that (2) disability benefits would end. (3) no longer entitled to benefits as of (4). However, during the appeals process (5) requested to have Medicare coverage continued.

Fill-in values:

Fill-in (1)

 

Choice 1

you

Choice 2

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

Fill-in (2)

 

Choice 1

your

Choice 2

his
Choice 3 her

Fill-in (3)

 

Choice 1

You are

Choice 2

He is
Choice 3 She is

Fill-in (4)

 

Choice 1

Future dated DBC in Month CCYY format

Fill-in (5)

 

Choice 1

you

Choice 2

he

Choice 3

she

CDR084 – FAVORABLE REVERSAL OF THE MEDICAL CESSATION DECISION FOR A BENEFICIAIRY WITHOUT STATUTORY BENEFIT PAYMENT CONTINUATION

In an earlier letter, we told (1) that (2) disability benefits would end. Now, we decided that (3) still disabled and our previous notice should be disregarded.

Fill-in values:

Fill-in (1)

 

Choice 1

you

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

 

Choice 1

your

Choice 2

his
Choice 3 her

Fill-in (3)

 

Choice 1

you are

Choice 2

he is
Choice 3 she is

CDR701 – PAYMENTS WILL CONTINUE AT THE SAME RATE AFTER A FAVORABLE REVERSAL OF THE MEDICAL CESSATION DECISION

We previously advised (1) that (2) disability benefits would terminate because (3) no longer entitled to benefits. However, during the appeals process (4) monthly benefit check(s) continued. It has been determined that (5) still disabled and our previous notice should be disregarded.

Fill-in values:

Fill-in (1)

 

Choice 1

you

Choice 2

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

Fill-in (2)

 

Choice 1

your

Choice 2

his
Choice 3 her

Fill-in (3)

 

Choice 1

you are

Choice 2

he is
Choice 3 she is

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (5)

 

Choice 1

you are

Choice 2

he is

Choice 3

she is

C. “CFD” Universal Text Identifiers – Conserved Funds

CFDC02 – CAPTION

If You Saved Any Money

CFD003 – CONSERVED FUNDS REQUESTED FROM FORMER PAYEE

While you were (1) payee, you may have saved some money for (2). If you have, you should return it to us unless you have already made other plans with us for handling it. The money you will need to return includes:

  • Saved and invested benefits.

  • Interest earned from these savings and investments.

  • Money you have left over from any checks we sent you.

  • Any checks you might receive after the date of this letter.

Fill-in values:

Fill-in (1)

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

Fill-in (2)

 

Choice 1

him

Choice 2

her

CFD004 – TELLS FORMER PAYEE HOW TO RETURN CONSERVED FUNDS

To do this, you can write us a check or money order. Make it out to the Social Security Administration. Be sure to write “Conserved Funds for (1), (2)” on that check or money order. Please mail it in the enclosed envelope.

Fill-in values:

Fill-in (1)

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

Fill-in (2)

Claim Number plus Payment Identification Code (PIC)

D. “CHK” Universal Text Identifiers – Information about Checks

CHKC05 – CAPTION

When We Begin Your Payments Again

CHKC09 – CAPTION

Your Benefits

CHKC10 – CAPTION

Information About Your Checks

E. “CIC” Universal Text Identifiers – Child in Care

CIC006 – AGED SPOUSE MONTHLY BENEFIT AMOUNT IS CHANGING BECAUSE A CHILD HAS LEFT THE SPOUSE’S CARE

We changed (1) monthly benefit to (2) beginning (3). We changed 4) benefit because (5) no longer (6) a child who is entitled to benefits in (7) care.

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)

Monthly Benefit Amount (MBA) in the format $$$$$.¢¢

Fill-in (3)

Effective date of Monthly Benefit Amount (MBA) change in the format Month CCYY

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (6)

 

Choice 1

has

Choice 2

have

Fill-in (7)

 

Choice 1

his

Choice 2

her

Choice 3

your

CIC007 – AGED SPOUSE BENEFIT AMOUNT CHANGED DUE TO HAVING A CHILD IN CARE

We changed (1) monthly benefit to (2) beginning (3). We changed (4) benefit because (5) now (6) a child who is entitled to benefits in (7) care.

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)

Monthly Benefit Amount (MBA) in the format $$$$$.¢¢

Fill-in (3)

Effective date of Monthly Benefit Amount (MBA) change in the format Month CCYY

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (6)

 

Choice 1

has

Choice 2

have

Fill-in (7)

 

Choice 1

his

Choice 2

her

Choice 3

your

CIC008 – AGED SPOUSE BENEFIT AMOUNT CHANGE DUE TO NOT HAVING A CHILD IN CARE BECAUSE THE CHILD IS NO LONGER ENTITLED

We changed (1) monthly benefit to (2) beginning (3). We changed (4) benefit because the child in (5) care is no longer entitled to 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)

Monthly Benefit Amount (MBA) in the format $$$$.¢¢

Fill-in (3)

Effective date of Monthly Benefit Amount (MBA) change in the format Month CCYY

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

CIC012 – TELLS PARENT THAT CHILDHOOD DISABILITY BENEFITS (CDB) REVIEW IS EVERY 3 YEARS

You are entitled to benefits because doctors and other trained staff decided that your child is disabled under our rules. But, this decision must be reviewed at least once every 3 years. We will send you or your child a letter before we start the review. Based on that review, your benefits will continue if your child is still disabled, but will end if your child is no longer disabled.

CIC013 – TELLS PARENT THAT CHILDHOOD DISABILITY BENEFITS (CDB) REVIEW IS EVERY 5 TO 7 YEARS

You qualify for benefits because doctors and other trained staff found that you have a disabled child in your care. However, we must review all disability cases. Therefore, we will review your child's case in 5 to 7 years. We will send you a letter before we start the review. Based on that review, your benefits will continue if your child is still disabled, but will end if your child is no longer disabled.

CIC014 – CHILDHOOD DISABILITY BENEFITS (CDB) DISABILITY NOT PERMANENT

You are entitled to benefits because you have a disabled child in your care. The doctors and other trained personnel who made the disability decision expect your child's health to improve. Therefore, we will review your child's case in (1). We will send you a letter before we start the review. Based on that review, your benefits will continue if your child is still disabled. But they will end if your child is no longer disabled.

Fill-in values:                                                                           

Fill-in (1)

the future                                        

F. “CLO” Universal Text Identifiers – Closeout

CLOC01 – CAPTION

Other Social Security Benefits

CLO002 – EXPLAINS THE LIMITATION OF BENEFITS

(1) (2) can receive from us at this time. In the future, if you think (3) might qualify for another benefit from us, (4) will need to apply again.

Fill-in values:

Fill-in (1)

                    

Choice 1 This benefit is the only benefit

Choice 2

These benefits are the only benefits

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

you

Choice 2

he

Choice 3

she

CLO029 – BENEFICIARY IDENTIFICATION CODE (BIC) B ENTITLEMENT CONVERSION TO BIC D OR E

If (1) married more than once, please contact us. (2) may be able to get a higher benefit on the record of a prior spouse.

Fill-in values:                                                                                     

Fill-in (1)

 

Choice 1

you were                                          

Choice 2

he was

Choice 3

she was

Fill-in (2)

 

Choice 1

You

Choice 2

He

Choice 3

She

G. “COA” Universal Text Identifiers – Change of Address

COA004 – TAX TREATY WITH SWITZERLAND

We will deduct a 15 percent Federal income tax from (1) monthly benefits. This is because of a treaty with Switzerland which says we will tax Social Security benefits paid to residents of Switzerland at this rate.

Please let us know if (2) (3) address again.

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

Beneficiary’s Given Name (BGN) (possessive)

Choice 3

your

Fill-in (2)

 

Choice 1

he changes

Choice 2

she changes

Choice 3

you change

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

COA005 – TAX TREATY - CHANGE TAX STATUS

We are no longer deducting Federal income tax from (1) benefits. We do not deduct this, if (2) a U.S. citizen, or if (3) in the United States, Canada, Egypt, Germany, Ireland, Israel, Italy, Japan, Romania or the United Kingdom.

Also, if an individual is a citizen and resident of India, all or part of that person's benefits can be exempt from this Federal income tax if those benefits are based on Federal, State, or local government employment.

Please let us know if (4) (5) address again.

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 is

Choice 2

she is

Choice 3

you are

Fill-in (3)

 

Choice 1

he lives

Choice 2

she lives

Choice 3

you live

Fill-in (4)

 

Choice 1

he changes

Choice 2

she changes

Choice 3

you change

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

COA011 – CHANGE OF ADDRESS (COA) - DOMESTIC TO FOREIGN ADDRESS

We have changed (1) address as you asked. However, we will continue to send (2) payments to (3) financial institution. Please check the mailing address we used for (4). If it is not complete or if you move again, please let us know.

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

Fill-in (4)

 

Choice 1

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

Choice 2

you

H. “COP” Universal Text Identifier – Copy of Notice

COP001 – TELLS THE BENEFICIARY A COPY OF THE NOTICE IS BEING SENT TO HIS OR HER REPRESENTATIVE

We are sending a copy of this notice to (1) (2) (3) (4) (5).

Fill-in values:                                                                   

Fill-in (1)

your representative                                     

Fill-in (2)

Null

Fill-in (3)

Null

Fill-in (4)

Null

Fill-in (5)

Null

COP002 – TELLS THE AUTHORIZED REPRESENTATIVE THAT A COPY OF THE NOTICE WE SENT TO THE BENEFICIARY THEY REPRESENT IS ENCLOSED

Enclosed is a copy of a letter we sent to (1).

Fill-in values:                                                                   

Fill-in (1)

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

I. “CPS” Universal Text Identifiers – Critical Payment System

CPS001 – CRITICAL PAYMENT SYSTEM (CPS) PAID AND DEDUCTED FROM PRIOR MONTH ACCRUAL AMOUNT (PAMT) CHECK

Based on the information we have, (1) (2) previously paid benefits on this record. The amount deducted for these benefits paid will be shown under the heading What We Will Pay and When.

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

was

Choice 2

were

CPS002 – CRITICAL PAYMENT SYSTEM (CPS) PAID AND DEDUCTED FROM PRIOR MONTH ACCRUAL AMOUNT (PAMT) CHECK

  • We deducted (1) for money (2) (3) already paid from the check (4) will receive on or about (5).

Fill-in values:

Fill-in (1)

 

Choice 1

Deductions/Additions History Amount that corresponds to Deductions/Additions
History Item Code 330 (Critical Payment Being Withheld)

Fill-in (2)

 

Choice 1

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

Choice 2

you

Fill-in (3)

 

Choice 1

was

Choice 2

were

Fill-in (4)

 

Choice 1

 

he

 

Choice 2

 

she

Choice 3

you

Fill-in (5)

Run Date plus 15 days in the format Month DD, CCYY

NL 00730.116 “H” Paragraphs and Captions

A. List of “H” paragraphs and captions

HBN001 – AUTOMATED CMS BILLING NOTICE USED WITH HIB225

(appears after the signature page of the notice)

NOTICE OF MEDICARE PREMIUM PAYMENT DUE

CENTERS FOR MEDICARE & MEDICAID SERVICES

BILLING DATE: (1)

MEDICAL PREMIUMS FOR

PERIOD ENDING: (2)

CURRENT AMOUNT DUE: (3)

PAYMENT DUE BY: (4)

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

You must pay by check or money order. 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 should have any questions concerning this Notice of Medicare Premium Payment Due, please write or visit any Social Security Office.

 

PLEASE DETACH AT DOTTED LINE

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

CMS-500A

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

Name: (7)

Make Checks Payable To:

CMS MEDICARE INSURANCE

Send To:

Medicare Premium Collection Center

PO Box 790355

St. Louis, MO 63179-0355

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

 

            ________________________________________________________

      

Fill-in values:

 

Fill-in (1)

the date of the T2 Redesign notice in the format June 27, 2001

Fill-in (2)

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

Fill-in (3)

SMI premiums due

Fill-in (4)

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

Fill-in (5)

Medicare Beneficiary Identification (MBI) Number

Fill-in (6)

SMI premiums due

Fill-in (7)

BGN plus BLN (not possessive)

B. “HDR” - Headings

HDR030 - DATE AND BENEFICIARY NOTICE CONTROL NUMBER

Fill-in values:

 

Fill-in (1)

Show T2R Run Date plus 7 days in the format Month DD, CCYY

Fill-in (2)

Show 13 character alphanumeric Beneficiary Notice Control # plus 1-4 character alphanumeric Beneficiary Identification Code in the format XXXXXXXXXXXXX-XXXX

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

HIBC01 – CAPTION

Information About Medicare

HIBC02 – CAPTION

Health Insurance For Children

HIBC05 – CAPTION

Why (1) Cannot Quality For Medicare

Fill-in values:

 

Fill-in (1)

show the BGN plus BLN (not possessive)

HIBC15 – CAPTION

To Cancel This Insurance

HIBC19 – CAPTION

Notice of Group Billing

HIB001 – ENTITLED TO HI AND/OR SMI

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

Your

Choice 2

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

Fill-in (2)

 

Choice 1

Part A (hospital insurance) starts

Choice 2

Part B (medical insurance) starts

Choice 3

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

Fill-in (3)

Date in format Month CCYY

Fill-in (4)

 

Choice 1

and Part B (medical insurance) starts

Choice 2

Null

Fill-in (5)

 

Choice 1

Date in format Month CCYY

Choice 2

Null

HIB002 - TEMPORARY SUBSTITUTION OF NOTICE FOR HEALTH INSURANCE CARD

(1) will get a Medicare card within 2 weeks. (2) show this card when (3) medical care.  To learn more about what Medicare covers, visit Medicare.gov. If (4) questions about (5) Medicare coverage, call 1-800-MEDICARE (1-800-633-4227).

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

BGN plus BLN (not possessive)

Fill-in (2)

 

Choice 1

You should

Choice 2

He should

Choice 3

She should

Fill-in (3)

 

Choice 1

you need

Choice 2

he needs

Choice 3

she needs

Fill-in (4 )

 

Choice 1

you have

Choice 2

he has

Choice 3

she has

Fill-in (5)

 

Choice 1

your

Choice 2

his

Choice 3

her

HIB005 – SMI PREMIUM BILLING

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

Your

Choice 2

His

Choice 3

Her

Fill-in (2)

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

Fill-in (3)

Date in MMCCYY format

Fill-in (4)

 

Choice 1

null

Choice 2

and

Fill-in (5)

 

Choice 1

null

Choice 2

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

HIB008 – SMI PREMIUM DEDUCTIONS

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (2)

 

Choice 1

next

Choice 2

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

HIB011 – HI PREMIUM BILLING

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (2)

Show the current HI premium rate in the format 999.99

Fill-in (3)

 

Choice 1

this premium

Choice 2

the combined premium for hospital and medical insurance

HIB013 – MEDICARE HI/SMI PREMIUM PENALTY

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

This medical insurance premium includes

Choice 2

This hospital insurance premium includes

Choice 3

These hospital and medical insurance premiums include

Fill-in (2)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

HIB015 – PREMIUMS DEDUCTED FROM CIVIL SERVICE ANNUITY

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (2)

 

Choice 1

him

Choice 2

her

Choice 3

you

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

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

Leave Blank

Choice 2

The State of

Fill-in (2)

show State name

Fill-in (3)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (4)

Show the TP START DATE in the format MMCCYY

Fill-in (5)

 

Choice 1

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

Choice 2

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

Choice 3

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

Choice 4

Null

Fill-in (6)

 

Choice 1

Leave Blank

Choice 2

The State of

Fill-in (7)

show State name

Fill-in (8)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (9)

Show the TP START date in the format MMCCYY

Fill-in (10)

 

Choice 1

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

Choice 2

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

Choice 3

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

Choice 4

Null

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

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

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

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

Leave Blank

Choice 2

The State of

Fill-in (2)

Show State name

Fill-in (3)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (4)

Show TP STOP date in the format MMCCYY

Fill-in (5)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (6)

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

Fill-in (7)

 

Choice 1

Leave Blank

Choice 2

The State of

Fill-in (8)

Show State name

Fill-in (9)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (10)

Show the TP STOP date in the format MMCCYY

Fill-in (5)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (12)

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

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

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

Leave Blank

Choice 2

The State of

Fill-in (2)

Show the State name

Fill-in (3)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (4)

 

Choice 1

MMCCYY

Choice 2

MMCCYY and MMCCYY

Choice 3

MMCCYY through MMCCYY

Fill-in (5)

 

Choice 1

Leave Blank

Choice 2

The State of

Fill-in (6)

Show the State name

Fill-in (7)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (8)

 

Choice 1

MMCCYY

Choice 2

MMCCYY and MMCCYY

Choice 3

MMCCYY through MMCCYY

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

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (2)

MMCCYY

Fill-in (3)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (4)

MMCCYY

Fill-in (5)

 

Choice 1

BGN plus BLN possessive

Choice 2

your

Fill-in (6)

MMCCYY

Fill-in (7)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (8)

MMCCYY

HIB034 –ADVISE THAT SMI DEDUCTION WILL START/CONTINUE

We will (1) to deduct Medicare Part B (medical insurance) premium of (2) from (3) payments.

Fill-in values:

 

Fill-in (1)

 

Choice 1 start
Choice 2 continue

Fill-in (2)

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

Fill-in (3)

 

Choice 1

your

Choice 2

BGN plus BLN (possessive)

HIB038 – MEDICARE DISALLOWANCE CRIME AGAINST UNITED STATES

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (2)

 

Choice 1

he has

Choice 2

she has

Choice 3

you have

HIB042 – MEDICARE DISALLOWANCE FEHB ACT OF 1959

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (2)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Choice 4

he could be

Choice 5

she could be

Choice 6

you could be

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

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

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

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

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

(1) not entitled to (2) insurance coverage under Medicare because (3) application was filed too late. However, (4) may apply for coverage again during the next general enrollment period. A general enrollment period takes place in January, February and March of each year.

Fill-in values:

 

Fill-in (1)

 

Choice 1

Beneficiary Full Name plus the word “is”

Choice 2

You are

Fill-in (2)

 

Choice 1

medical

Choice 2

hospital

Choice 3

hospital and medical

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

he

Choice 2

she

Choice 3

you

HIB054 – HI AND/OR SMI PERIOD NOT PREVIOUSLY COVERED

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN the word “has”

Choice 2

Beneficiary First Name plus the word “has”

Choice 3

you have

Fill-in (2)

 

Choice 1

he believes

Choice 2

she believes

Choice 3

you believe

Fill-in (3)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

HIB060 – SUSPENSE FOR PRISON/MENTAL ADVISES OF SMI PREMIUMS

Generally, Medicare will not pay for hospital or medical items or services (1) while (2) (3). However, you may want to pay (4) Medicare medical insurance premiums for two reasons:

  • The premiums may be higher if you cancel the Medicare medical insurance now and reenroll after (5) released from (6).

  • (7) may not have medical insurance for a period of time after (8) released from (9). This is because (10) will have to wait until a general enrollment period to reenroll. A general enrollment period takes place in January, February and March of each year.

If you want to cancel (11) medical insurance, please let us know. If you decide to keep Medicare medical insurance, we will bill you for the premium. The first bill we send will be for all premiums now due. After that, each bill we send will be for a 3-month period and will be sent to you shortly before the payment is due.

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN plus the word “receives”

Choice 2

you receive

Fill-in (2)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (3)

 

Choice 1

imprisoned

Choice 2

confined in an institution

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (6)

 

Choice 1

prison

Choice 2

the institution

Fill-in (7)

 

Choice 1

BGN plus BLN

Choice 2

You

Fill-in (8)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (9)

 

Choice 1

prison

Choice 2

the institution

Fill-in (10)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (11)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB061 – SMI PREMIUM CONTINUES DEDUCTION FROM CS ANNUITY

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

Beneficiary Full Name (possessive)

Choice 2

your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB066 – HI/SMI PREMIUMS ALREADY PAID

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

medical

Choice 2

hospital

Choice 3

hospital and medical

Fill-in (2)

 

Choice 1

BGN plus BLN plus “has”

Choice 2

BGN plus “has”

Choice 3

you have

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB067 – SMI PREMIUM BILLING

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB068 – HI/SMI EQUITABLE RELIEF

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

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

(13)

Fill-in values:

 

Fill-in (1)

 

Choice 1

he wants

Choice 2

she wants

Choice 3

you want

Fill-in (2)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (3)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (4)

 

Choice 1

Show the HI-NONEQRELST date in MMCCYY

Choice 2

Show the SMI-NONEQRELST date in MMCCYY

Fill-in (5)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (6)

 

Choice 1

he wants

Choice 2

she wants

Choice 3

you want

Fill-in (7)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (8)

 

Choice 1

Show the HI-NONEQRELST date in MMCCYY

Choice 2

Show the SMI-NONEQRELST date in MMCCYY

Fill-in (9)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (10)

 

Choice 1

Show the total amount for HI premiums calculated

Choice 2

Show the total amount for SMI premiums calculated

Choice 3

Show the combined total amount for HI and SMI premiums calculated

Fill-in (11)

 

Choice 1

Show the HI-NONEQRELST date in MMCCYY

Choice 2

Show the SMI-NONEQRELST date in MMCCYY

Fill-in (12)

Show the COM month in MMCCYY

Fill-in (13)

 

Choice 1

tell us we can withhold this amount from the check.

Choice 2

tell us to bill you for this amount.

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

Your

Fill-in (2)

 

Choice 1 in the amount of + money amount for HI/SMI premiums due in $99,999.99 format
Choice 2 Null

Fill-in (3)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (6)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (7)

 

Choice 1

is

Choice 2

was

Fill-in (8)

 

Choice 1

Show the HI TERM date minus 1 month in MMCCYY

Choice 2

Show the SMI TERM date minus 1 month in MMCCYY

Fill-in (9)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (10)

 

Choice 1

he receives

Choice 2

she receives

Choice 3

you receive

Fill-in (11)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB070 – PREMIUM HI DWI CONTINUES SMI TERMINATES NON-PAYMENT

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (2)

 

Choice 1

medical

Choice 2

hospital

Fill-in (3)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (4)

 

Choice 1

medical

Choice 2

hospital

HIB071 – RRB JURIS STARTS AND COLLECTS MEDICARE PREMIUMS

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

HIB072 – RRB JURIS STARTS AND COLLECTS MEDICARE PREMIUMS

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN

Choice 2

You

Fill-in (2)

 

Choice 1

is

Choice 2

are

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (6)

 

Choice 1

him

Choice 2

her

Choice 3

you

HIB073 – RRB SENDS NEW MEDICARE CARD

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

Your

Fill-in (2)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB074 – NEW MEDICARE CARD

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (not possessive)

Choice 2

BGN (not possessive)

Choice 3

you

Fill-in (2)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (3)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

HIB075 – EQUITABLE RELIEF/HARDSHIP

If (1) benefits beginning (2) but (3) it hard to pay the premium amount in a lump sum, ask us about other ways to pay the money.

Fill-in values:

 

Fill-in (1)

 

Choice 1

he wants

Choice 2

she wants

Choice 3

you want

Fill-in (2)

 

Choice 1

Show the HI NONEQRELST date in MMCCYY

Choice 2

Show the SMI NONEQRELST date in MMCCYY

Fill-in (3)

 

Choice 1

find

Choice 2

finds

HIB076 – HI/SMI TERMINATION INFORMATIONAL

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

 If (9) to sign up for (10) later, (11) will usually have to wait until the general enrollment period. The general enrollment period takes place in January, February, and March of each year. If (12) up in the general enrollment period, (13) Part B coverage will start July 1 of the year (14) up.

Fill-in values:

 

Fill-in (1)

 

Choice 1

you do

Choice 2

he does

Choice 3

she does

Fill-in (2)

 

Choice 1

you are

Choice 2

he is

Choice 3

she is

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

you have

Choice 2

he has

Choice 3

she has

Fill-in (5)

 

Choice 1

Your

Choice 2

His

Choice 3

Her

Fill-in (6)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (7)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (8)

 

Choice 1

you sign

Choice 2

he signs

Choice 3

she signs

Fill-in (9)

 

Choice 1

you want

Choice 2

BGN plus BLN plus “wants”

Fill-in (10)

 

Choice 1

Part A

Choice 2

Part B

Choice 3

Part A and Part B

Fill-in (11)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (12)

 

Choice 1

you sign

Choice 2

he signs

Choice 3

she signs

Fill-in (13)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (14)

 

Choice 1

you sign

Choice 2

he signs

Choice 3

she signs

HIB077 – SMI TERMINATION INFORMATIONAL

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

you do

Choice 2

he does

Choice 3

she does

Fill-in (2)

 

Choice 1

you are

Choice 2

he is

Choice 3

she is

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

you have

Choice 2

he has

Choice 3

she has

Fill-in (5)

 

Choice 1

Your

Choice 2

His

Choice 3

Her

Fill-in (6)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (7)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (8)

 

Choice 1

you sign

Choice 2

he signs

Choice 3

she signs

HIB078 – HI TERMINATION INFORMATIONAL

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

His

Choice 2

Her

Choice 3

Your

Fill-in (2)

 

Choice 1

he re-enrolls

Choice 2

she re-enrolls

Choice 3

you re-enroll

HIB079 – VOLUNTARY TERMINATION FOR PREMIUM HI OR SMI

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN plus the word “is”

Choice 2

BGN plus the word “is”

Choice 3

you are

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

medical

Choice 2

hospital

Fill-in (4)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (5)

 

Choice 1

hospital

Choice 2

medical

Fill-in (6)

 

Choice 1

His

Choice 2

Her

Choice 3

Your

Fill-in (7)

Show the HI TERM date minus 1 month in MMCCYY format

HIB080 – VOLUNTARY SMI TERMINATION CIVIL SERVICE INVOLVED

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

BGN (possessive)

Choice 3

your

Fill-in (2)

 

Choice 1

him

Choice 2

her

Choice 3

you

HIB082 – HI AND/OR SMI VOLUNTARY TERMINATION

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN

Choice 2

You

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (4)

 

Choice 1

Show the HI TERM date minus 1 month in MMCCYY format

Choice 2

Show the SMI TERM date minus 1 month in MMCCYY format

HIB083 – SPECIAL ENROLLMENT PERIOD DISABILITY

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

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

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (not possessive)

Choice 2

BGN (not possessive)

Choice 3

You

Fill-in (2)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

meets

Choice 2

meet

Fill-in (5)

 

Choice 1

He is

Choice 2

She is

Choice 3

You are

Fill-in (6)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (7)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (8)

 

Choice 1

He is

Choice 2

She is

Choice 3

You are

Fill-in (9)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (10)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (11)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (12)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (13)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (14)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (15)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (16)

 

Choice 1

he has

Choice 2

she has

Choice 3

you have

HIB084 – SPECIAL ENROLLMENT PERIOD AGED

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

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

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (not possessive)

Choice 2

BGN (not possessive)

Choice 3

You

Fill-in (2)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (3)

 

Choice 1

he meets

Choice 2

she meets

Choice 3

you meet

Fill-in (4)

 

Choice 1

His

Choice 2

Her

Choice 3

Your

Fill-in (5)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (6)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (7)

 

Choice 1

He has

Choice 2

She has

Choice 3

You have

Fill-in (8)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (9)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (10)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (11)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (12)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (13)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB085 – VOLUNTARY SMI TERMINATION CURRENT PAY

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

BGN (possessive)

Choice 3

your

HIB086 – VOLUNTARY HI/SMI TERMINATION PREMIUMS DUE

(1) (2) (3) in premiums through (4). Please make (5) check or money order payable to the "Centers for Medicare & Medicaid Services" and mail it to us in the enclosed envelope. Include (6) Medicare number on (7) check or money order.

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (not possessive)

Choice 2

You

Fill-in (2)

 

Choice 1

owes

Choice 2

owe

Fill-in (3)

Show total past due amount in $999,999.99 format

Fill-in (4)

Show the HI/SMI termination date minus 1 month in the format May 1999

Fill-in (5)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (6)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (7)

 

Choice 1

your

Choice 2

his

Choice 3

her

HIB087 – VOLUNTARY SMI TERMINATION HI CONTINUES / MEDICARE WILL CONTINUE AFTER REQUEST FOR STATUTORY BENEFIT CONTINUATION (SBC) IS PROCESSED

(1) (2) coverage will continue.

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

Your

Fill-in (2)
Choice 1 Part A (hospital insurance)
Choice 2 Part B (medical insurance)

Choice 3

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

HIB088 – HI/SMI FOREIGN ADDRESS

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (2)

 

Choice 1

BGN plus BLN (not possessive)

Choice 2

BGN (not possessive)

Choice 3

you

Fill-in (3)

 

Choice 1

receives

Choice 2

receive

Fill-in (4)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (5)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (6)

 

Choice 1

he returns

Choice 2

she returns

Choice 3

you return

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN plus the word “is”

Choice 2

you are

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

hospital

Choice 2

hospital and medical

Fill-in (4)

Show HI-TERM date in MMCCYY format

Fill-in (5)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

HIB090 – TERMINATION ALL MEDICARE COVERAGE

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

Your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

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

Choice 2

Medicare Part B (medical insurance)

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB092 – STATE/LOCAL GOVT CONTINUES TO PAY SMI PREMIUM

(1) State or local government retirement system will continue to pay (2) Medicare medical insurance late enrollment premium penalty. (3) must continue to pay the basic Medicare medical insurance premium.

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

Your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

He

Choice 2

She

Choice 3

You

HIB093 – STATE OR GROUP CONTINUES TO PAY SMI PREMIUMS

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

the State

Choice 2

an organization

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

hospital and medical

Choice 2

medical

HIB101 – MEDICARE STATE BUY-IN

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

Leave blank

Choice 2

The State of

Fill-in (2)

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

Fill-in (3)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (4)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (5)

TP START date in MMCCYY format

Fill-in (6)

 

Choice 1

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

Choice 2

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

Choice 3

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

Choice 4

NULL

HIB102 – STATE BUY-OUT

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

Leave blank

Choice 2

The State of

Fill-in (2)

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

Fill-in (3)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (4)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (5)

Show the TP STOP date in MMCCYY format

Fill-in (6)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (7)

Show the TP STOP date plus 1 month in MMCCYY format

HIB103 – LIMITED BUY-IN AND BUY-OUT

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

Leave blank

Choice 2

The State of

Fill-in (2)

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

Fill-in (3)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (4)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (5)

 

Choice 1

MMCCYY

Choice 2

MMCCYY and MMCCYY

Choice 3

MMCCYY through MMCCYY

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

he currently has

Choice 2

she currently has

Choice 3

you currently have

Choice 4

he does not currently have

Choice 5

she does not currently have

Choice 6

you do not currently have

Fill-in (2)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

HIB105 – RETRO BUYIN/BUYOUT PAST DUE PREMIUMS

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

he still owes

Choice 2

she still owes

Choice 3

you still owe

Fill-in (2)

MMCCYY

HIB106 – STATE BUYIN FOR SMI PREMIUM PENALTY ONLY

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (2)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

His

Choice 2

Her

Choice 3

Your

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (6)

MM/YYYY

Fill-in (7)

 

Choice 1

he

Choice 2

she

Choice 3

you

HIB107 – STATE STOPS PAYING SMI PREMIUM PENALTY

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

Your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

show date in MMCCYY format

Fill-in (5)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (6)

show date in MMCCYY format

HIB108 – GROUP PAYER BUY-OUT

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (2)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (3)

show date in MMCCYY format

Fill-in (4)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (5)

Show date in MMCCYY format

HIB109 – 3RD Party SMI PREMIUM DEDUCTED FROM MBA

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

Fill-in values:

 

Fill-in (1)

Medicare medical insurance premium

Fill-in (2)

SMI premium amount in $9999.99 format

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (5)

 

Choice 1

he disagrees

Choice 2

she disagrees

Choice 3

you disagree

Fill-in (6)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB110 – SMI PREMIUM DEDUCTED FROM MBA PAST DUE PREMIUMS

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

Fill-in values:

 

Fill-in (1)

Medicare medical insurance premium

Fill-in (2)

SMI premium amount in $9999.99 format

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

premium amount due in 99999.99 format

Fill-in (5)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (6)

 

Choice 1

he disagrees

Choice 2

she disagrees

Choice 3

you disagree

Fill-in (7)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB111 – BUY-IN AND REFUND OF MEDICARE PREMIUMS

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (2)

 

Choice 1

he

Choice 2

she

Choice 3

you

HIB112 – BUYIN PREMIUM NO LONGER DEDUCTED FROM MBA

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (2)

 

Choice 1

you

Fill-in (3)

 

Choice 1

you disagree

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB113 – BUY-OUT NOT IN PAY STATUS PREMIUM BILLING

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

BGN (possessive)

Choice 3

your

Fill-in (2)

 

Choice 1

Medicare hospital insurance premium

Choice 2

Medicare medical insurance premium

Choice 3

Medicare hospital and medical insurance premiums

Fill-in (3)

 

Choice 1

premium is

Choice 2

premiums total

Fill-in (4)

money amount in format 999,999.99

Fill-in (5)

 

Choice 1

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

Choice 2

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

Choice 3

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

Choice 4

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

Fill-in (6)

 

Choice 1

he does

Choice 2

she does

Choice 3

you do

HIB114 – BENEFITS TERM PROFRA MEDICARE CONTINUES

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

Your

Fill-in (2)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

HIB115 – HI/SMI BUY-OUT

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

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

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN plus “wants”

Choice 2

you want

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

he cancels

Choice 2

she cancels

Choice 3

you cancel

Fill-in (4)

 

Choice 1

he cancels

Choice 2

she cancels

Choice 3

you cancel

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (6)

 

Choice 1

he cancels

Choice 2

she cancels

Choice 3

you cancel

Fill-in (7)

 

Choice 1

he contacts

Choice 2

she contacts

Choice 3

you contact

Fill-in (8)

 

Choice 1

he waits

Choice 2

she waits

Choice 3

you wait

Fill-in (9)

 

Choice 1

he contacts

Choice 2

she contacts

Choice 3

you contact

HIB119 – BILLING TO CONFIRM GROUP PAYER

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

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN

Choice 2

You

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (4)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (5)

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (6)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (7)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (8)

 

Choice 1

him

Choice 2

her

Choice 3

you

HIB120 – BUY-OUT FOR HI AND SMI

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (2)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (3)

 

Choice 1

he cancels

Choice 2

she cancels

Choice 3

you cancel

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Choice 4

he has

Choice 5

she has

Choice 6

you have

Fill-in (2)

 

Choice 1

disabled

Choice 2

over age 65

Choice 3

end stage renal disease

HIB132 – ESRD TERMINATES AND RRB JURISDICTION

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB133 – ESRD TERMINATION - SAME HI/SMI TERMINATION DATES

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (not possessive)

Choice 2

you

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

Show HI-TERM date minus 1 month in MMCCYY format

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (not possessive)

Choice 2

you

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

Show HI-TERM date minus 1 month in MMCCYY format

Fill-in (4)

 

Choice 1

His

Choice 2

Her

Choice 3

Your

Fill-in (5)

Show SMI-TERM date minus 1 month in MMCCYY format

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

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

  • (4) regular dialysis, or

  • (5) a kidney transplant

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

12th

Choice 2

36th

Fill-in (2)

 

Choice 1

he gets a transplant

Choice 2

she gets a transplant

Choice 3

you get a transplant

Choice 4

regular dialysis stops

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

begins

Choice 2

begin

Fill-in (5)

 

Choice 1

gets

Choice 2

get

Fill-in (6)

 

Choice 1

he got a kidney transplant

Choice 2

she got a kidney transplant

Choice 3

you got a kidney transplant

Choice 4

his dialysis stopped

Choice 5

her dialysis stopped

Choice 6

your dialysis stops

Fill-in (7)

 

Choice 1

Show KDNY-TRNSDATE date in MMCCYY format

Choice 2

Show DLYS-STOP date in MMCCYY format

Fill-in (8)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (9)

Show HI-TERM date minus 1 month in format MMCCYY

Fill-in (10)

 

Choice 1

His

Choice 2

Her

Choice 3

Your

Fill-in (11)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB136 – TERMINATION OF ESRD COVERAGE

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

he resumes

Choice 2

she resumes

Choice 3

you resume

Fill-in (2)

 

Choice 1

gets

Choice 2

get

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB137 – ESRD TERMINATES SAME HI/SMI TERMINATION DATES

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

  • a kidney transplant, or

  • resume regular dialysis.

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

12th

Choice 2

36th

Fill-in (2)

 

Choice 1

regular dialysis stops

Choice 2

a kidney transplant

Fill-in (3)

 

Choice 1

he gets

Choice 2

she gets

Choice 3

you get

Fill-in (4)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (5)

 

Choice 1

stopped regular dialysis

Choice 2

received a kidney transplant

Fill-in (6)

 

Choice 1

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

Choice 2

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

HIB142 – CURRENT PAY TO SUSPENSE OR DEFERRED STATUS

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

HIB143 – SMI PENALTY RATE TO BASE RATE AT AGE 65

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (not possessive)

Choice 2

you

Fill-in (2)

 

Choice 1

qualifies

Choice 2

qualify

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

Show the SMI premium penalty rate

Fill-in (6)

Show the SMI premium base rate

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

He

Choice 3

She

Fill-in (2)

MMCCYY

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

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

The word 'Is' BGN plus BLN

Choice 2

Are you

Fill-in (2)

 

Choice 1

Is he

Choice 2

Is she

Choice 3

Are you

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

If this notice is for a child under age 19 who is not covered by health insurance, there is a Children's Health Insurance Program that may help. To find out more, you can look on the Internet at (1) or call, toll free, 1-877-KIDS-NOW (1-877-543-7669). The number connects you to your state program.

Fill-in values:

 

Fill-in (1)

www.insurekidsnow.gov

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus 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

Fill-in (4)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (5)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (6)

 

Choice 1

he does

Choice 2

she does

Choice 3

you do

Fill-in (7)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (2)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (5)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (6)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (7)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (8)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

HIB162 – REFUSAL OVER AUTOMATIC ENROLLMENT

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (not possessive)

Choice 2

You

Fill-in (2)

 

Choice 1

he does

Choice 2

she does

Choice 3

you do

Fill-in (3)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

HIB163 – SMI REFUSAL CURRENT PAY REFUND OF PREMIUMS

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

You do

Choice 2

BGN plus BLN plus does

Fill-in (2)

 

Choice 1

you were

Choice 2

he was

Choice 3

she was

Fill-in (3)

 

Choice 1

you

Choice 2

him

Choice 3

her

HIB164 – SMI REFUSAL PREMIUM BILLING AND NO OPEN THIRD PARTY

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

he was

Choice 2

she was

Choice 3

you were

Fill-in (2)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (3)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (4)

 

Choice 1

he receives

Choice 2

she receives

Choice 3

you receive

Fill-in (5)

 

Choice 1

he

Choice 2

she

Choice 3

you

HIB165 – REFUSAL/WITHDRAWAL STATE BUY-IN ESTABLISHED

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (4)

 

Choice 1

he

Choice 2

she

Choice 3

you

HIB170 – MEDICARE COVERAGE WILL CONTINUE WHILE MEDICAL CESSATION APPEAL IS PENDING EVEN THOUGH PAYMENTS HAVE CEASED (STATE BUY-IN IS NOT INVOLVED)

Even though (1) no longer receiving monthly payments, (2) will still have (3) coverage under Medicare. (4)

(5)

Fill-in values:

 

Fill-in (1)

 

Choice 1

Disabled Beneficiary’s Given Name plus Beneficiary's Last Name (not possessive) plus “is”

Choice 2

you are

Fill-in (2)

 

Choice 1

you

Choice 2

he

Choice

she

Fill-in (3)

 

Choice 1

Part A (hospital insurance)

Choice 2

Part B (medical insurance)

Fill-in (4)

 

Choice 1

Please keep the Medicare card.

Choice 2

Null

Fill-in (5)

 

Choice 1

There is a monthly premium for Medical Part B. Because we stopped monthly payments, we will bill you every 3 months for the premiums.

Choice 2

There is a monthly premium for Medical Part B. Because we stopped monthly payments, we will bill him every 3 months for the premiums.

Choice 3

There is a monthly premium for Medical Part B. Because we stopped monthly payments, we will bill her every 3 months for the premiums.

Choice 4

Null

HIB171 – MEDICARE COVERAGE WILL CONTINUE WHILE MEDICAL CESSATION APPEAL IS PENDING EVEN THOUGH PAYMENTS HAVE CEASED (STATE BUY-IN IS INVOLVED)

Even though (1) no longer receiving monthly payments, (2) will still have Part A (hospital insurance) and Part B (medical insurance) coverage under Medicare. (3) The State where (4) will continue to pay the premiums for (5) Part B coverage.

Fill-in values:

 

Fill-in (1)

 

Choice 1

Disabled Beneficiary’s Given Name plus Beneficiary's Last Name (not possessive) plus “is”

Choice 2

you are

Fill-in (2)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (3)

 

Choice 1

Please keep the Medicare card.

Choice 2

Null

Fill-in (4)

 

Choice 1

you live

Choice 2

he lives

Choice 3

she lives

Fill-in (5)

 

Choice 1

your

Choice 2

his

Choice 3

her

HIB175 – SMI PREMIUMS/ARREARAGE DEDUCTED FROM PMA OR CMA

We are deducting past-due premiums (1) from (2) check.

Fill-in values:

 

Fill-in (1)

 

Choice 1 “of” plus the total past due SMI premiums in $999,999.99 format
Choice 2 Null

Fill-in (2)

 

Choice 1

Beneficiary's full name (possessive)

Choice 2

your

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

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

In an earlier letter, we told you that (1) Medicare Part B (medical insurance) premium includes:

  • the standard Part B premium amount,

  • any surcharge that may apply for late enrollment or reenrollment, and

  • an income-related monthly adjustment amount (IRMAA).

If (2) prescription drug coverage, (3) also must pay a prescription drug coverage IRMAA. The IRMAA is in addition to (4) monthly premium. We base the IRMAA on (5) income. We deduct the IRMAA from (6) monthly Social Security benefits, regardless of how (7) premiums.

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

BGN plus BLN (possessive)

Fill-in (2)

 

Choice 1

you have

Choice 2

she has

Choice 3

he has

Fill-in (3)

 

Choice 1

you

Choice 2

she

Choice 3

he

Fill-in (4)

 

Choice 1

your

Choice 2

her

Choice 3

his

Fill-in (5)

 

Choice 1

your

Choice 2

her

Choice 3

his

Fill-in (6)

 

Choice 1

your

Choice 2

her

Choice 3

his

Fill-in (7)

 

Choice 1

you pay your

Choice 2

he pays his

Choice 3

she pays her

HIB183 – USE WITH HIB182 WHEN IRMAA AFFECTS PART B RATE

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

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

The amount you will receive around (1) was changed because of a change in (2) monthly Medicare Part B premium.

Fill-in values:

 

Fill-in (1)

 

Choice 1

using the PCI show the calendar date of the COM check

Choice 2

using the PCI show the calendar date of the DPD check

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB186 – SMI MATURITY AND NO IRMAA DATA ON POST MBR

IMPORTANT: A Medicare law requires some higher income persons to pay higher premiums. The law applies to premiums for Medicare Part B (medical insurance) and prescription drug coverage. The law generally affects individuals with incomes higher than (1) and couples with incomes higher than (2). We will contact the Internal Revenue Service to get information about (3) income. If we decide that (4) to pay higher premiums, we will send a letter explaining our decision. The higher amount will be effective (5). For more information, please visit www.socialsecurity.gov on the Internet or call us toll-free at 1-800-772-1213 (TTY 1-800-325-0778).

Fill-in values:

 

Fill-in (1)

Show the IRMAA level 1 yearly amount for singles

Fill-in (2)

Show the IRMAA level 1 yearly amount for couples

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

he has

Choice 2

she has

Choice 3

you have

Fill-in (5)

show the SMI START date

HIB215 – T2 BENEFITS TERMINATE HI/SMI TERMINATES

Since (1) no longer entitled to monthly Social Security benefits, we are stopping (2) (3) insurance coverage under Medicare. (4) (5) insurance coverage ends on the last day of (6). Please destroy (7) Medicare card after the coverage ends.

Fill-in values:

 

Fill-in (1)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

hospital

Choice 2

hospital and medical

Fill-in (4)

 

Choice 1

His

Choice 2

Her

Choice 3

Your

Fill-in (5)

 

Choice 1

hospital

Choice 2

hospital and medical

Fill-in (6)

Show HI-TERM date in format MMCCYY

Fill-in (7)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB218 – REASON SMI PREMIUM/ARREARAGE IS BEING DEDUCTED

When we figured the amount of (1) payment, we took into account all medical insurance premiums which were already paid or still due (2).

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (2)

 

Choice 1

Null

Choice 2

“through” plus date COM in Month CCYY format

HIB225 – HRFST LESSDO MBA LESS THAN SMI PREMIUM

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

Your

Fill-in (2)

Show the current SMI premium amount

Fill-in (3)

 

Choice 1

BGN plus BLN (not possessive)

Choice 2

you

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (6)

Show the first EFD in HIST Data that corresponds to LESSDO

Fill-in (7)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (8)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (9)

Show money amount for the remaining premiums

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (2)

Show the first EFD in HIST Data that corresponds to LESSDO

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

Show current SMI premium amount

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (6)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (7)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN plus the word “is”

Choice 2

you are

Fill-in (2)

he / she / you

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (3)

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

HIB249 – OFFER RELIEF FOR SMI PREMIUMS (VSMI RATES)

If you want your medical insurance to start earlier, you can choose to have it start in (1). To start your medical insurance earlier, you must do the following things within 60 days after the date of this notice:

  • tell us in writing that you want medical insurance beginning (2);

AND

  • pay us (3) or tell us we can withhold this amount from your check. This amount covers the premiums due from (4) through (5).

If you would find it hard to pay the premium amount you would owe in a lump sum, ask us about other ways to pay the premium.

If you choose to have your medical insurance start in (6), your current monthly premium will be (7). If you do not choose the earlier date, your monthly premium will be (8).

Fill-in values:

 

Fill-in (1)

Show the SMI-NONEQRELST date

Fill-in (2)

Show the SMI-NONEQRELST date

Fill-in (3)

Show the total amount of the SMI premiums

Fill-in (4)

Show the SMI-NONEQRELST date

Fill-in (5)

Show the current operating month date

Fill-in (6)

Show the SMI-NONEQRELST date

Fill-in (7)

Show the current VSMI rate

Fill-in (8)

Show the current Part B premium rate

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

As we told you in another letter, you owe more Medicare premiums because (1) income-related monthly adjustment amounts changed.

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

HIB261 – PREMIUM RELIEF ESTABLISHED DUE TO IRMAA B

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

Fill-in values:

 

Fill-in (1)

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

Fill-in (2)

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

Fill-in (3)

 

Choice 1

null

Choice 2

and

Choice 3

through

Fill-in (4)

 

Choice 1

Null

Choice 2

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

HIB262 – PREMIUM RELIEF ESTABLISHED DUE TO IRMAA D

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

Fill-in values:

 

Fill-in (1)

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

Fill-in (2)

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

Fill-in (3)

 

Choice 1

null

Choice 2

and

Choice 3

through

Fill-in (4)

 

Choice 1

Null

Choice 2

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

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

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

Fill-in values:

 

Fill-in (1)

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

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

If you would find it hard to pay the past-due Medicare amounts (1) at one time, please ask us about other ways to pay them. You may ask for waiver of these past-due Medicare amounts if paying them would be a severe financial hardship for you. If we do not hear from you within 30 days after the date of this letter, we will take the Medicare amounts (2) out of (3) monthly Social Security payments beginning (4).

Fill-in values:

 

Fill-in (1)

 

Choice 1

he owes

Choice 2

she owes

Choice 3

you owe

Fill-in (2)

 

Choice 1

he owes

Choice 2

she owes

Choice 3

you owe

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

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

HIB265 – DEDUCTION OF CURRENT SMI PREMIUMS

We will deduct (1) current Medicare Part B (medical insurance) premium from (2) monthly Social Security payments beginning (3).

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN possessive

Choice 2

your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

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

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

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

Fill-in values:

 

Fill-in (1)

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

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

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

Fill-in values:

 

Fill-in (1)

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

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

We will deduct past-due Medicare prescription drug coverage income-related monthly adjustment amounts from your monthly Social Security payments beginning (1). The total amount we will deduct is (2).

Fill-in values:

 

Fill-in (1)

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

Fill-in (2)

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

HIB269 – FULL WITHHOLDING CONTINUES UNTIL PREMIUMS PAID IN FULL

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (2)

 

Choice 1

he owes

Choice 2

she owes

Choice 3

you owe

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

We will deduct past-due Medicare Part B (medical insurance) premiums from your monthly Social Security payments beginning (1). The total amount we will deduct is (2).

Fill-in values:

 

Fill-in (1)

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

Fill-in (2)

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

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

We will deduct past-due Medicare Part B (medical insurance) premiums from your monthly Social Security payments beginning (1). The total amount we will deduct is (2).

Fill-in values:

 

Fill-in (1)

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

Fill-in (2)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (3)

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

Fill-in (4)

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

HIB288 – SUBSEQUENT NOTICE WITH CMS BILLING STATEMENT AND INSTRUCTIONS FOR COMPLETING THE PAYMENT COUPON

We told you in another letter your Centers for Medicare & Medicaid Services (CMS) Billing Statement would be mailed in another envelope. At the end of this letter, you will find the CMS Billing Statement and instructions for completing the payment coupon.

HIB289 – (CMS) BILLING STATEMENT WIL L BE MAILED IN ANOTHER ENVELOPE

Your Centers for Medicare & Medicaid Services (CMS) Billing Statement will be mailed in another envelope.

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) (not possessive)

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) (not possessive)

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) (not possessive)

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) (not possessive)

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) (not possessive)

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) (not possessive)

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

Now that (1) (2) eligible for Medicare, (3) can enroll in a Medicare prescription drug plan (Part D).

To learn more about the Medicare prescription drug plans and when (4) can enroll, visit (5) or call 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048). Medicare also can tell (6) about agencies in (7) area that can help (8) choose (9) prescription drug coverage.

If (10) limited income and resources, we encourage (11) to apply for the extra help that is available to assist with Medicare prescription drug costs.  The extra help can pay the monthly premiums, annual deductibles and prescription co-payments.  To learn more or apply, please visit (12), call 1-800-772-1213 (TTY 1-800-325-0778) or visit the nearest Social Security office.

Fill-in values:

 

Fill-in (1)

 

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 benefits on another record. We will send you another letter about those 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

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 benefits on another record. We will send you another letter about those 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

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

NL 00730.130 "O" Paragraphs and Captions

A. "ONS" Paragraphs and Captions

ONS003 – EXPLANATION TO THE DISABLED ADULT CHILD WHEN HE OR SHE BECAME ENTITLED TO DISABILITY BENEFITS

We found that (1) became disabled under our rules on (2).

Fill-in values:

 

Fill-in (1)

 

Choice 1

you

Choice 2

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

Fill-in (2)

Date of entitlement

B. "OPT" Paragraphs and Captions

OPTC01 – CAPTION

Overpayment Information

OPT029 – NEW OVERPAYMENT – OVERPAYMENT NOT DUE TO TERMINATION

We paid (1) (2) for (3). Since we should have paid (4) (5) for (6), we paid (7) (8) more than (9) (10) due.

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)

Sum of the Monthly Benefit Credited (MBCs) on the pre-MBR starting with the internal Business Start Date and ending with Current Operating Month (COM) minus 1 month in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

Internal Business Start Date in format Month CCYY

Choice 2

Internal Business Start Date plus “and” plus Current Operating Month (COM) minus 1 month in the format Month CCYY

Choice 3

Internal Business Start Date plus “through” plus Current Operating Month (COM) minus 1 month in the format Month CCYY

Fill-in (4)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (5)

Sum of the Monthly Benefit Credited (MBCs) on the pre-MBR starting with the internal Business Start Date and ending with Current Operating Month (COM) minus 1 month in the format $$$$$.¢¢

Fill-in (6)

 

Choice 1

Internal Business Start Date in format Month CCYY

Choice 2

Internal Business Start Date plus “and” plus Current Operating Month (COM) minus 1 month in the format Month CCYY

Choice 3

Internal Business Start Date plus “through” plus Current Operating Month (COM) minus 1 month in the format Month CCYY

Fill-in (7)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (8)

Difference between Trigger Record New Overpayment Amount (TR-NEW-OPA-AMOUNT) and total Trigger Record Other Beneficiary Overpayment Amount (TR-OTH-BENE-OPA) in the format $$$$$.¢¢

Fill-in (9)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (10)

 

Choice 1

was

Choice 2

were

OPT064 – EXPLAINS TO A WORKING BENEFICIARY THERE IS AN OVERPAYMENT ON HIS OR HER RECORD FOR ONE YEAR BECAUSE THE EARNINGS THEY REPORTED IS DIFFERENT FROM WHAT SSA RECORDS SHOW

We recently found that the earnings (1) for (2) and the earnings information we have do not match. (3) told us (4) earned (5) in (6) but our records show that (7) earned (8). If our records are correct, we paid (9) (10) too much.

Fill-in values

 

Fill-in (1)

 

Choice 1

”reported for” plus Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)

Choice 2

“reported for you”

Fill-in (2)

Year in the format CCYY

Fill-in (3)

 

Choice 1

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

Choice 2

You

Fill-in (4)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (5)

Amount of reported earnings (AORE)

Fill-in (6)

Year of Earnings Report (YOER) in the format CCYY

Fill-in (7)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (8)

Amount of reported earnings (AORE)

Fill-in (9)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (10)

Overpayment amount

OPT065 – EXPLAINS TO A WORKING BENEFICIARY THAT BECAUSE THE EARNINGS PREVIOUSLY POSTED FOR MULTIPLE YEARS ARE LESS THAN THE EARNINGS ON THE MASTER EARNINGS RECORD, THERE ARE OVERPAYMENTS FOR MULTIPLE YEARS

We recently found that the earnings reported for (1) for the years shown below and the earnings on our records do not match. If our records are correct, we paid (2) (3) too much.

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

you

Choice 2

him

Choice 3

her

Fill-in (3)

Overpayment amount in the format $$$$$.¢¢

OPT084 – EXPLAINS TO A WORKING BENEFICIARY THAT BECAUSE THE EARNINGS PREVIOUSLY POSTED FOR A SINGLE YEAR ARE LESS THAN THE EARNINGS ON THE MASTER EARNINGS RECORD AND NO BENEFITS WERE WITHHELD FOR THIS YEAR, THERE IS AN OVERPAYMENT FOR JUST ONE YEAR

Our records show that (1) had earnings in (2) of (3) that we did not consider when we paid (4). If our records are correct, we paid (5) (6) too much.

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)

Year of Earnings Report (YOER) in the format CCYY

Fill-in (3)

Amount of reported earnings (AORE)

Fill-in (4)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (5)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (6)

Overpayment amount

OPT085 – TELLS THE BENEFICIARY THE OVERPAYMENT AMOUNT

(1), (2) us (3).

Fill-in values:

 

Fill-in (1)

 

Choice 1

After all the changes (use when earnings caused more than 1 adjustment)

Choice 2

As a result (use when earnings caused a single adjustment)

Fill-in (2)

 

Choice 1

you owe

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) plus “owes”

Fill-in (3)

Total overpayment amount

OPT086 – EARNINGS PREVIOUSLY POSTED FOR MULTIPLE YEARS ARE LESS THAN THE EARNINGS ON THE MASTER RECORD AND NO BENEFITS WERE WITHHELD, THEREFORE, THERE ARE OVERPAYMENTS FOR EACH YEAR

Our records show that (1) had earnings for the years shown below that we did not consider when we paid (2). If our records are correct, we paid (3) (4) too much.

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

him

Choice 2

her

Choice 3

you

Fill-in (3)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (4)

Total overpayment amount

OPT087 – CHART HEADING UTI THAT PROVIDES THE WORKING BENEFICIARY THE EARNINGS POSTED WITH NO BENEFITS PREVIOUSLY WITHHELD FOR THAT YEAR EARNINGS

Earnings On

Year Our Records

OPT088 – EXPLAINS TO A WORKING BENEFICIARY IN A CHART THE EARNINGS POSTED WHEN NO BENEFITS WERE PREVIOUSLY WITHHELD FOR THESE EARNINGS

(1) (2)

Fill-in values:

 

Fill-in (1)

Year of Earnings Report (YOER) in format CCYY

Fill-in (2)

Amount of reported earnings (AORE)

OPT096 – PRIOR OVERPAYMENT WITH A PROTEST AND PROTEST DECISION STILL PENDING

We already told you that we paid (1) (2) too much for a past period. We will send you another letter to let you know what we will do about the recovery of that money.

Fill-in values

 

Fill-in (1)

 

Choice 1

you

Choice 2

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

Fill-in (2)

 

Choice 1

Due process overpayment amount in the format $$$$$.¢¢

Choice 2

Null

OPT097 – RECOVERY OF AN INCORRECT PAYMENT

Once we get back the money (1) not due for this year, we will start to withhold (2) benefits to get back the other money (3).

Fill-in values

 

Fill-in (1)

 

Choice 1

you were

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) plus “was”

Fill-in (2)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (3)

 

Choice 1

you owe

Choice 2

he owes

Choice 3

she owes

OPT107 – FULL OR PARTIAL WITHHOLDING FOR ONE MONTH

We will withhold (1) (2) (3) (4) payment to recover the money we (5) (6). This is the payment you would normally receive about (7).

Fill-in values:

 

Fill-in (1)

 

Choice 1

Overpayment amount

Choice 2

Null

Fill-in (2)

 

Choice 1

from

Choice 2

Null

Fill-in (3)

 

Choice 1

your

Choice 4

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

Fill-in (4)

Recovery of the overpayment date in the format Month CCYY

Fill-in (5)

 

Choice 1

overpaid

Choice 2

incorrectly paid

Fill-in (6)

 

Choice 1

you

Choice 2

him

Choice 3

her

Fill-in (7)

Date the overpayment will be deducted in the format Month DD, CCYY

OPT122 – NEW OVERPAYMENT DUE TO RETROACTIVE TERMINATION

Since we did not stop (1) payments until (2), (3) paid (4) too much in 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)

Current Operating Month (COM) in format Month CCYY

Fill-in (3)

 

Choice 1

he was

Choice 2

she was

Choice 3

you were

Fill-in (4)

New overpayment amount in $$$$$.¢¢

OPT123 – TOTAL OVERPAYMENT INCLUDES PRIOR OVERPAYMENT

(1) total overpayment of (2) includes (3) prior overpayment.

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)

Due Process Overpayment (DPO) on the post-MBR in format $$$$$.¢¢

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

OPT125 – BENEFICIARY'S OVERPAYMENT BEING RECOVERED FROM ANOTHER AUXILIARY

We paid other person(s) on this record (1) more in benefits than we should have. Under Social Security law, you are responsible for this overpayment.

Fill-in values:

 

Fill-in (1)

Other beneficiary's overpayment amount in format $$$$$.¢¢

OPT127 – ADVISES OF OVERPAYMENT RECOVERY AMOUNT (OPRA) ON POST-MBR

We used (1) of (2) benefits to recover (3) of an overpayment on this record.

Fill-in values:

 

Fill-in (1)

Overpayment Recovery Amount (OPRA) on post-MBR in format $$$$$$.¢¢

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

all

Choice 2

part

OPT128 – BENEFICIARY’S NEW OVERPAYMENT, BENEFICIARY’S PRIOR OVERPAYMENT AND ANOTHER BENEFICIARY’S OVERPAYMENT

(1) total overpayment of (2) includes (3) prior overpayment and another beneficiary's overpayment that (4) (5) liable for under Social Security law.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Fill-in (2)

Due Process Overpayment (DPO) amount on the post-MBR in format $$$$$.¢¢

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (5)

 

Choice 1

is

Choice 2

are

OPT131 – REMAINING BALANCE ON PRIOR OVERPAYMENT

(1) (2) an outstanding balance remaining on a prior overpayment. That remaining balance is (3).

Fill-in values:

Fill-in (1)
Choice 1 Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
Choice 2 You
Fill-in (2)
Choice 1 has
Choice 2 have

Fill-in (3)

Show the remaining overpayment amount or the old overpayment amount in format $999,999.99

OPT132 – PIC A (H) DIES OR PIC B DIES AND HAVE JOINT BANK DATA ON MBR AND THERE IS AN OVERPAYMENT

We paid (1) more in benefits than we should have. We deposited (2) benefits for (3) into a bank account which (4) also owned. We can't pay benefits for the month of death, (5), or later. Because (6) a joint owner of the bank account, (7) overpaid (8).

Fill-in values:

 

Fill-in (1)

 

Choice 1

New overpayment amount

Fill-in (2)

 

Choice 1

NH-FULL name (possessive) when PIC A died and PIC B is responsible for the overpayment

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) when PIC B died and PIC A is responsible for the overpayment

Fill-in (3)

 

Choice 1

Beneficiary's date of death when Beneficiary Date of Death (BDOD) = Current Operating Month (COM) minus 1 month

Choice 2

Beneficiary's date of death plus “and” plus the Current Operating Month (COM) minus 1 month when the Beneficiary Date of Death (BDOD) = Current Operating Month (COM) minus 2 months

Choice 3

Beneficiary's date of death plus “through” plus Current Operating Month (COM) minus 1 month when the Beneficiary Date of Death (BDOD) > Current Operating Month (COM) minus 2 months

Fill-in (4)

Choice 1

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

Choice 2

you

Fill-in (5)

 

Choice 1

Beneficiary Date of Death (BDOD) for PIC A in the format Month CCYY

Choice 2

Beneficiary Date of Death (BDOD) for PIC B in the format Month CCYY

Fill-in (6)

 

Choice 1

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) plus “is”

Choice 2

you are

Fill-in (7)

 

Choice 1

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) plus “is”

Choice 2

you are

Fill-in (8)

 

Choice 1

Trigger Record New Overpayment Amount (WS-TR-NEW-OPA) in the format $$$$$.¢¢

Choice 2

Trigger Record Other Beneficiary Overpayment Amount (WS-TR-OTH-BENE-OPA) for WS-TR-OTH-OPA-BIC = A or WS-TR-OTH-BENE-OPA-BIC = B in the format $$$$$.¢¢

OPT133 – BENEFICIARY(S) DIE AND OVERPAYMENT RECOVERED FROM ANOTHER ENTITLED BENEFICIARY

We paid you (1) more in benefits than we should have. The overpayment occurred because we did not stop (2) benefits for (3). We can't pay benefits for the month of death, (4), or later.

Fill-in values:

 

Fill-in (1)

 

Choice 1

New overpayment amount

Choice 2

If more than one dead beneficiary is overpaid and overpayments are being recovered from another entitled beneficiary, then show the total amount of all overpaid beneficiaries

Fill-in (2)

 

Choice 1

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) for one overpaid beneficiary

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) plus “and” for two overpaid beneficiaries followed by the Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) for the second overpaid beneficiary

Choice 3

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) followed by a comma followed by Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) for the second overpaid beneficiary plus “and” followed by Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) for the third overpaid beneficiary

NOTE: If more than three dead beneficiaries with the same BDOD and overpaid, then an Incomplete notice will be generate (see Incomplete Notices under the Completion Code section for the CODE and more information)

Fill-in (3)

 

Choice 1

Beneficiary's date of death when Beneficiary Date of Death (BDOD) = Current Operating Month (COM) minus 1 month

Choice 2

Beneficiary's date of death plus “and” plus the Current Operating Month (COM) minus 1 month when the BDOD = COM minus 2 months

Choice 3

Beneficiary's date of death plus “through” plus COM minus 1 month when the Beneficiary Date of Death (BDOD) > Current Operating Month (COM) minus 2 months

Fill-in (4)

Beneficiary Date of Death (BDOD)

OPT147 – DUE PROCESS TITLE II OVERPAYMENT RECOVERY LESS THAN FULL MONTHLY BENEFIT AMOUNT

We plan to recover this overpayment (1) the payment (2) would normally receive about (3).

Fill-in values:

 

Fill-in (1)

 

Choice 1

from

Choice 2

by withholding

Fill-in (2)

 

Choice 1

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

Choice 2

you

Fill-in (3)

Use the Due Process Recovery Date (DPRD) plus 1 month to determine the month and year; then using the Payment Cycle Indicator (PCI) on the post-MBR call the PCI utility to get the correct day that corresponds to the determined month and year and show this date as the Fill-in value in the format Month DD, CCYY

OPT148 – TITLE XVI (SSI) UNDERPAYMENT USED TO REDUCE OR RECOVERY A TITLE II OVERPAYMENT (CROSS PROGRAM RECOVERY PHASE 3)

We used (1) of (2) SSI benefits to recover some or all of an overpayment on this record.

Fill-in values:

 

Fill-in (1)

Deductions Additions History Amount (DAH-AMOUNT) that corresponds to the Deductions Additions History Type of Payment Code (DAH-TOP) = P and Deductions Additions History Item Code (DAH-ITEM) = 382 in the format $$$$$$.¢¢

Fill-in (2)

 

Choice 1

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

Choice 2

your

OPT149 – TITLE XVI (SSI) UNDERPAYMENT NOT USED TO REDUCE OR RECOVERY A TITLE II OVERPAYMENT (CROSS PROGRAM RECOVERY PHASE 3)

We did not use any of (1) SSI benefits to recover an overpayment on this record.

Fill-in values:

Fill-in (1)

Choice 1

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

Choice 2

your

OPT216 – OVERPAYMENT CAUSED BY SUBSTANTIAL GAINFUL WORK ACTIVITY (SGA) DURING THE EXTENDED PERIOD OF ELIGIBILITY (EPE) OR DISABILITY CESSATION DUE TO SGA

(1) received (2) too much in benefits because of (3) work activity. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

Choice 1

your

Choice 2

his

Choice 3

her

Choice 4

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

Fill-in (4)

Choice 1

your

Choice 2

his

Choice 3

her

OPT217 – OVERPAYMENT ESTABLISHED VIA CROSS PROGRAM RECOVERY (CPR) TO RECOVER A TITLE VIII SPECIAL VETERANS BENEFITS (SVB) PAID IN EXCESS

(1) received (2) too much in Special Veterans Benefit (SVB) payments. Please read the rest of this letter carefully. In it, we explain the changes we made to (3) benefits.

Fill-in values:

Fill-in (1)

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

Choice 1

your

Choice 2

his

Choice 3

her

OPT218 – OVERPAYMENT CAUSED DUE TO INCORRECT PAYMENTS FOR MEDICARE SERVICES

(1) received (2) too much in benefits because of incorrect payments for Medicare services. Please read the rest of this letter carefully. In it, we explain the changes we made to (3) benefits.

Fill-in values:

Fill-in (1)

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT219 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFCIARY WAS CONVICTED OF A CRIME OR IMPRISONED FOR MORE THAN 30 DAYS DUE TO FELONIOUS HOMICIDE

(1) received (2) too much in benefits because (3) criminal conviction and imprisonment for more than 30 days. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

Fill-in (1)

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (4)

Choice 1

your

Choice 2

his

Choice 3

her

OPT220 – OVERPAYMENT CAUSED BY WINDFALL OFFSET

(1) received (2) too much in benefits because (3) received Supplemental Security Income (SSI) payments (4) (5). Please read the rest of this letter carefully. In it, we explain the changes we made to (6) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

Choice 1

from

Choice 2

in

Fill-in (5)

Choice 1

Month CCYY through Month CCYY

Choice 2

Month CCYY

Fill-in (5)

Choice 1

your

Choice 2

his

Choice 3

her

OPT221 – OVERPAYMENT ESTABLISHED BECAUSE MORE THAN ONE PAYMENT WAS CASHED FOR THE SAME MONTH

(1) received (2) too much in benefits because we should not have paid two payments for the same month(s). Please read the rest of this letter carefully. In it, we explain the changes we made to (3) benefits.

Fill-in values:

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT222 – OVERPAYMENT ESTABLISHED DUE TO INVALID FAMILY RELATIONSHIPS

(1) received (2) too much in benefits because (3) did not meet the relationship requirements to receive benefits. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT223 – OVERPAYMENT ESTABLISHED BECAUSE OF INVALID ENTITLEMENT

(1) received (2) too much in benefits because (3) did not qualify for benefits. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT224 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY WAS DEPORTED

(1) received (2) too much in benefits because (3) deported from the United States. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you were

Choice 2

he was

Choice 3

she was

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT225 – OVERPAYMENT ESTABLISHED DUE TO INCORRECT COMPUTATION, A LEGALLY DEFINED OVERPAYMENT OR TO RECOVER A SKELETON DUE PROCESS OVERPAYMENT

(1) received (2) too much in benefits because the payment amount was incorrect. We corrected (3) record, which caused (4) benefit amount to decrease. Please read the rest of this letter carefully. In it, we explain the changes we made to (5) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (5)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT226 – OVERPAYMENT ESTABLISHED DUE TO SUBVERSIVE ACTIVITY

(1) received (2) too much in benefits because (3) convicted of a crime against the United States. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you were

Choice 2

he was

Choice 3

she was

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT227 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY DID NOT HAVE A CHILD IN THEIR CARE

(1) received (2) too much in benefits because (3) a child in (4) care who receives benefits from us. Please read the rest of this letter carefully. In it, we explain the changes we made to (5) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you no longer have

Choice 2

he no longer has

Choice 3

she no longer has

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (5)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT229 – OVERPAYMENT ESTABLISHED BECAUSE A WARRANT FOR THE BENEFICIARY’S ARREST EXISTS

(1) received (2) too much in benefits. We should not have paid (3) because of a warrant for (4) arrest. Please read the rest of this letter carefully. In it, we explain the changes we made to (5) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you

Choice 2

him

Choice 3

her

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (5)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT230 – OVERPAYMENT ESTABLISHED BECAUSE OF STATE OR FEDERAL ASSISTANCE

(1) received (2) too much in benefits because (3) received State or Federal assistance. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT231 – OVERPAYMENT CAUSED BY REPRESENTATIVE PAYEE MISUSE OF BENEFITS

(1) received (2) too much in benefits because (3) misused funds while acting as a representative payee. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT232 – OVERPAYMENT CAUSED BY DISABILITY CESSATION

(1) received (2) too much in benefits because we cannot pay benefits after (3) disability ends. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

Choice 4

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

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT234 – OVERPAYMENT ESTABLISHED DUE TO RECEIPT OF PROVISIONAL BENEFITS ON A CLAIM THAT WAS LATER DENIED

(1) received (2) too much in benefits because (3) you received temporary benefits while we were making a decision on (4) claim that we later denied. Please read the rest of this letter carefully. In it, we explain the changes we made to (5) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

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)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT235 – OVERPAYMENT ESTABLISHED DUE TO CROSS-BENEFIT ADJUSTMENT

We moved (1) overpayment of (2) to (3) for collection. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

another person's

Choice 2

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

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you

Choice 2

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

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT236 – OVERPAYMENT ESTABLISHED DUE TO CHANGE IN THE AMOUNT OR COMMENCEMENT OF THE GOVERNMENT PENSION OFFSET

(1) received (2) too much in benefits because we must offset (3) benefit payments due to (4) receipt of a government pension. Please read the rest of this letter carefully. In it, we explain the changes we made to (5) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (5)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT237 – OVERPAYMENT ESTABLISHED DUE TO RECEIPT OF A PENSION BASED ON WORK NOT COVERED BY SOCIAL SECURITY TAXES

(1) received (2) too much in benefits because (3) received a pension based on work not covered by Social Security taxes. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill -in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Choice 4

Wage Earner’s Name

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT238 – OVERPAYMENT ESTABLISHED DUE TO RECEIPT OF PAYMENTS AFTER CONFINEMENT TO A MENTAL INSTITUTION BECAUSE OF A COURT ORDER

(1) received (2) too much in benefits because (3) received payments after being confined to an institution because of a court order. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT239 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY WAS AN ALIEN LIVING OUTSIDE THE UNITED STATES WHILE RECEIVING BENEFITS

(1) received (2) too much in benefits because (3) not a United States citizen and (4) outside the country for six months in a row. Please read the rest of this letter carefully. In it, we explain the changes we made to (5) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you are

Choice 2

he is

Choice 3

she is

Fill-in (4)

 

Choice 1

you were

Choice 2

he was

Choice 3

she was

Fill-in (5)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT240 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY WORKED OUTSIDE THE US IN A JOB NOT COVERED UNDER SOCIAL SECURITY TAXES

(1) received (2) too much in benefits because (3) you worked outside the United States in a job not covered by United States Social Security taxes. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT241 – OVERPAYMENT ESTABLISHED DUE TO PRISONER SUSPENSION

(1) received (2) too much in benefits because of (3) criminal conviction and confinement in a correctional institution for more than 30 days. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT242 – OVERPAYMENT ESTABLISHED DUE TO DEATH RECLAMATION, REPRESENTATIVE PAYEE ELECTRONIC FUNDS TRANSFER (EFT) AFTER DEATH OR REPRESENTATIVE PAYEE DEATH

(1) received (2) too much in benefits because we cannot pay benefits for the month of death or later. Please read the rest of this letter carefully. In it, we explain the changes we made to (3) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT243 – OVERPAYMENT ESTABLISHED DUE TO PERMANENT DEDUCTIONS RESULTING FROM THE ANNUAL EARNINGS TEST

(1) received (2) too much in benefits because of (3) work and earnings. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT244 – OVERPAYMENT ESTABLISHED DUE TO DEATH SUPER-ENDORSEMENT

(1) received (2) too much in benefits because (3) signed and cashed a check for the month of death or later . Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT245 – OVERPAYMENT ESTABLISHED DUE TO A CHANGE IN MARITAL STATUS

(1) received (2) too much in benefits because of a change in (3) marital status. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT246 – OVERPAYMENT ESTABLISHED DUE TO ENTITLEMENT TO WORKERS’ COMPENSATION, PUBLIC DISABILITY OR BOTH

(1) received (2) too much in benefits because of (3) receipt of workers’ compensation, pubic disability payments or both of these payments. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT247 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY CONTINUED TO RECEIVE BENEFITS AFTER THE AGE OF 18

(1) received (2) too much in benefits because we do not pay benefits once a student reaches age 18, unless he or she is a full time student elementary or high school student. Please read the rest of this letter carefully. In it, we explain the changes we made to (3) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT248 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY CONTINUED TO RECEIVE BENEFITS AFTER AGE 19 OR 22

(1) received (2) too much in benefits because we do not pay benefits once a full-time student reaches age 19, unless (3) disabled or meet(s) an exception which allows benefits to continue:

  • for 2 months after a student turns 19, or;

  • until the end of the school term, whichever comes first.

Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you are

Choice 2

he is

Choice 3

she is

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT249 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY IS NO LONGER IN FULL-TIME SCHOOL ATTENDANCE

(1) received (2) too much in benefits because we do not pay benefits once a student stops going to school full-time. Please read the rest of this letter carefully. In it, we explain the changes we made to (3) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT250 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY REFUSED TO ACCEPT VOCATIONAL REHABILITATION

(1) received (2) too much in benefits because we should not have paid benefits when (3) refused vocational rehabilitation services. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT252 – OVERPAYMENT ESTABLISHED DUE TO UNPAID ATTORNEY FEES

(1) received (2) too much in benefits because of unpaid attorney’s fees. Please read the rest of this letter carefully. In it, we explain the changes we made to (3) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT253 – OVERPAYMENT ESTABLISHED RAILROAD RETIREMENT BOARD EARNINGS WERE INCORRECTLY USED TO ESTABLISH THE BENEFICARY’S ENTITLEMENT

(1) received (2) too much in benefits because (3) received incorrect payments from the Railroad Retirement Board. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT254 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICARY WAS NOT A UNITED STATES (U.S.) CITIZEN OR LAWFULLY PRESENT IN THE U.S.

(1) received (2) too much in benefits because (3) received payments even though (4) not a United States citizen or lawfully present in the U.S. Please read the rest of this letter carefully. In it, we explain the changes we made to (5) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

you were

Choice 2

he was

Choice 3

she was

Fill-in (5)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT255 – OVERPAYMENT ESTABLISHED BECAUSE THE MONTH OF ENTITLEMENT WAS INCORRECT

(1) received (2) too much in benefits because of a change in the month (3) benefits started. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT257 – OVERPAYMENT ESTABLISHED DUE TO MULTIPLE ENTITLEMENTS

(1) received (2) too much in benefits because (3) received payments on two or more records for the same month(s). Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT258 – OVERPAYMENT ESTABLISHED BECAUSE INSURED STATUS WAS NOT MET

(1) received (2) too much in benefits because (3) worked long enough under Social Security to receive monthly benefits. Please read the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you have not

Choice 2

he has not

Choice 3

she has not

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT259 – OVERPAYMENT ESTABLISHED BECAUSE THE BENFICIARY MISUSED FUNDS WHILE SERVING AS A REPRESENTATIVE PAYEE

(1) received (2) too much in benefits because (3) misused benefits that (4) received as the representative payee for another person. Please read the rest of this letter carefully. In it, we explain the changes we made to (5) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Fill-in (2)

Overpayment amount in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (5)

 

Choice 1

your

Choice 2

his

Choice 3

her

OPT302 – OVERPAYMENT TRANSFERRED FROM ANOTHER RECORD FOR A DUALLY ENTITLED BENEFICIARY

We have determined that (1) (2) overpaid (3) on another record. We will recover this overpayment on this record.

Fill-in values:

 

Fill-in (1)

 

Choice 1

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)

Choice 2

you

Fill-in (2)

 

Choice 1

is

Choice 2

are

Fill-in (3)

Overpayment amount in the format $$$$$.¢¢

NL 00730.132 “P” Paragraphs and Captions

List of “P” Paragraphs and Captions

A. “PAY” Universal Text Identifiers - Payment

PAYB02 – PRIOR MONTH ACCRUAL AMOUNT (PAMT) PAID WITH CURRENT TITLE II REDESIGN RUN DATE

You will receive (1) around (2).

Fill-in values:

Fill-in (1)

Prior Month Accrual Amount (PAMT) in the Schedule Pay field on the post-MBR

Fill-in (2)

Run Date plus 15 days in the format Month DD, CCYY

PAYB04 – CURRENT OR DEFERRED PAYMENT AMOUNT DUE AND CURRENT AMOUNT (CAMT) > $0.00

You will receive (1) for (2) around (3).

Fill-in values:

Fill-in (1)

 

Choice 1

Payment amount in the format $$$$$.¢¢ or $$$$$ [Special Payment Amount (SPA) or Monthly Benefit Payable(MBP)]

Choice 2

Current Amount (CMA) in the format $$$$$.¢¢ or $$$$$

Fill-in (2)

 

Choice 1

Current Operating Month (COM) in the format Month CCYY

Choice 2

Deferred Payment Date (DPD) in the format Month CCYY

Fill-in (3)

 

Choice 1

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

Choice 2

Using the Payment Cycle Indicator (PCI), show the calendar date in which the Deferred Payment Date (DPD) check will be paid

PAYB09 – TELLS BENEFICIARY THEIR MONTHLY BENEFIT PAYMENT

(1) After that, you will receive (2) (3) (4) (5).

Fill-in values:

Fill-in (1)

Null

Fill-in (2)

Monthly Benefit Payable (MBP) in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

for

Choice 2

through

Choice 3

on or about the

Fill-in (4)

 

Choice 1

third

Choice 2

second Wednesday

Choice 3

third Wednesday

Choice 4

fourth Wednesday

Choice 5

Current Operating Month (COM) + 1 month in the format Month CCYY

Choice 6

Work Resumption Diary Date 1 (WRDD1) - 1 month in the format Month CCYY

Fill-in (5)

 

Choice 1

of each month

Choice 2

Null

PAYB15 – MATURING ACTIONS - PAYMENT MONTH

(1) will receive (2) around (3). This is the money, after all deductions, (4) due for (5).

Fill-in values:

Fill-in (1)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (2)

Current Amount (CAMT) in the format $$$$$.¢¢

Fill-in (3)

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

Fill-in (4)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (5)

Show the Current Operating Month (COM) in the format Month CCYY

PAYB16 – MATURING ACTIONS SMI AND/OR VOLUNTARY TAX WITHHOLDING DEDUCTED BENEFITS

We withheld (1) (2) from this payment.

Fill-in values:

Fill-in (1)

 

Choice 1

Supplemental Medical Insurance Premium Due Amount (SMI-PREMIUM-AMOUNT) deducted in the format $$$$

Choice 2

Voluntary Tax Current Payment Withholding Amount (VCAMT) in the format $$$$

Choice 3

Total Supplemental Medical Insurance Premium Due Amount (SMI-PREMIUM-AMOUNT) plus the Voluntary Tax Current Payment Withholding Amount (VCAMT) in the format $$$$

Fill-in (2)

 

Choice 1

for medical insurance premiums

Choice 2

for voluntary tax withholding

Choice 3

for medical insurance premiums and for voluntary tax withholding

PAYC01 – CAPTION

What We Will Pay and When

PAYC07 – CAPTION

Information About (1) Payments

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

Your

PAYC12 – CAPTION

Why We Cannot Pay Current Benefits

PAYC27 – CAPTION

How (1) Benefits Can Be Paid

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

Your

PAY037 – PRIOR AERO ACTION DIFFERENCE IN CURRENT MONTHLY ACCRUAL (CMA) CHECK - SAME CURRENT OPERATING MONTH (COM)

You will receive (1) increase in benefits in a separate payment.

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

your

PAY084 – BENEFICIARY'S NOTICE PAYEE CHANGE – CURRENT AMOUNT (CAMT) PAID

We are sending your regular monthly check of (1) to (2) around (3).

Fill-in values:

Fill-in (1)

 

Choice 1

Amount in the Special Payment Amount (SPA) in the format $$$$$.¢¢ or $$$$$$

Choice 2

Current Amount (CAMT) in the format $$$$$.¢¢ or $$$$$$

Choice 3

Monthly Benefit Payable (MBP) in the format $$$$$.¢¢ or $$$$$$

Fill-in (2)

New Payee's Name

Fill-in (3)

 

Choice 1

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

Choice 2

Using the Payment Cycle Indicator (PCI), show the calendar date in which the Deferred Payment Date (DPD) check will be paid

PAY085 – BENEFICIARY’S NOTICE - PAYEE CHANGE PRIOR MONTH ACCRUAL AMOUNT (PAMT) AND CURRENT AMOUNT (CAMT) BOTH PAID

We are sending (1) to (2) for you around (3). We will begin sending your regular monthly check of (4) to your payee around (5).

Fill-in values:

Fill-in (1)

Prior Month Accrual Amount (PAMT) > $0.00

Fill-in (2)

New Payee's Name

Fill-in (3)

Trigger Run Date (TR-RUN-DATE) plus 15 days in format Month DD, CCYY

Fill-in (4)

 

Choice 1

Amount in the Special Payment Amount (SPA) in the format $$$$$.¢¢ or $$$$$$

Choice 2

Current Amount (CAMT) in the format $$$$$.¢¢ or $$$$$$

Choice 3

Monthly Benefit Payable (MBP) in the format $$$$$.¢¢ or $$$$$$

Fill-in (5)

 

Choice 1

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

Choice 2

Using the Payment Cycle Indicator (PCI), show the calendar date in which the Deferred Payment Date (DPD) check will be paid

PAY092 – USED WITH PARAGRAPH PAY002 WHEN PAYING A PRIOR MONTHLY ACCRUAL (PMA) CHECK

This is the (1) money (2) (3) due (4) (5) (6) (7).

Fill-in values:

 

Fill-in (1)

Null

Fill-in (2)

 

Choice 1

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

Choice 2

Beneficiary’s Given Name (BGN)

Choice 3

you

Fill-in (3)

 

Choice 1

are

Choice 2

is

Fill-in (4)

through

Fill-in (5)

Prior Month Accrual Amount Payment Date (PAMT-PAID-REL-D) for the Prior Month Accrual Amount (PAMT) > $0.00 on the post-MBR

Fill-in (6)

Null

Fill-in (7)

Null

PAY116 – BENEFITS TERMINATE CURRENT OPERATING MONTH (COM) + 1 – CURRENT AMOUNT (CAMT) PAID FOR CURRENT OPERATING MONTH (COM)

This is the last payment (1) will receive.

Fill-in values:

Fill-in (1)

 

Choice 1

Mr. plus Beneficiary Last Name (BLN)

Choice 2

Ms. plus Beneficiary Last Name (BLN)

Choice 3

you

PAY126 – BENEFICIARY'S NOTICE - PAYEE CHANGE – PRIOR MONTH ACCRUAL AMOUNT (PAMT) PAID

We are sending (1) to (2) for you around (3).

Fill-in values:

Fill-in (1)

Prior Month Accrual Amount (PAMT) > $0.00

Fill-in (2)

New Payee's Name

Fill-in (3)

Prior Month Accrual Amount Payment Date (PAMT- PAID-REL-D) associated with the Prior Month Accrual Amount (PAMT) > $0.00

PAY148 – DEFERRED FOR OVERDUE OVERPAYMENT OR PARTIAL RECOVERY ESTABLISHED

We are withholding (1) of (2) monthly benefits (3) (4) to recover (5).

Fill-in values:

Fill-in (1)

 

Choice 1

all

Choice 2

some

Choice 3 Monthly Recovery Amount (MRA) on the Post-MBR

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 beginning
Choice 2 Null

Fill-in (4)

 

Choice 1

Current Operating Month (COM) + 1 in the format Month CCYY

Choice 2

Current Operating Month (COM) in the format Month CCYY

Choice 3 Null

Fill-in (5)

 

Choice 1 an overpayment
Choice 2 past due medical insurance premiums
Choice 3 an overpayment and past due medical insurance premiums

PAY161 – LEDGER ACCOUNT FILE (LAF) = C AND CURRENT AMOUNT (CAMT) = $0.00

No payment is due at this time because of adjustments made to (1) benefits.

Fill-in values:

Fill-in (1)

 

Choice 1

his

Choice 2

her

Choice 3

your

PAY176 – PART B REFUND DUE TO INCOME-RELATED MONTHLY ADJUSTMENT AMOUNT (IRMAA) AND REFUND PAID AS A PRIOR MONTH ACCRUAL AMOUNT (PAMT) OR IN THE CURRENT AMOUNT (CAMT) CHECK

Based on the information we have, (1) (2) due a Medicare Part B premium refund.

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

PAY218 – EXPLAINS THAT BENEFITS CANNOT CURRENTLY BE PAID

We cannot pay you (1) regular monthly benefit at this time.

Fill-in values:

Fill-in (1)

 

Choice 1

your

Choice 2

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

PAY219 – EXPLAINS THAT INCREASE ONLY APPLIES TO PAST BENEFITS – CURRENT MONTHLY BENEFIT REMAINS THE SAME

The increase applies only to past benefits. It does not affect (1) monthly payment of (2).

Fill-in values:

Fill-in (1)

 

Choice 1

your

Choice 2

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

Choice 3

his

Choice 4

her

Fill-in (2)

Net Amount of check to be issued

PAY220 – EXPLAINS THAT THE CHECK CONTAINS THE CURRENT MONTHLY BENEFIT PLUS ANY INCREASED AMOUNT DUE FOR PRIOR MONTHS

This payment includes (1) new monthly benefit amount. This payment also includes any increase in benefits we owe (2).

Fill-in values:

Fill-in (1)

 

Choice 1

your

Choice 2

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

Choice 3

his

Choice 4

her

Fill-in (2)

 

Choice 1

you

Choice 2

him

Choice 3

her

PAY221 – DUALLY ENTITLED BENEFICIARIES – RECEIVING A PIA INCREASE ON OWN ACCOUNT AND ONGOING MONTHLY PAYMENT AMOUNT REMAINS THE SAME

(1) will continue to receive the same amount each month. When we add the amounts of the two benefits together, the total amount does not change.

Fill-in values:

Fill-in (1)

 

Choice 1

You

Choice 2

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

Choice 3

He

Choice 4

She

PAY222 – DUALLY ENTITLED BENEFICIARIES – PIA CHANGES – PROVIDES AMOUNT DUE ON EACH RECORD

The new monthly benefit on (1) Social Security record will be (2). (3) new monthly benefit on the other record will be (4).

Fill-in values:

Fill-in (1)

 

Choice 1

your

Choice 2

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

Choice 3

his

Choice 4

her

Fill-in (2)

Smaller Actuarially Reduced Monthly Benefit Amount (SAMBA)

Fill-in (3)

 

Choice 1

Your

Choice 2

His

Choice 3

Her

Fill-in (4)

Larger Excess Monthly Benefit Amount (LEMBA)

B. “PMT” Universal Text Identifiers – Payment Cycling

PMT003 – LEDGER ACCOUNT FILE (LAF) C, S, OR D CYCLE DATE CHANGED

As requested, we are changing the day we make (1) monthly payments.

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

your

PMT011 – AUXILARY NOTICE THAT EXPLAINS BENEFITS HAVE CHANGED DUE TO ANOTHER PERSON'S EARNINGS ON THE RECORD.

(1) payments can change based on the work and earnings of another person entitled on the same record.

Fill-in values:

Fill-in (1)

 

Choice 1

Your

Choice 2

Auxiliary’s First Name and Last Name (possessive)

PMT012 – CORRECT BENEFITS WERE NOT PAID IN THE CURRENT OR PRIOR YEAR(S) DUE TO THE WAGES OF SOMEONE ON THE RECORD

We paid (1) (2) (3) than we should have (4) (5).

Fill-in values:

Fill-in (1)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (2)

Incorrect/over/under payment amount

Fill-in (3)

 

Choice 1

less

Choice 2

more

Fill-in (4)

 

Choice 1

for

Choice 2

Year in the format CCYY

Choice 3

through

Choice 4

and

Fill-in (5)

 

Choice 1

so far this year

Choice 2

Null

PMT013 – CORRECT BENEFITS WERE NOT PAID IN THE CURRENT YEAR AND IN ONLY ONE PRIOR YEAR DUE TO THE WAGES OF SOMEONE ON THE RECORD

We paid (1) (2) than we should have for (3) and (4) than we should have so far this year.

Fill-in values:

Fill-in (1)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (2)

 

Choice 1

less

Choice 2

more

Fill-in (3)

Year of Earnings Report (YOER) in the format CCYY

Fill-in (4)

 

Choice 1

less

Choice 2

more

PMT016 – PAYMENT CYCLE REQUEST DENIED

We are not changing the day we make (1) monthly payments. This means that you will continue to receive (2) monthly payments on or about the third of each month.

We must make payment on the third of the month to everyone entitled to Social Security whenever anyone on that record:

  • receives Supplemental Security Income (SSI) payments, or railroad retirement payments, or

  • has income and/or resources considered when we determine whether an SSI claimant is eligible for benefits, or

  • moves outside the U.S., or

  • has Medicare premiums paid by the state, or

  • has payments garnished.

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

Beneficiary Given Name (BGN) (possessive)

Choice 2

your

PMT017 – PRE-MBR PAYMENT CYCLE INDICATOR (PCI) = 2, 3, OR 4, POST-MBR PCI = 1

We are changing the date we make (1) monthly payments. (2) new payment date will be the third of the month. We will also change the payment date of everyone on this record to the third of the month.

We must make payment on the third of the month when anyone on this record:

  • receives railroad retirement or Supplemental Security Income (SSI) payments,

  • has income or resources used to decide if someone else is eligible for SSI,

  • moves outside the U.S.,

  • has Medicare premiums paid by the State,

  • has payments garnished, or

  • is entitled on more than one record.

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

PMT018 – REFER TO WORKSHEET HEADER NL 00730.149C.2.

PMT019 – REFER TO WORKSHEET HEADER NL 00730.149C.3.

PMT020 – REFER TO WORKSHEET HEADER NL 00730.149C.4.

PMT022 – REFER TO WORKSHEET HEADER NL 00730.149C.5.

PMT025 – REFER TO WORKSHEET HEADER NL 00730.149C.6.

PMT027 – ADVISES ALL BENEFICIARIES ON THE RECORD IN LEDGER ACCOUNT FILE (LAF) C, D OR S THAT SOCIAL SECURITY ADMINISTRATION HAS CHANGED PAYMENT CYCLE DATE BASED UPON ENTITLEMENT ON MORE THAN ONE RECORD

We are changing the day we make (1) monthly payments due to entitlement on more than one record.

Fill-in values:

Fill-in (1)

 

Choice 1

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

Choice 2

your

C. “PRI” Universal Text Identifiers - Prisoners

PRI011 – PRISON SUSPENSION PRIOR TO 2/1995

We may be able to pay (1) up to February 1995 if (2) in a rehabilitation program while (3) imprisoned. Two things must be true about the program:

  • It must be approved for (4) by the court; and

  • It must be designed to make it possible for (5) to work after (6) release.

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

he was

Choice 2

she was

Choice 3

you were

Fill-in (3)

 

Choice 1

he was

Choice 2

she was

Choice 3

you were

Fill-in (4)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (5)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (6)

 

Choice 1

his

Choice 2

her

Choice 3

your

PRI014 – PRISON SUSPENSION 2/1995 – 3/2000

We cannot pay (1) because (2) imprisoned for the conviction of a crime that can carry a sentence of more than one year. We cannot pay (3) even if (4) actual sentence is shorter.

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

he is

Choice 2

she is

Choice 3

you are

Fill-in (3)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (4)

 

Choice 1

him

Choice 2

her

Choice 3

your

PRI015 – PRISON SUSPENSION < 2/1995

We cannot pay (1) because (2) imprisoned before February 1995 for the conviction of a crime considered to be a felony. Beginning February 1995, the law changed. Now, we cannot pay Social Security benefits if (3) imprisoned for conviction of a crime that can carry a sentence of more than one year. We cannot pay (4) benefits even if (5) actual sentence is shorter.

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

he was

Choice 2

she was

Choice 3

you were

Fill-in (3)

 

Choice 1

he was

Choice 2

she was

Choice 3

you were

Fill-in (4)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

PRI016 – NUMBER HOLDER PRISON SUSPENSION - AUXILIARIES CAN BE PAID

Even though we cannot pay (1), we can pay other members of (2) family if they are entitled on (3) record.

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

PRI017 – BENEFITS MAY BE PAID ONCE OUT OF PRISON

We may be able to pay (1) when (2) released. Please get in touch with us after (3) released. Then we will review your case to see if we can pay (4).

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

he is

Choice 2

she is

Choice 3

you are

Fill-in (3)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (4)

 

Choice 1

him

Choice 2

her

Choice 3

you

PRI030 – PRISON SUSPENSION 4/2000 ON

We cannot pay (1) because (2) imprisoned for the conviction of a crime.

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

he is

Choice 2

she is

Choice 3

you are

PRI047 – MENTAL SUSPENSION < 4/2000

We cannot pay (1) because (2) charged with a crime that can carry a prison sentence of more than one year. Because of (3) mental condition, (4) criminal case resulted in a court order that (5) confined in an institution and (6) stay is being paid for with public funds.

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

he was

Choice 2

she was

Choice 3

you were

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

he be

Choice 2

she be

Choice 3

you be

Fill-in (6)

 

Choice 1

his

Choice 2

her

Choice 3

your

PRI048 – MENTAL SUSPENSION = 4/2000

We cannot pay (1) because (2) confined to an institution as a result of a court order in connection with a criminal case and (3) stay is being paid for with public funds.

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

he is

Choice 2

she is

Choice 3

you are

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

PRI049 – USED FOR AN ONGOING OR EMBEDDED FUGITIVE FELON SUSPENSION

Beginning January 2005, the law prohibits us from paying Social Security benefits to individuals who have an outstanding arrest warrant for a crime which is a felony (or, in jurisdictions that do not define crimes as felonies, a crime that is punishable by death or imprisonment for a term exceeding 1 year), or who have violated a condition of probation or parole under Federal or State law. We have information that (1) (2) into one of these categories.

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

fall

Choice 2

falls

PRI059 – USED TO NOTIFY BENEFICIARIES CURRENTLY SUBJECT TO PRISONER MONTHLY SUPENSION PROVISIONS THAT WE ARE HOLDING PAST DUE MONTHLY BENEFITS

We cannot pay back benefits to people who are:

  • convicted of a crime and imprisoned for more than 30 days, or

  • confined for more than 30 days to an institution at public expense because of a court order.

Contact us when (1) (2) released. We may be able to pay the back benefits then.

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

PRI060 – USED TO NOTIFY BENEFICIARIES CURRENTLY SUBJECT TO FUGITIVE FELON, OR PROBATION OR PAROLE VIOLATION MONTHLY SUSPENSION PROVISIONS THAT WE ARE HOLDING PAST DUE MONTHLY BENEFITS

We cannot pay back benefits while (1) (2):

  • fleeing to avoid prosecution, custody, or confinement for a crime that is punishable by death or a prison term of over 1 year, or

  • violating probation or parole under Federal or State law.

Please contact us when (3) (4) the arrest warrant or (5) probation or parole violation ends. We may be able to pay the back benefits then.

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

resolves

Choice 2

resolve

Fill-in (5)

 

Choice 1

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

Choice 2

your

PRI061 – USED IN RESUMPTION NOTICES TO INFORM BENEFICIARIES, WHEN RETROACTIVE BENEFITS ARE POSTED TO RECORD, THAT WE CAN RESUME BENEFITS DUE TO NO LONGER BEING SUBJECT TO CURRENT PRISONER, FUGITIVE FELON, COURT-ORDERED CONFINEMENT, OR PROBATION OR PAROLE VIOLATION MONTHLY SUSPENSION PROVISIONS

We can pay (1) monthly benefits again because (2) (3) no longer:

  • a prisoner,

  • confined to an institution at public expense because of a court order,

  • a fugitive felon, or

  • a probation or parole violator.

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

he

Choice 2

she

Choice 3

you

Fill-in (3)

 

Choice 1

is

Choice 2

are

NL 00730.138 “S” Paragraphs and Captions

List of “S” Paragraphs and Captions

A. “SNO” Universal Text Identifiers – Special Notice Option

SNO002 – SPECIAL NOTICE OPTION – USED FOR BRAILLE (3), DATA CD (4), AUDIO CD (6) AND LARGE PRINT (7)

We are sending you this letter in both a standard print version and (1). You will receive them in separate envelopes.

Fill-in values:

 

Fill-in (1)

 

Choice 1

in a Braille version

Choice 2

on a compact disc in Microsoft Word format

Choice 3

on an audio compact disc

Choice 4

a large print version

SNO004 – SPECIAL NOTICE OPTION – USED FOR TELEPHONE CONTACT (2)

As you requested, we will call you within 5 business days of the date of this letter to read it to you.

B. “SSA” Universal Text Identifiers – Headings and Signatures

SSAH16 – BNC NUMBER HEADER ON SUBSEQUENT PAGES

(1)

Fill-in values:

 

Fill-in (1)

Show BNC# derived from the BNC utility plus BIC code

SSAH30 – NAME AND ADDRESS

(1)

(2)

(3)

(4)

(5)

(6)

Fill-in values:

 

Fill-in (1)

Payee Name

Fill-in (2)

Payee Address Line 1

Fill-in (3)

Payee Address Line 2

Fill-in (4)

Payee Address Line 3

Fill-in (5)

Payee Address Line 4

Fill-in (6)

Payee Address Line 5

SSAH32 – APPOINTED REPRESENTATIVE'S NAME AND ADDRESS

(1)

(2)

(3)

(4)

(5)

(6)

Fill-in values:

 

Fill-in (1)

Appointed Representative Name

Fill-in (2)

Appointed Representative Address Line 1

Fill-in (3)

Appointed Representative Address Line 2

Fill-in (4)

Appointed Representative Address Line 3

Fill-in (5)

Appointed Representative Address Line 4

Fill-in (6)

Appointed Representative Address Line 5

C. “SUS” Universal Text Identifiers - Suspension

SUSC02 – CAPTION

We May Be Able To Pay (1) Again

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

You

SUS013 – SUSPENSION HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF WAIVER OF BENEFIT PAYMENTS (WAIVER)

If (1) to receive (2) benefits, we will pay benefits beginning with the month we receive a signed statement from you (3) asking for the benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) plus “decides”

Choice 2

you decide

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

“or” plus Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)

Choice 2

Null

SUS014 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF NO CHILD IN CARE (NOCICS)

We cannot pay (1) because (2) not taking care of a child who (3) entitled to Social Security 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

he is

Choice 2

she is

Choice 3

you are

Choice 4

he was

Choice 5

she was

Choice 6

you were

Fill-in (3)

 

Choice 1

is

Choice 2

are

SUS025 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF PAYEE DEVELOPMENT (DEVPYE) OR DEATH OF PAYEE (DTHPYE) - NO DAA BENEFICIARY OR SUSPENSION HRFST OF PAYEE IS A FUGITIVE FELON (RPFUGF)

The person who received your payments will no longer be your representative payee. We are looking for another qualified person to receive your payments and use them for your needs.

SUS026 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF PAYEE DEVELOPMENT (DEVPYE) - NO DAA BENEFICIARY

We have determined that you need help managing your payments. We will be selecting a qualified person to receive your payments. We call this person a representative payee. It will be your payee's duty to manage your (1) payments for you and use them for your needs.

Fill-in values:

 

Fill-in (1)

Social Security

SUS027 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF PAYEE DEVELOPMENT (DEVPYE) OR DEATH OF PAYEE (DTHPYE)

When we begin your (1) payments again, you will be paid all the money that is due you. When we make a decision about your payee, we will send you another letter. This letter will explain what you can do if you disagree with our payee decision.

Fill-in values:

 

Fill-in (1)

Social Security

SUS035 – AUXILIARY (AUX) SUSPENDED - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF DEVDIB DUE TO NUMBER HOLDER'S (NH) CDR OR AUX SUSPENDED - HRFST OF CDRFTC DUE TO NH'S FAILURE TO COOPERATE OR PIC B/E SUSPENDED HRFST OF CDRFTC DUE TO PIC C (CDB) FAILURE TO COOPERATE OR AUX SUSPENDED - HRFST OF MISC DUE TO NH'S REQUEST FOR MEDICARE ONLY STATUTORY BENEFIT CONTINUATION DURING AN APPEAL OF A DIBCESS DECISION

We cannot pay further benefits until we can study the facts and decide whether (1) still meets the requirements to receive disability benefits. We will let you know when we make this decision and will tell you whether we can start (2) benefits again.

Fill-in values:

 

Fill-in (1)

 

Choice 1

NH-NAME

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) for PIC C with the BCLM-CEC = B (disabled)

Fill-in (2)

 

Choice 1

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

Choice 2

your

SUS040 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF TREASURY BARRED (BARRED)

We cannot pay (1) benefits because the rules of the United States Treasury Department do not allow payment while (2) (3) in (4). We will let you know if the tax rules change.

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

he

Choice 2

she

Choice 3

you

Fill-in (3)

 

Choice 1

lives

Choice 2

live

Fill-in (4)

 

Choice 1

Cuba

Choice 2

North Korea

SUS041 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF FOREIGN ENFORCEMENT REPORT NOT RETURNED (FORENF)

We cannot pay (1) benefits because (2) (3) not returned the form, “Report to United States Social Security Administration.” We need the information requested on this form to decide if (4) can receive benefits again.

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

he

Choice 2

she

Choice 3

you

Fill-in (3)

 

Choice 1

has

Choice 2

have

Fill-in (4)

 

Choice 1

he

Choice 2

she

Choice 3

you

SUS045 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF ENTITLEMENT TO HIGHER BENEFITS ON ANOTHER ACCOUNT (T5NENT) OR TECHNICAL ENTITLEMENT (TECENT)

We cannot pay benefits because (1) (2) eligible for a higher benefit on another record.

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

SUS047 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF GOVERNMENT PENSION OFFSET (GPOOFF)

We cannot pay benefits because (1) (2) eligible for a government pension that is equal to or greater than the monthly Social Security 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

is

Choice 2

are

SUS052 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF DOMESTIC WORK (DOMWRK) OR FOREIGN WORK (FORWRK)

We cannot pay benefits because of (1) work.

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

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

Choice 3

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

SUS054 – HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF NON-RESPONDER TO RECONTACT FORM (RECONT) OR TERMINATION BASED ON NON-RESPONSE TO RECONTACT NOTICE (RECONM) FOR PIC E OR PIC C AND NO PAYEE INVOLVED

We cannot pay (1) benefits because (2) (3) not returned the form, SSA-1588 “Beneficiary Recontact Report”. We need the information requested on this form to decide if (4) can receive benefits again.

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

he

Choice 2

she

Choice 3

you

Fill-in (3)

 

Choice 1

has

Choice 2

have

Fill-in (4)

 

Choice 1

he

Choice 2

she

Choice 3

you

SUS055 – HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF NON-RESPONDER TO RECONTACT FORM (RECONT) OR TERMINATION BASED ON NON-RESPONSE TO RECONTACT NOTICE (RECONM) FOR PIC C AND PAYEE INVOLVED

We cannot pay (1) benefits because (2) (3) not returned the Form SSA-1587 “Beneficiary Recontact Report.” We need the information requested on this form to decide if (4) can receive benefits again.

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

has

Choice 2

have

Fill-in (4)

 

Choice 1

he

Choice 2

she

SUS068 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF NO CHILD IN CARE (NOCICS)

Please let us know if you are taking care of a child again who is entitled to benefits and under 16 or disabled. We may be able to pay you again.

SUS069 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF SUSPENSION FOR CDR (DEVDIB) (HA, CDB, WIDOW'S DIB) NO DAA

We cannot pay (1) benefits because our records show that (2):

  • did not return information we asked for; or

  • (3) returned to work; or

  • (4) health improved; or

  • (5) could not be located.

We cannot pay benefits because we must study the facts and decide whether (6) still (7) the requirements to receive disability 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

he

Choice 2

she

Choice 3

you

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (6)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (7)

 

Choice 1

meets

Choice 2

meet

SUS070 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF WHEREABOUTS UNKNOWN (WHEREU), ADDRESS DEVELOPMENT (DEVADD), AGE DEVELOPMENT (DEVAGE), PENDING DISABILITY DETERMINATION (DISDET), DUAL ENTITLEMENT POTENTIAL WIDOW (CERTEL)

We cannot pay (1) starting (2). We need more information before we can start (3) payments again.

Fill-in values:

 

Fill-in (1)

 

Choice 1

you

Choice 2

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

Fill-in (2)

Date of Suspension

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

SUS071 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF BARRED (SSA)

We cannot pay benefits because Social Security rules do not allow payment while a beneficiary lives or lived in a barred country.

SUS072 – SUSPENSION LEAD - FOLLOW BY SPECIFIC UTI

Based on the information we have, we cannot pay benefits (1) (2) (3) (4).

Fill-in values:

 

Fill-in (1)

 

Choice 1

beginning

Choice 2

for

Fill-in (2)

 

Choice 1

Date of Suspension or Termination (DOST) that corresponds to the ongoing suspension in the format Month CCYY

Choice 2

NA-HIST-START date in the format Month CCYY

Fill-in (3)

 

Choice 1

and

Choice 2

through

Choice 3

Null

Fill-in (4)

 

Choice 1

NA-HIST-STOP date in the format Month CCYY

Choice 2

Null

SUS073 – RESUMPTION OR REINSTATEMENT OF BENEFITS

Based on the information we have, we can pay benefits (1) (2) (3) (4).

Fill-in values:

 

Fill-in (1)

 

Choice 1

beginning

Choice 2

for

Fill-in (2)

 

Choice 1

First Effective Date (EFD) in History data that corresponds to the reinstatement period

Choice 2

NH-HIST-START date in the format Month CCYY for the embedded reinstatement period

Fill-in (3)

 

Choice 1

and

Choice 2

through

Choice 3

Null

Fill-in (4)

 

Choice 1

NA-HIST-STOP date for the embedded reinstatement period in the format Month CCYY

Choice 2

Null

SUS074 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF NOT LAWFULLY PRESENT (NOTLAW)

We cannot pay (1) benefits because (2) not lawfully present in the U.S.

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

he is

Choice 2

she is

Choice 3

you are

SUS075 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF NOT A U.S. CITIZEN (NOUSCP)

We cannot pay (1) benefits because (2) not a U.S. citizen.

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

he is

Choice 2

she is

Choice 3

you are

SUS076 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF LEF U.S. ALIEN SUSPENSION (ALNSUS)

We cannot pay (1) benefits because (2) not a United States citizen and (3) been outside the United States for more than 6 months.

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

he is

Choice 2

she is

Choice 3

you are

Fill-in (3)

 

Choice 1

has

Choice 2

have

 

SUS077 – ONGOING VOLUNTARY SUSPENSION TO EARN DELAYED RETIREMENT CREDITS (VOLDRC or LEGIS1)

We received (1) request to suspend (2) retirement benefits to earn delayed retirement credits. Suspending these benefits will also stop payments to (3) on any other record on which (4) entitled. We will restart (5) benefits at the earlier of:

  • The month (6) age 70, or

  • The month after (7) for payments to restart.

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

Choice 2

him

Choice 3

her

Fill-in (4)

 

Choice 1

you are

Choice 2

he is

Choice 3

she is

Fill-in (5)

 

Choice 1

your

Choice 2

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

Fill-in (6)

 

Choice 1

you reach

Choice 2

he reaches

Choice 3

she reaches

Fill-in (7)

 

Choice 1

you ask

Choice 2

he asks

Choice 3

she asks

SUS078 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF MONTHLY BENEFIT AMOUNT (MBA) < $1.00 (LESSDO) AND HIB225 OR HIB226 NOT USED

We cannot pay (1) beginning (2) because (3) monthly payment is less than a dollar. At the end of the year, we will adjust (4) record and pay all money (5) due.

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)

Effective Date (EFD) in History (HIST) Data on the post-MBR that corresponds to the HRFST LESSDO in format Month CCYY

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

SUS079 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF WAIVER

We are withholding (1) benefits because (2) requested us to do so.

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 has

Choice 2

she has

Choice 3

you have

SUS080 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF PREDATOR (PREDTR)

We cannot pay (1) because:

  • (2) convicted of a crime and confined in a jail or prison;

  • The crime included sexual activity, and

  • When (3) completed (4) sentence, (5) immediately sent by court order to an institution at public expense.

  • The court decided (6) a sexually dangerous person.

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

He was

Choice 2

She was

Choice 3

You were

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

he was

Choice 2

she was

Choice 3

you were

Fill-in (6)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

SUS084 – HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF VOLUNTARY SUSPENSION TO EARN DELAYED RETIREMENT CREDIT (VOLDRC or LEGIS1) FOR AN EMBEDDED PERIOD OF SUSPENSION

We received (1) request to suspend (2) retirement benefits for (3) to earn delayed retirement credits. Suspending these benefits will also stop payments to (4) on any other record on which (5) entitled. We will restart (6) benefits for (7) in (8), unless (9) us to restart (10) benefits earlier.

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

If one month of suspension, show the Effective Date (EFD) in History Data that corresponds to the embedded month of VOLDRC or LEGIS1 suspension in Month CCYY format

Choice 2

If two or more months of suspension, show the first Effective Date (EFD) in History Data that corresponds to the embedded period of VOLDRC or LEGIS1 suspension in Month CCYY format plus the word “through” and ending with the last Effective Date (EFD) in History Data that corresponds to the embedded period of VOLDRC or LEGIS1 in Month CCYY format

Fill-in (4)

 

Choice 1

you

Choice 2

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

Fill-in (5)

 

Choice 1

you are

Choice 2

he is

Choice 3

she is

Fill-in (6)

 

Choice 1

your

Choice 2

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

Fill-in (7)

Show the first Effective Date (EFD) in History Data after the embedded period where VOLDRC or LEGIS1 suspension is not present in Month CCYY format

Fill-in (8)

Show the first Effective Date (EFD) in History Data after the embedded period where VOLDRC or LEGIS1 suspension is not present plus one month in Month CCYY format

Fill-in (9)

 

Choice 1

you ask

Choice 2

he asks

Choice 3

she asks

Fill-in (10)

 

Choice 1

your

Choice 2

his

Choice 3

her

SUS087 – PIC A SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF DEPORTATION (DEPORT) – ONGOING OR EMBEDDED PERIOD OF SUSPENSION

We cannot pay (1) benefits because (2) deported or removed from the United States under one of the following sections of the Immigration and Nationality Act (INA):

  • Section 241(a) of the INA in effect prior to April 1, 1997;

  • Section 237(a);

  • Section 212(a)(6)(A).

This is based on information from the U.S. Department of Homeland Security. Please get in touch with us if in the future (3) permitted to return to the United States as a lawful permanent resident. Benefits may again be payable at that time.

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

he was

Choice 2