Identification Number:
NL 00720 TN 25
Intended Audience:See Transmittal Sheet
Originating Office:Systems
Title:Manual Adjustment, Credit and Award Process (MADCAP) Beneficiary Notice Print Program
Type:POMS Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part NL – Notices, Letters and Paragraphs
Chapter 007 – Letters and Paragraphs for Title II, Title XVI, and Title XVIII
Subchapter 20 – Manual Adjustment, Credit and Award Process (MADCAP) Beneficiary Notice Print Program
Transmittal No. 25, 09/09/2022

Audience

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

Originating Component

OEIS

Effective Date

Upon Receipt

Background

We are updating Program Operations Manual System (POMS) sections in NL 00720 effective with Manual Adjustment Credit and Award Process (MADCAP) August 26, 2022 release. Language changes for notices in the attached sections are a direct result of updates requested by Policy and the Office of Electronic Services Technology (OEST) for the IT Modernization Notice Referral Language Project.

Summary of Changes

NL 00720.010 Paragraph Sequenced by Caption

We updated MADCAP sequencing to replace the obsolete referral Universal Text Identifiers (UTIs) with the new referral UTIs.

NL 00720.040 ALS Appeals

We revised the language for MADCAP UTI ALS023 . We removed "You can also call, write, or visit us to request the form" from the last bulleted paragraph, replaced "call, write, or visit" with "You can also contact us" and updated the social security web address.

NL 00720.210 MHP Medical Health Plan

We revised the language for MADCAP UTI MHP053. We removed "please visit" from the last paragraph with "please contact us".

NL 00720.280 REF Referral

We replaced MADCAP UTIs REF001 and REF127 with REF210, REF003 and REF142 with REF196, REF008 and REF141 with REF211, and REF185 and REF140 with REF197. Additionally, we are introducing a new UTI, REF198, to provide referral information for rail road beneficiaries.

NL 00720.390 WAV Waiver

We revised the language for MADCAP UTI WAV001 and WAV002. FOR WAV001, we replaced "The people in any Social Security office will be glad to help you complete" with "Please contact us if you need help completing". Additionally, we revised the last paragraph for both UTIs.

NL 00720.410 WEP Windfall Elimination Provision

We revised the language for WEP001 and WEP004. We updated the value for last fill-in #5 of WEP004, replaced "www.socialsecurity.gov/pubs/EN-05-10045.pdf” with “www.ssa.gov/pubs”. Additionally, we removed "please see" in the last paragraph with "please view".

NL 00720.010 Paragraph Sequence by Caption

A. Introduction to the Manual Adjustment, Credit, and Award Process (MADCAP) notice system

The MADCAP notice system prints each generated or requested Universal Text Identifier (UTI) according to a pre-determined sequence under the appropriate caption.

B. Sequence chart

The sequence chart in this section shows the paragraph order for the MADCAP Notices.

Attorney Copies

GROUP 2 (Adjustments)

GROUP 3 (Adjustments)

COP002

 

 

COP014

LIS004

LIS004

AWD013

RPY015

OPT158

AET064

CFDC02

ERN086

HIB198

CFD003

ERN087

DIB002

RCYC01

ERN046

AWD011

CFD004

RNS031

BEN089

REFC07

XRP001

ENT027

REF210

RNS032

RRB001

REF211

RNS033

RPY039

REF197

INF130

AWD012

REF196

AET064

DTH012

 

TER039

DID001

 

XRP018

BEN090

 

XRP008

XRP001

 

TER016

FUGC05

 

TER040

FUG104

 

OPT161

FUG105

 

OPT163

FUG106

 

OPT164

RNSC02

 

BEN090

RNS033

 

FUGC05

CHKC03

 

FUG104

SUS026

 

FUG105

INFC06

 

FUG106

RPY003

 

XRPC02

SUS063

 

XRP006

CHKC11

 

XRP012

SUS021

 

XRP009

INFC09

 

RNSC02

SUS065

 

RNS033

SUS064

 

CHKC03

SUS057

 

SUS026

PAYC38

 

INFC06

XRP002

 

RPY003

ADJ024

 

CHKC11

ADJ025

 

SUS021

PAY161

 

CHKC09

OCO001

 

INS001

ADJ020

 

ENT071

PAY032

 

ADJ027

BEV018

 

ADJ028

ADJ054

 

ADJ029

ADJ055

 

ADJ032

ADJ046

 

ADJ035

ADJ047

 

ADJ037

PMT001

 

ADJ038

SSI066

 

ADJ039

WFO003

 

RIN048

SSI067

 

ADJ041

ATY059

 

ADJ050

ATY060

 

ADJ051

ADJ021

 

ADJ052

ADJ058

 

ADJ053

ADJ048

 

ADJ043

ADJ049

 

ADJ044

OPT149

 

ADJ045

DTH011

 

OPT159

ENT063

 

AWD014

ENT064

 

AWD016

PAYB15

 

HIB188

DTH009

 

ADJ023

DTH010

 

ENT056

LSP013

 

BEN080

ENT067

 

BEN081

PAY067

 

ENT038

PAY068

 

BEN031

PAY072

 

SUS006

PAY073

 

BEN086

BEN084

 

SUS095

LVY022

 

SUS087

GAR003

 

SUS094

GAR064

 

SUS014

LVY038

 

SUS001

LVY023

 

SUS040

GAR004

 

FOB012

PAY176

 

CHKC09

 

SUS077

ADJ050

 

SUS084

ENT071

 

SUS099

FOBR21

 

SUS100

BEN087

 

PRI015

MISR02

 

PRI014

FOBR21

 

PRI006

BEN087

 

PRI029

MISR02

 

PRI030

MISR03

 

PRIR01

MISR04

 

FUG058

PAY212

 

PRI049

WDW005

 

FUG059

SEIR02

 

FUG060

SEIR03

 

FUG061

SEIR04

 

FUG031

ERN038

 

FUG063

SEIR06

 

FUG064

SEIR07

 

FUG065

ERNR09

 

SUS211

ERNR10

 

BEN102

ERNR11

 

TER043

ERN039

 

TER001

MSVR06

 

TER002

INS018

 

TER010

INS001

 

TER003

CLOR20

 

TER016

INS008

 

BEN050

INS002

 

TER041

INS003

 

TER042

INS004

 

TER044

INS005

 

TER045

INS007

 

TER046

INS006

 

TER048

INS017

 

TER049

AWD014

 

CICR11

TAX027

 

ERN040

RRB002

 

ERN041

ADJ023

 

WDS019

ENT056

 

WDS020

BEN080

 

WDS021

BEN081

 

ERN042

ENT038

 

ERN054

BEN031

 

ERN043

SUS006

 

ERN050

BEN086

 

ERN044

SUS095

 

ERN056

SUS087

 

OPT262

SUS094

 

OPT263

SUS014

 

OPT264

OPT148

 

OPT265

SUS001

 

OPT266

SUS040

 

OPT267

FOB012

 

OPT268

 

OPT269

PRI015

 

OPT270

PRI014

 

OPT271

PRI006

 

OPT272

PRI029

 

OPT273

PRI030

 

OPT274

PRIR01

 

OPT275

FUG058

 

OPT276

PRI049

 

OPT277

FUG059

 

OPT278

FUG060

 

OPT279

FUG061

 

OPT280

FUG031

 

OPT281

FUG063

 

OPT282

FUG064

 

OPT283

FUG065

 

OPT284

SUS211

 

OPT285

BEN102

 

OPT286

TER043

 

OPT287

TER001

 

OPT288

TER002

 

OPT289

TER010

 

OPT290

TER003

 

OPT291

BEN050

 

OPT292

TER041

 

OPT293

TER042

 

OPT294

TER045

 

OPT295

TER046

 

OPT296

TER048

 

OPT297

TER049

 

OPT298

CICR11

 

OPT299

ERN040

 

OPT300

ERN041

 

OPT301

WDS019

 

OPT168

WDS020

 

OPT028

WDS021

 

OPT179

ERN042

 

OPT166

ERN052

 

OPT181

ERN054

 

PAY182

ERN043

 

OPT169

ERN047

 

OPT122

ERN048

 

OPT171

ERN050

 

PAY184

ERN022

 

OPT127

ERN025

 

OPT170

ERN090

 

AET043

 

PAY181

ERN044

 

UPT010

ERN056

 

PAY183

ERN057

 

OPT167

ERN058

 

BEN032

ERN093

 

ERN049

ERN059

 

ERN071

ERN060

 

ERN077

ERN061

 

ERN080

ERN062

 

ERN047

ERN063

 

ERN048

ERN081

 

ERN022

TWPR01

 

ERN025

TWPR02

 

ERN090

ERN064

 

AET043

UPT010

 

RRB009

OPT262

 

OPT152

OPT263

 

ADJ022

OPT264

 

OPT154

OPT265

 

OPT155

OPT266

 

GAR008

OPT267

 

COA002

OPT268

 

ERN089

OPT269

 

ERN045

OPT270

 

ERN053

OPT271

 

ERN088

OPT272

 

AET035

OPT273

 

ERN082

OPT274

 

ERN069

OPT275

 

ERN072

OPT276

 

WEP001

OPT277

 

LVY026

OPT278

 

ADJ016

OPT279

 

OPT280

 

ADJ019

OPT281

 

RCY006

OPT282

 

RFU008

OPT283

 

RIN016

OPT284

 

ENT028

OPT285

 

ENT029

OPT286

 

BEN053

OPT287

 

BEN051

OPT288

 

BEN052

OPT289

 

AMN008

OPT290

 

ATY061

OPT291

 

RFU007

OPT292

 

AMN009

OPT293

 

SSI062

OPT294

 

AWD017

OPT295

 

PMT002

OPT296

 

PMT017

OPT297

 

PMT027

OPT298

 

PMT003

OPT299

 

TAX021

OPT300

 

TAX011

OPT301

 

TAX022

PAY181

 

TAX023

PAY182

 

ERN051

BEN104

 

ERN052

PAY183

 

ERN078

ERN049

 

ERN067

ERN071

 

WCP010

ERN077

 

WCP048

ERN080

 

WCP012

RRB009

 

WCPR13

OPT152

 

WCP018

ADJ022

 

WCPR20

OPT154

 

WCPR23

OPT155

 

WCPR24

COA002

 

WCPR25

ERN089

 

WCP050

ERN045

 

WCP051

ERN053

 

WCP052

ERN088

 

WCP053

AET035

 

ENT075

ERN082

 

WCP026

ERN069

 

WCP058

ERN072

 

WCPR15

ADJ027

 

WCP054

ADJ038

 

WCP013

ADJ032

 

WCP057

RIN048

 

WCP049

ADJ043

 

COL007

ADJ028

 

TAX050

ADJ029

 

TAX002

ADJ044

 

TAX025

ADJ035

 

TAX003

ADJ045

 

TAX024

ADJ037

 

WCP004

WEP001

 

OPT153

LVY026

 

OPT156

ADJ016

 

LVY054

 

TAX004

ADJ019

 

LVY055

RCY006

 

LVY056

RFU008

 

TAX019

RIN016

 

TAX020

ENT028

 

ERN083

ENT029

 

ERN079

BEN053

 

WCP055

BEN051

 

BEN077

BEN052

 

CIC002

AMN008

 

BEN076

ATY061

 

OPT132

RFU007

 

WCP019

RCY002

 

WCP015

AMN009

 

WCP017

SSI062

 

ERN065

AWD017

 

ERN066

PMT002

 

WDS002

PMT017

 

ERN073

PMT027

 

ERN076

PMT003

 

TAX026

TAX021

 

ADJ017

TAX011

 

ADJ018

TAX022

 

OPT151

ERN051

 

OPT107

ERN078

 

OPT165

ERN067

 

OPT162

WCP010

 

MOE003

WCP048

 

ENT062

WCP012

 

PEN029

WCPR13

 

PEN030

WCP018

 

ERN057

WCP019

 

ERN092

WCP015

 

ERN058

WCP017

 

ERN093

WCPR20

 

ERN059

WCPR23

 

ERN060

WCPR24

 

ERN061

WCPR25

 

ERN062

WCP050

 

ERN063

WCP051

 

ERN081

WCP052

 

TWPR01

WCP053

 

TWPR02

ENT075

 

ERN064

WCP026

 

ENT048

WCP058

 

TOT004

WCPR15

 

CIC010

WCP054

 

BEN082

WCP013

 

WIB001

WCP057

 

WIB002

WCP049

 

OPT148

COL007

 

SUS074

TAX050

 

BEN075

TAX002

 

WDW017

TAX025

 

VTW001

TAX003

 

VTW002

TAX024

 

VTW003

WCP004

 

VTW006

OPT153

 

VTW004

OPT156

 

VTW005

LVY054

 

VTW008

TAX004

 

VTW009

LVY055

 

VTW011

LVY056

 

VTW012

TAX019

 

VTW021

TAX020

 

VTW024

ERN083

 

CDR063

ERN079

 

SUS035

WCP055

 

CDR066

OPT179

 

CDR067

BEN077

 

TER010

CIC002

 

RCY002

BEN076

 

SUSC04

OPT166

 

SUS065

OPT181

 

PAYC38

OPT169

 

ADJ020

OPT171

 

PAY032

OPT122

 

ADJ024

OPT132

 

ADJ025

PAY184

 

OCO001

ERN065

 

PMT001

ERN066

 

SSI066

OPT028

 

WFO003

OPT127

 

SSI067

OPT168

 

ATY059

TAX026

 

ATY060

OPT170

 

ADJ021

ADJ017

 

DTH011

ADJ018

 

ENT063

OPT167

 

ENT064

OPT151

 

PAY180

OPT107

 

BEN100

BEN032

 

ADJ015

MOE003

 

PAY073

ENT062

 

PAYB15

PEN029

 

DTH010

PEN030

 

ENT067

WDS002

 

PAY067

ERN073

 

PAY068

ERN076

 

TAX006

ENT048

 

XRP002

TOT004

 

XRP003

CIC010

 

GAR005

BEN082

 

LVY024

GAR005

 

GAR006

VTW001

 

GAR007

VTW002

 

LVY025

VTW003

 

GAR008

VTW006

 

LVY026

VTW004

 

GAR009

VTW005

 

LVY027

VTW008

 

LVY022

VTW009

 

GAR003

VTW011

 

GAR064

VTW012

 

LVY038

VTW021

 

LVY023

VTW024

 

GAR004

WIB002

 

OPT149

CDR063

 

PAY176

SUS035

 

RCYC05

CDR066

 

RCY021

CDR067

 

WAVC01

TER010

 

WAV005

RCYC05

 

XRPC01

RCY021

 

XRP004

WAVC01

 

COPC01

WAV005

 

XRP005

XRPC01

 

BRR075

XRP004

 

BRR076

TOTC01

 

COP013

TOT009

 

COP001

DIBC01

DIB075

 

AETC02

ONS004

 

ERN091

ONS002

 

INFC09

DIB003

 

SUS065

OPTC05

 

SUS064

RFU001

 

SUS057

RFU020

 

DIBC01

DIB075

RFU012

 

ONS004

OPT180

 

ONS002

OPT165

 

DIB003

RFU003

 

OPTC05

ALSC06

 

RFU001

WAV001

 

RFU020

WAV002

 

RFU012

PENC02

 

OPT180

PEN001

 

OPT165

PEN024

 

RFU003

PEN025

 

ALSC06

PEN026

 

WAV001

PEN027

 

WAV002

PEN028

 

PENC02

ERN068

 

PEN001

HIBC01

 

PEN024

AGE006

 

PEN025

HIB187

 

PEN026

HIB021

 

PEN027

HIB188

 

PEN028

HIB189

 

ERN068

HIB256

 

HIBC01

 

HIB187

HIB003

 

HIB021

HIB004

 

HIB189

HIB200

 

HIB190

HIB212

 

HIB256

ENT051

 

HIB191

 

ENT051

ENT052

 

HIB033

HIB252

 

HIB191

HIB249

 

HIB036

MHP001

 

ENT052

MHP002

 

HIB192

MHP003

 

HIB184

MHP004

 

HIB257

MHP005

 

HIB095

HIB095

 

HIB254

HIB254

 

HIB255

HIB255

 

HIB193

HIB192

 

HIB139

HIB193

 

HIB250

HIB139

 

HIB194

HIB250

 

HIB015

HIB194

 

HIB195

HIB015

 

MHP001

HIB195

 

MHP002

MHP054

 

MHP003

HIB196

 

MHP004

HIB197

 

MHP005

HIBR60

 

HIB061

HIB190

 

HIB093

HIB199

 

HIB092

HIB011

 

MHP054

HIB039

 

HIB196

HIB217

 

HIB197

HIB218

 

HIBR60

HIB219

 

HIB252

HIB220

 

HIB249

HIB221

 

HIB039

HIB223

 

HIB217

HIB224

 

HIB218

 

HIB219

HIB228

 

HIB220

HIB229

 

HIB221

 

HIB223

HIB041

 

HIB224

HIB234

 

HIB215

 

HIB228

HIB235

 

HIB229

HIB236

 

HIB237

 

HIB041

HIB244

 

HIB234

HIB170

 

HIB215

HIB171

 

HIB045

HIB239

 

XRP007

HIB242

 

XRP013

HIB243

 

XRP010

HIB152

 

HIB236

HIB002

 

HIB237

HIB052

 

HIB244

HIB231

 

HIB170

HIB251

 

HIB171

HIB232

 

HIB239

HIB233

 

HIB243

HIB240

 

HIB242

HIB241

 

HIB002

HIB213

 

HIB152

HIB214

 

HIB052

HIB216

 

HIB231

HIB019

 

HIB251

HIB182

 

HIB232

HIB260

 

HIB233

HIB261

 

HIB240

HIB262

 

HIB241

HIB263

 

HIB213

HIB264

 

HIB214

HIB265

 

HIB216

HIB266

 

HIB019

HIB267

 

HIB040

HIB268

 

HIB043

HIB269

 

HIB182

HIB270

 

HIB260

HIB183

 

HIB261

HIB185

 

HIB262

HIB184

 

HIB263

HIB186

 

HIB264

HIB175

 

HIB265

HIB257

 

HIB266

HIB033

 

HIB267

HIB036

 

HIB268

HIB040

 

HIB269

HIB045

 

HIB270

HIB043

 

HIB183

XRP007

 

HIB185

XRP013

 

HIB186

XRP010

 

HIB175

MPDC31

 

MPDC31

MPD350

 

MPD350

MPD348

 

MPD348

MPD352

 

MPD352

MPD349

 

MPD349

MPD351

 

MPD351

ASTC02

 

ASTC02

HIB271

 

HIB271

MHPC02

 

MHPC02

MHP009

 

MHP009

MHP016

 

MHP016

MHP035

 

MHP035

MHP038

 

MHP038

MHP015

 

MHP015

HIB258

 

HIB258

MHP012

 

MHP012

MHP013

 

MHP013

MHP017

 

MHP017

MHP018

 

MHP018

MPDC19

 

MPDC19

MHP053

 

MHP053

MHPC03

 

MHPC03

MHP033

 

MHP033

MHP045

 

MHP045

MHP036

 

MHP036

MHP039

 

MHP039

MHP043

 

MHP043

MHP041

 

MHP041

MHP047

 

MHP047

MHP049

 

MHP049

MHPC04

 

MHPC04

HIB238

 

HIB238

MHP046

 

MHP046

MHP037

 

MHP037

MHP040

 

MHP040

MHP044

 

MHP044

MHP042

 

MHP042

MHP048

 

MHP048

MHP050

 

MHP050

MPD346

 

MPD346

MPD347

 

MPD347

HIBC02

 

ATYC01

HIB157

 

ATY054

ATYC01

 

ATY055

ATY054

 

ATY056

ATY055

 

ATY057

ATY056

 

ATY058

ATY057

 

ATYR03

ATY058

 

ATY800

ATYR03

 

ATY801

ATY800

 

ATY804

ATY801

 

ATYR20

ATY804

 

ATY834

ATYR20

 

ATYR02

ATY834

 

ATY069

ATYR02

 

ATY070

ATY069

 

ATYR22

ATY070

 

ATYR05

ATYR22

 

ATYR15

ATYR05

 

ATY816

ATYR15

 

ATY062

ATY816

 

ATY825

ATY062

 

ATY064

ATY825

 

ATY016

ATY064

 

ATY065

ATY031

 

ATY066

ATY016

 

ATY067

ATY065

 

ATYC04

ATY066

 

ATY063

ATY067

 

ATYC05

ATYC04

 

ATY808

ATY063

 

ATY809

ATYC05

 

ATYC02

ATY808

 

ATY817

ATY809

 

ATYC03

ATYC02

 

ATY836

ATY817

 

ATYR12

ATYC03

 

ATY068

ATY836

 

ATY838

ATYR12

 

DIBC09

ATY068

 

WCPR02

ATY838

 

WCP001

DIBC09

 

WCP003

WCPR02

 

WCP005

WCP001

 

WCPR06

WCP003

 

WCPR07

WCP005

 

WCP021

WCPR06

 

WCPR22

WCPR07

 

WCP008

WCP021

 

WCPR27

WCPR22

 

WCPR09

WCP008

 

ERNC09

WCPR27

 

AET002

WCPR09

 

ERN075

ERNC09

 

SEI006

AET002

 

ERNR09

ERN075

 

MSVC01

SEI006

 

MSV008

ERNR09

 

MSVR06

MSVC01

 

MSV001

MSV008

 

MSVR02

MSVR06

 

MSVR07

MSV001

 

DIBC02

MSVR02

 

ENT070

MSVR07

 

AGER09

DIBC02

 

BEN085

ENT070

 

DIB004

AGER09

 

DIB005

BEN085

 

CLOC01

DIB004

 

BEN078

DIB005

 

CLO029

CLOC01

 

TOT010

CLO002

 

CLOR05

CLOR11

 

ENT015

CLOR12

 

ENT065

CLOR13

 

DOA044

BEN078

 

INS021

CLO029

 

REL011

TOT010

 

CLO002

CLOR05

 

INFC02

ENT015

 

ENT068

ENT065

 

ENT069

DOA044

 

RPY041

INS021

 

AET031

REL011

 

STU001

AWD010

 

ENT001

INFC02

 

BRRR13

BRR004

 

VRN001

ENT068

 

WCP029

ENT069

 

WCP009

BEN088

 

WCPR31

BRR016

 

WCP032

RPY041

 

BRR040

STU001

 

ERN055

ENT001

 

ERN070

BRRR13

 

FWK001

VRN001

 

BRR026

WCP029

 

ALSC04

WCP009

 

ALS113

WCPR31

 

ALSC26

WCP032

 

ALS171

BRR040

 

ALSC27

ERN055

 

ALS172

ERN070

 

ALSC28

WDS019

 

ALS123

FWK001

 

ALSC05

ALSC04

 

ALS125

ALS113

 

ALSC08

ALSC26

 

ALS054

ALS171

 

INFC08

ALSC27

 

FOB005

ALS172

 

BEN083

ALSC28

 

BRR057

ALS123

 

CDR001

ALSC05

 

CDR002

ALS125

 

CDR003

ALSC08

 

BRR006

ALS054

 

WCP028

INFC08

 

CIC003

FOB005

 

CIC004

BEN083

 

CICR12

BRR057

 

PRI023

CDR001

 

BRR006

CDR002

 

TER047

CDR003

 

TER050

BRR006

 

RRB008

WCP028

 

ENT066

CIC003

 

AETR32

CIC004

 

ERN074

CICR12

 

PRI011

PRI023

 

PRI044

BRR006

 

CIC012

TER047

 

CIC013

TER050

 

CIC014

RRB008

 

CDR065

ENT066

 

SNO002

AETR32

 

SNO004

ERN074

 

GARC01

PRI011

 

GAR088

PRI044

 

ALSC01

CIC012

 

ALS023

CIC013

 

ALS185

CIC014

 

ALS046

CDR065

 

ALS186

SNO002

 

RCN021

SNO004

 

ALS170

GARC01

 

REPC01

GAR088

 

REP001

ALSC01

 

REFC01

ALS023

 

REF210

ALS185

 

REF211

ALS046

 

REF197

ALS186

 

REF196

RCN021

 

REF198

ALS170

 

 

REPC01

NL 00720.040 ALS Appeals

ALS023 INITIAL RECONSIDERATION (G17)

(System Generated)

Caption: Do You Think We Are Wrong

If you do not agree with this decision, you have the right to appeal. We will review  (1)  case and look at any new facts you have. A person who did not make the first decision will decide  (2)  case. We will review the parts of the decision that you think are wrong and correct any mistakes. We may also review the parts of our decision that you think are right. We will make a decision that may or may not be in  (3)  favor.

  • You have 60 days to ask for an appeal.

  • The 60 days start the day after you receive this letter. We assume you received this letter 5 days after the date on it unless you show us that you did not receive it within the 5-day period.

  • You must have a good reason for waiting more than 60 days to ask for an appeal.

  • You must ask for an appeal in writing. Please use our “Request for Reconsideration” form, SSA-561-U2. You may go to our website at  (4)  to locate the form. You can also contact us to request the form, or if you need help filling out the form.


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

ALS054 REMINDER OF IMPORTANCE TO ATTEND HEARING (G87)

(System Generated)

Caption: It Is Important That You Go To The Hearing

It is very important that you go to the hearing. If for any reason you can't go, contact the ALJ as soon as possible before the hearing and explain why. The ALJ will reschedule the hearing if you have a good reason.

If you don't go to the hearing and don't have a good reason for not going, the ALJ may dismiss your request for a hearing.

ALS113 FPM CASE-RIGHT TO APPEAL (G82)

(System Generated)

Caption: If You Disagree With The Decision

If you disagree with the decisions, you have the right to appeal. A person who did not make the first decision will decide your case. We will review those parts of the decisions you disagree with and will look at any new facts you have. We may also review those parts of the case that you believe are correct and may make them unfavorable or less favorable to you.

ALS123 FPM CASE-EXPLANATION THAT HEARING WILL BE PROCESSED FIRST (G85)

(System Generated)

Caption: If You Ask For A Reconsideration And A Hearing

If you ask for both a reconsideration and a hearing, we will process the hearing first, even if you made the reconsideration request first. When we make our decisions, we will send you letters explaining our decisions on both the reconsideration and the hearing.

ALS125 FPM CASE-EXPLANATION OF HEARING PROCESS (G86)

(System Generated)

Caption: How The Hearing Process Works

After we send your case for a hearing, an Administrative Law Judge (ALJ) will mail you a letter at least 20 days before the hearing to tell you its date, time and place. The letter will explain the law in your case and tell you what has to be decided. Since the ALJ will review all the facts in your case, it is important that you give us any new facts as soon as you can.

The hearing is your chance to tell the ALJ why you disagree with the decisions in your case. You can give the ALJ new evidence and bring people to testify for you. The ALJ also can require people to bring important papers to your hearing and give facts about your case. You can question these people at your hearing.

ALS170 ALJ OR APPEALS COUNCIL DECISION (C13)

(Requested)

Caption: Do You Think We Are Wrong

 (1)  entitled to benefits because of a decision made  (2)  .

If you disagree with this decision, you have the right to appeal. We will review your case and consider any new facts you have. A person who did not make the first decision will decide  (3)  case. We will correct any mistakes. We will review those parts of the decision, which you believe are wrong and will look at any new facts you have. We may also review those parts, which you believe are correct and may make them unfavorable or less favorable to  (4)  .

  • You have 60 days to ask for an appeal.

  • The 60 days start the day after you get this letter. We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period.

  • You will have to have a good reason for waiting more than 60 days to ask for an appeal.

  • You have to ask for an appeal in writing. We will ask you to sign a form SSA-561-U2, called “Request for Reconsideration.” Contact one of our offices if you want help.


Fill-in values:
Fill-in (1) – System Generated
Choice 1: You are
Choice 2: Beneficiary's Name is
Fill-in (2) - Requested As A One Position Alpha Character
Choice 1 (A): by the Appeals Council
Choice 2 (B): by the Administrative Law Judge
Choice 3 (C): on your hearing request
Fill-in (3) – System Generated
Choice 1: Beneficiary's Name
Choice 2: your
Fill-in (4) – System Generated
Choice 1: you
Choice 2: him
Choice 3: her

ALS171 FPM CASE-EXPLANATION OF THE DIFFERENCE BETWEEN A RECONSIDERATION AND A HEARING (G83)

(System Generated)

Caption: About The Appeals

If you disagree with the non-medical decisions we made on  (1)  case, the appeal is called a reconsideration. Some examples of non-medical decisions are the amount of your payment and the month your payment starts. You will not meet the person who decides  (2)  case.

If you disagree with the disability (medical) decision made by the state, the appeal is called a hearing. Some examples of medical decisions are the date your disability started or whether you are still disabled.


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

ALS172 FPM CASE-EXPLANATION OF 60 DAY APPEAL PERIOD (G84)

(System Generated)

Caption: If You Want To Appeal

 (1)  60 days to ask for an appeal.

  • The 60 days start the day after  (2)  this letter. We assume  (3)  got this letter 5 days after the date on it unless  (4)  us that  (5)  did not get it within the 5 day period.

  •  (6)  must have a good reason if  (7)  more than 60 days to ask for an appeal.

  •  (8)  to ask for an appeal in writing. We will ask  (9)  to sign a form SSA-561-U2, called “Request for Reconsideration” or a form HA-501, called “Request for Hearing.” Contact one of our local offices if  (10)  help.


Fill-in values:
Fill-in (1)
Choice 1: You have
Choice 2: Beneficiary name plus has
Fill-in (2)
Choice 1: you receive
Choice 2: he receives
Choice 3: she receives
Fill-in (3)
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4)
Choice 1: you show
Choice 2: he shows
Choice 3: she shows
Fill-in (5)
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (6)
Choice 1: You
Choice 2: He
Choice 3: She
Fill-in (7)
Choice 1: you want
Choice 2: he wants
Choice 3: she wants
Fill-in (8)
Choice 1: You have
Choice 2: He has
Choice 3: She has
Fill-in (9)
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (10)
Choice 1: you want
Choice 2: he wants
Choice 3: she wants

ALS185 DECISION REVISED BASED ON RECONSIDERATION (A11)

(Requested)

Caption: Do You Think We Are Wrong

As you asked, we have reviewed  (1)  case, and are changing an earlier decision we made. If you think we are wrong, you have the right to request a hearing. At the hearing, a person who has not seen your case before will look at it. That person is an Administrative Law Judge. In the rest of this letter, we will call this person an ALJ. The ALJ will review those parts of the decision, which you believe are wrong. The ALJ will look at any new facts you have and correct any mistakes. The ALJ may also review those parts, which you believe are correct and make them unfavorable or less favorable to  (2)  .

  • You have 60 days to ask for a hearing.

  • The 60 days start the day after you receive this letter. We assume you received this letter 5 days after the date on it unless you show us that you did not receive it within the 5-day period.

  • You must have a good reason if you wait more than 60 days to ask for a hearing.

  • You have to ask for a hearing in writing. If you want to make a request, please contact one of our offices. We can help you complete the required form.

Please read the enclosed pamphlet, “Your Right To An Administrative Law Judge Hearing And Appeals Council Review Of Your Social Security Case”. It contains more information about the hearing.

 

 

NOTE: MADCAP suppresses ALS120 if ALS185 is requested. If ALS185 is used in a manual Aurora notice, DO NOT include ALS120.


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

ALS186 DECISION REVISED BASED ON RECONSIDERATION - POSTENTITLEMENT LETTERS - FOREIGN (A17)

(Requested)

Caption: Do You Think We Are Wrong

We are sending you this letter because we changed an earlier decision we made. We made this change because you asked us to review  (1)  case.

If you still think any of our decisions are wrong, you have the right to appeal. A person who has not seen  (2)  case before will look at it. That person will be an Administrative Law Judge. The Administrative Law Judge will correct any mistakes and look at any new facts you have before deciding  (3)  case. We call this a hearing.

  • You have 60 days to ask for a hearing.

  • The 60 days start the day after you get this letter.

  • You will have to have a good reason for waiting more than 60 days to ask for a hearing.

  • You can only have a hearing in the United States. You would have to pay any costs for traveling to the United States for the hearing. If you cannot come to the hearing, the Administrative Law Judge will review your case plus any new information you send us. We will send you a letter about the Administrative Law Judge's decision.

You have to ask for a hearing in writing. Contact us if you want help.


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

ALS190 (WB5) BOND

(System Generated)

Caption: Do You Think We Are Wrong

If you think this information is not correct or you want to report any changes in  (1)  work plans or earnings, please get in touch with  (2)  benefits counselor at Abt Associates. Please call their toll-free number at 1-877–726–6309 (877–7BOND09) to report any changes. If you have a hearing or speech impairment, you may call their TTY number, 1-877-726-6390 (877-7BOND90).


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

ALS193 HEARING PARAGRAPH - FOREIGN-FOR AWARD LETTERS AFTER A FAVORABLE RECONSIDERATION DETERMINATION (A15)

(Requested)

Caption: Do You Think We Are Wrong

 If you think we are wrong, you have the right to request a hearing. At the hearing, a person who has not seen your case before will look at it. That person is an Administrative Law Judge. In the rest of our letter, we will call this person an ALJ. The ALJ will review those parts of the decision which you believe are wrong. The ALJ will look at any new facts you have and correct any mistakes. The ALJ may also review those parts which you believe are correct and may make them unfavorable or less favorable to you.

  • You have 60 days to ask for a hearing

  • The 60 days start the day after you receive this letter.

  • You must have a good reason if you wait more than 60 days to ask for a hearing.

  • You can only have a hearing in the United States. You would have to pay any costs for traveling to the United States for the hearing. If you cannot come to the hearing, the Administrative Law Judge will review your case plus any new information you send us. We will send you a letter about the Administrative Law Judge's decision.

  • You have to ask for a hearing in writing. Contact us if you want help.

 Please read the enclosed pamphlet, "Your Right to an Administrative Law Judge Hearing and Appeals Council Review of Your Social Security Case." It contains more information about the hearing.

ALS197 HEARING PARAGRAPH FOR AWARD LETTERS AFTER A FAVORABLE RECONSIDERATION DETERMINATION — DOMESTIC (A12)

(Requested)

Caption: Do You Think We Are Wrong

If you think we are wrong, you have the right to request a hearing. At the hearing, a person who has not seen your case before will look at it. That person is an Administrative Law Judge. In the rest of our letter, we will call this person an ALJ. The ALJ will review those parts of the decision which you believe are wrong. The ALJ will look at any new facts you have and correct any mistakes. The ALJ may also review those parts which you believe are correct and may make them unfavorable or less favorable to you.

  • You have 60 days to ask for a hearing.

  • The 60 days start the day after you receive this letter.

  • You must have a good reason if you wait more than 60 days to ask for a hearing.

  • You have to ask for a hearing in writing. If you want to make a request, please contact one of our offices. We can help you complete the required form.

Please read the enclosed pamphlet, “Your Right To An Administrative Law Judge Hearing And Appeals Council Review Of Your Social Security Case”. It contains more information about the hearing.

NL 00720.210 MHP Medicare Health Plan

MHP001 ENROLLMENT IN HMO – PART B PREMIUM REDUCTION STARTS OR CHANGES (H33)

(Requested)

Caption: Information About Medicare

 (1)  enrolled in a Medicare health plan which reduces  (2)  Medicare Part B premium.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary Full Name + has
Choice 2: You have
Fill-in (2) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your

MHP002 PART B PREMIUM AFTER REDUCTION AMOUNT IS APPLIED (H34)

(Requested)

Caption: Information About Medicare

 (1)  Part B premium is  (2)  beginning  (3)  .


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary First Name possessive
Choice 2: Your
Fill-in (2) - Systems Generated
Choice 1: reduced SMI premium $amount
Fill-in (3) - Systems Generated
Choice 1: MCR Start DATE, corr. to amount above

MHP003 DISENROLLMENT IN HMO – PART B PREMIUM REDUCTION STOPS (H35)

(Requested)

Caption: Information About Medicare

 (1)  no longer enrolled in a Medicare health plan which reduces  (2)  Medicare Part B premium.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary Full Name + is
Choice 2: You are
Fill-in (2) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your

MHP004 ERRONEOUS ENROLLMENT IN A MEDICARE HEALTH PLAN – WIPEOUT (H36)

(Requested)

Caption: Information About Medicare

 (1)  not enrolled in a Medicare health plan which reduces  (2)  Medicare Part B premium.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary Full Name + is
Choice 2: You are
Fill-in (2) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your

MHP005 ENROLLMENT IN A HMO – CLOSED PERIOD REDUCTION OF PART B (H37)

(Requested)

Caption: Information About Medicare

 (1)  enrolled in a Medicare health plan which reduced  (2)  Medicare Part B premium.  (3)  Part B premium was reduced to  (4)  from  (5)  through  (6)  .


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary Full Name + was
Choice 2: You were
Fill-in (2) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Fill-in (3) - Systems Generated
Choice 1: His
Choice 2: Her
Choice 3: Your
Fill-in (4) - Systems Generated
Choice 1: Reduced SMI premium amount
Fill-in (5) - Systems Generated
Choice 1: MCR start date
Fill-in (6) - Systems Generated
Choice 1: MCR stop date

MHP009 INTRODUCTORY UTI FOR HEALTH PLAN PREMIUMS (H17)

(Requested/Generated)

Caption: Information About Health Plan Premiums

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


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

MHP012 (H25)

(Requested/Generated)

Caption: Information About Health Plan Premiums

This represents all health plan premiums due to date.


Fill-in values:

 

None

MHP013 ADVISES BENEFICIARY THAT SOME MANAGED HEALTH PLANS OFFER PREMIUM DEDUCTION (H57)

(Requested/Generated)

Caption: Information About Health Plan Premiums

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


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary's Full Name possessive
Choice 2: your
Choice 3: his
Choice 4: her

MHP015 HEALTH PLAN PREMIUMS CONTINUING TO BE DEDUCTED FROM ONGOING MONTHLY BENEFITS (H22)

(Requested/Generated)

Caption: Information About Health Plan Premiums

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


Fill-in values:
Fill-in (1) - Requested As A Money Amount in Format $$$$$.¢¢
Choice 1: Money amount
Fill-in (2) - Systems Generated
Choice 1: Beneficiary's Full Name possessive
Choice 2: your
Choice 3: his
Choice 4: her

MHP016 CHANGE IN HEALTH PLAN PREMIUM DEDUCTION AMOUNT (H58)

(Requested/Generated)

Caption: Information About Health Plan Premiums

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


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary's Full Name possessive
Choice 2: your
Choice 3: his
Choice 4: her

MHP017 HEALTH PLAN PREMIUMS NO LONGER BEING DEDUCTED (H29)

(Requested/Generated)

Caption: Information About Health Plan Premiums

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


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary's Full Name possessive
Choice 2: your
Choice 3: his
Choice 4: her
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Choice 4: the

MHP018 ADVISES BENEFICIARY/PAYEE TO CONTACT HEALTH PLAN CARRIER FOR QUESTIONS ABOUT THEIR HEALTH PLAN PREMIUMS (H38)

(Requested/Generated)

Caption: Information About Health Plan Premiums

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


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Choice 4: the
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Choice 4: the

MHP033 INTRODUCTORY UTI FOR MEDICARE PRESCRIPTION DRUG PLAN COSTS (H08)

(Requested/Generated)

Caption: Information About Medicare prescription drug plan costs

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


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

MHP035 HEALTH PLAN PREMIUMS DEDUCTED FROM PMA PAYMENT (H19)

(Requested/Generated)

Caption: Information About Health Plan Premiums

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


Fill-in values:
Fill-in (1) - Requested As A Money Amount in Format $$$$$.¢¢
Choice 1: Amount
Fill-in (2) - Systems Generated
Choice 1: Beneficiary's Name
Choice 2: your
Fill-in (3) - Requested As A Date In Format Shown Below
Choice 1: MM/DD/CCYY

MHP036 MEDICARE PRESCRIPTION DRUG PLAN COSTS DEDUCTED FROM PMA PAYMENT (H68)

(Requested/Generated)

Caption: Information About Medicare prescription drug plan costs

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) - Requested As A Money Amount in Format $$$$$.¢¢
Choice 1: Amount
Fill-in (2) - Systems Generated
Choice 1: Beneficiary's Name
Choice 2: your
Fill-in (3) - Requested As A Date In Format Shown Below
Choice 1: MM/DD/CCYY

MHP037 HEALTH PLAN PREMIUMS AND MEDICARE PRESCRIPTION DRUG PLAN COSTS DEDUCTED FROM PMA PAYMENT (H89)

(Requested/Generated)

Caption: Information about health plan premiums and prescription drug plan costs

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) - Requested As A Money Amount in Format $$$$$.¢¢
Choice 1: Amount
Fill-in (2) - Systems Generated
Choice 1: Beneficiary's Name
Choice 2: your
Fill-in (3) - Requested As A Money Amount in Format $$$$$.¢¢
Choice 1: Amount
Fill-in (4) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Fill-in (5) - Requested As A Date In Format Shown Below
Choice 1: MM/DD/CCYY

MHP038 HEALTH PLAN PREMIUMS DEDUCTED FROM CMA PAYMENT (H20)

(Requested/Generated)

Caption: Information About Health Plan Premiums

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) - Requested As A Money Amount in Format $$$$$.¢¢
Choice 1: Amount
Fill-in (2) - Systems Generated
Choice 1: Beneficiary's Name possessive
Choice 2: your
Fill-in (3) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (4) - Requested As A Date In Format Shown Below
Choice 1: MM/DD/CCYY

MHP039 MEDICARE PRESCRIPTION DRUG PLAN COSTS DEDUCTED FROM CMA PAYMENT (H69)

(Requested/Generated)

Caption: Information About Medicare Prescription Drug Costs

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) - Requested As A Money Amount in Format $$$$$.¢¢
Choice 1: Amount
Fill-in (2) - Systems Generated
Choice 1: Beneficiary's Name possessive
Choice 2: your
Fill-in (3) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (4) - Requested As A Date In Format Shown Below
Choice 1: MM/DD/CCYY

MHP040 HEALTH PLAN PREMIUMS AND MEDICARE PRESCRIPTION DRUG PLAN COSTS DEDUCTED FROM CMA PAYMENT (H93)

(Requested/Generated)

Caption: Information About Health Plan Premiums And Prescription Drug Plan Costs

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) - Requested As A Money Amount in Format $$$$$.¢¢
Choice 1: Amount
Fill-in (2) - Systems Generated
Choice 1: Beneficiary's Name possessive
Choice 2: your
Fill-in (3) - Requested As A Money Amount in Format $$$$$.¢¢
Choice 1: Amount
Fill-in (4) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Fill-in (5) - Systems Generated
Choice 1: he
Choice 2: she
Choice 3: you
Fill-in (6) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (7) - Requested As A Date In Format Shown Below
Choice 1: MM/DD/CCYY

MHP041 ALL MEDICARE PRESCRIPTION DRUG PLAN COSTS DUE TO DATE WITHHELD (HA1)

(Requested/Generated)

Caption: Information About Medicare Prescription Drug Costs

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


Fill-in values:

 

None

MHP042 ALL HEALTH PLAN PREMIUMS AND MEDICARE PRESCRIPTION DRUG PLAN COSTS DUE TO DATE WITHHELD (HA2)

(Requested/Generated)

Caption: Information About Health Plan Premiums And Prescription Drug Plan Costs

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


Fill-in values:

 

None

MHP043 MEDICARE PRESCRIPTION DRUG PLAN COSTS CONTINUING TO BE DEDUCTED FROM ONGOING MONTHLY BENEFITS (H70)

(Requested/Generated)

Caption: Information About Medicare Prescription Drug Costs

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


Fill-in values:
Fill-in (1) - Requested As A Money Amount in Format $$$$$.¢¢
Choice 1: Amount
Fill-in (2) - Systems Generated
Choice 1: Beneficiary's Name possessive
Choice 2: your

MHP044 HEALTH PLAN PREMIUMS AND MEDICARE PRESCRIPTION DRUG PLAN COSTS CONTINUING TO BE DEDUCTED FROM ONGOING MONTHLY BENEFITS (H94)

(Requested/Generated)

Caption: Information About Health Plan Premiums And Prescription Drug Plan Costs

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) - Requested As A Money Amount in Format $$$$$.¢¢
Choice 1: Amount
Fill-in (2) - Systems Generated
Choice 1: Beneficiary's Name (possessive)
Choice 2: your
Fill-in (3) - Requested As A Money Amount in Format $$$$$.¢¢
Choice 1: Amount
Fill-in (4) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your

MHP045 CHANGE IN MEDICARE PRESCRIPTION DRUG PLAN COSTS (HA7)

(Requested/Generated)

Caption: Information About Medicare prescription drug plan costs

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


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

MHP046 CHANGE IN HEALTH PLAN PREMIUM DEDUCTION AMOUNT AND MEDICARE PRESCRIPTION DRUG PLAN COSTS (HA8)

(Requested/Generated)

Caption: Information About Health Plan Premiums And 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) - Systems Generated
Choice 1: Beneficiary's Name possessive
Choice 2: your
Fill-in (2) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your

MHP047 MEDICARE PRESCRIPTION DRUG PLAN COSTS NO LONGER BEING DEDUCTED (HA3)

(Requested/Generated)

Caption: Information About Medicare prescription drug plan costs

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


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

MHP048 HEALTH PLAN PREMIUMS AND MEDICARE PRESCRIPTION DRUG PLAN COSTS NO LONGER BEING DEDUCTED (HA4)

(Requested/Generated)

Caption: Information About Health Plan Premiums And Prescription Drug Plan Costs

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

MHP049 ADVISES BENEFICIARY/PAYEE TO CONTACT MEDICARE PRESCRIPTION DRUG PLAN CARRIER FOR QUESTIONS ABOUT THEIR MEDICARE PRESCRIPTION DRUG PLAN COSTS (HA5)

(Requested/Generated)

Caption Information About Medicare Prescription Drug Plan Costs

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

MHP050 ADVISES BENEFICIARY/PAYEE TO CONTACT HEALTH PLAN CARRIER AND MEDICARE PRESCRIPTION DRUG PLAN CARRIER FOR QUESTIONS ABOUT THEIR HEALTH PLAN PREMIUMS AND MEDICARE PRESCRIPTION DRUG PLAN COSTS (HA6)

(Requested/Generated)

Caption: Information About Health Plan Premiums And Prescription Drug Plan Costs

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) - Systems Generated
Choice 1: your
Choice 2: Beneficiary's Name possessive
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) - Systems Generated
Choice 1: you have
Choice 2: he has
Choice 3: she has
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

MHP053 ENROLLMENT INFORMATION FOR MEDICARE PRESCRIPTION DRUG PLAN (HB6)

(Requested/Generated)

Caption: Prescription Drug Plan Enrollment

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 contact us.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary Name (not-possessive)
Choice 2: you
Fill-in (2) - Systems Generated
Choice 1: is
Choice 2: are
Fill-in (3) - Systems Generated
Choice 1: he
Choice 2: she
Choice 3: you
Fill-in (4) - Systems Generated
Choice 1: he
Choice 2: she
Choice 3: you
Fill-in (5) - Systems Generated
Fill-in (6) - Systems Generated
Choice 1: him
Choice 2: her
Choice 3: you
Fill-in (7) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Fill-in (8) - Systems Generated
Choice 1: him
Choice 2: her
Choice 3: you
Fill-in (9) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Fill-in (10) - Systems Generated
Choice 1: he has
Choice 2: she has
Choice 3: you have
Fill-in (11) - Systems Generated
Choice 1: him
Choice 2: her
Choice 3: you

MHP054 TERMINATION OF STATE BUY-IN (H39)

(Requested/Generated)

Caption: Information About Medicare

 (1)  State Public Assistance Agency has stopped paying the premiums for  (2)  medical insurance under Medicare.  (3)  must start to pay the premiums beginning  (4)  .

If  (5)  to cancel  (6)  medical insurance, please let us know.

If  (7)  within 30 days of the date of this letter, we will stop  (8)  medical insurance at the same time the State stopped paying  (9)  premiums.

If  (10)  within 6 months of the month when the State stopped paying  (11)  premiums, we will stop the insurance at the end of the month when  (12)  asked us to cancel.  (13)  will have to pay the premiums for all the months before  (14)  .

 (15)  can still cancel after the 6-month period is over. We will stop the insurance at the end of the month after the month when  (16)  us to cancel.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Your
Choice 2: Beneficiary's Name possessive
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: her
Choice 3: his
Fill-in (3) - Systems Generated
Choice 1: You
Choice 2: She
Choice 3: He
Fill-in (4) - Requested As A Date In Format Shown
Choice 1: MM/CCYY
Fill-in (5) - Systems Generated
Choice 1: you want
Choice 2: she wants
Choice 3: he wants
Fill-in (6) - Systems Generated
Choice 1: your
Choice 2: her
Choice 3: his
Fill-in (7) - Systems Generated
Choice 1: you cancel
Choice 2: she cancels
Choice 3: he cancels
Fill-in (8) - Systems Generated
Choice 1: your
Choice 2: her
Choice 3: his
Fill-in (9) - Systems Generated
Choice 1: your
Choice 2: her
Choice 3: his
Fill-in (10) - Systems Generated
Choice 1: you cancel
Choice 2: she cancels
Choice 3: he cancels
Fill-in (11) - Systems Generated
Choice 1: your
Choice 2: her
Choice 3: his
Fill-in (12) - Systems Generated
Choice 1: you
Choice 2: she
Choice 3: he
Fill-in (13) - Systems Generated
Choice 1: You
Choice 2: She
Choice 3: He
Fill-in (14) - Systems Generated
Choice 1: you cancel
Choice 2: she cancels
Choice 3: he cancels
Fill-in (15) - Systems Generated
Choice 1: You
Choice 2: She
Choice 3: He
Fill-in (16) - Systems Generated
Choice 1: you ask
Choice 2: she asks
Choice 3: he asks

NL 00720.280 REF Referral

REF137 (GA7) BOND UTI

(System Generated)

Caption: If You Have Questions About The BOND Project

Please visit our website at  (1)  for general information about the Benefit Offset National Demonstration (BOND) project. If you have any questions about the BOND project, you may call our partner Abt Associates. Their toll-free number is 1-877-726-6309 (877-7BOND09). They will help you by phone or they will set up an appointment with the Abt local office that serves your area. If you have a hearing or speech impairment, you may call their TTY number, 1-877-726-6390 (877-7BOND90). When you call, please have this letter with you. It will help the counselors at Abt answer your questions.


Fill-in value:

REF196 DOMESTIC REFERRALS PARAGRAPH

(Systems Generated)

Caption: If You Have Any Questions

Need more help?

  1. 1. 

    Visit www.ssa.gov for fast, simple, and secure online service.

  2. 2. 

    Call us at 1-800-772-1213, weekdays from 8:00 am to 7:00 pm. If you are deaf or hard of hearing, call TTY 1-800-325-0778. Please mention this letter when you call.

  3. 3. 

    You may also call your local office at  (1)  (Field Office General Inquiry Line phone number).

     (2) 

     (3) 

     (4) 

     (5) 

     (6) 

     (7) 


Fill-in values
Fill-in (1) System Generated
Choice 1: Business Number from DOORS
Choice 2: T2 Number from DOORS
Choice 3: T16 Number from DOORS
Fill-in (2) Systems Generated
Choice: Line 1 of FO Physical Address in DOORS
Fill-in (3) Systems Generated
Choice 1: Line 2 of FO Physical Address in DOORS
Fill-in (4) Systems Generated
Choice1: Line 3 of FO Physical Address in DOORS
Fill-in (5) Systems Generated
Choice 1: Line 4 of FO Physical Address in DOORS
Fill-in (6) Systems Generated
Choice 1: Line 5 of FO Physical Address in DOORS
Fill-in (7) Systems Generated
Choice 1: Line 6 of FO Physical Address in DOORS

REF197 REFERRAL FOREIGN

(Systems Generated)

Caption: If You Have Any Questions

Need more help?

  1. 1. 

    Visit www.ssa.gov for fast, simple, and secure online service.

  2. 2. 

    If you are in the United States, American Samoa, Guam, Northern Mariana Islands, Puerto Rico, or the U.S. Virgin Islands, call us at 1-800-772-1213. If you are deaf or hard of hearing, call TTY 1-800-325-0778.

  3. 3. 

    You may also call your local Social Security office.

If you are outside the United States or its territories:

  • If you are in Canada, visit  (1)  to find the office that services your area.

  • Contact your nearest Federal Benefits Unit (FBU). Visit  (2)  for a list of FBUs.

  • Write to the Social Security Administration at:

P.O. Box 17769
Baltimore, Maryland 21235-7769, USA

If you contact us, please refer to this letter. It will help us answer your questions.

How are we doing? Go to www.ssa.gov/feedback to tell us.


Fill-in values
Fill-in (1) Systems Generated
Fill-in (2) Systems Generated

REF198 REFERRAL RAIL ROAD BOARD (RBB)

(Systems Generated)

Caption: If You Have Any Questions

If you have any questions about railroad annuities or about your monthly check, please contact your local Railroad District Office or the Railroad Retirement Board. The address is U.S. Railroad Retirement Board, 844 Rush Street, Chicago, Illinois 60611-2092. You can also reach the Railroad Retirement Board on their website at www.rrb.gov or by calling 1-877-772-5772. If you are deaf or hard of hearing, please call the TTY number at 312-751-4701.

REF210 DOMESTIC REFERRAL PARAGRAPH

(Systems Generated)

Caption: If You Have Any Questions

Need more help?

  1. 1. 

    Visit www.ssa.gov for fast, simple, and secure online service.

  2. 2. 

    Call us at 1-800-772-1213, weekdays from 8:00 am to 7:00 pm. If you are deaf or hard of hearing, call TTY 1-800-325-0778. Please mention this letter when you call.

  3. 3. 

    The office that serves your area is located at:

 (1) 

 (2) 

 (3) 

 (4) 

 (5) 

 (6) 

 

How are we doing? Go to www.ssa.gov/feedback/ to tell us.


Fill-in values
Fill-in (1) Systems Generated
Choice 1: Line 1 of FO Physical Address in DOORS
Fill-in (2) Systems Generated
Choice 1: Line 2 of FO Physical Address in DOORS
Fill-in (3) Systems Generated
Choice 1: Line 3 of FO Physical Address in DOORS
Fill-in (4) Systems Generated
Choice 1: Line 4 of FO Physical Address in DOORS
Fill-in (5) Systems Generated
Choice 1: Line 5 of FO Physical Address in DOORS
Fill-in (6) Systems Generated
Choice 1:Line 6 of FO Physical Address in DOORS

REF211 REFERRAL DOMESTIC DEFAULT

(Systems Generated)

Caption: If You Have Any Questions

Need more help?

  1. 1. 

    Visit www.ssa.gov for fast, simple, and secure online service.

  2. 2. 

    Call us at 1-800-772-1213, weekdays from 8:00 am to 7:00 pm. If you are deaf or hard of hearing, call TTY 1-800-325-0778. Please mention this letter when you call.

How are we doing? Go to www.ssa.gov/feedback/ to tell us.

NL 00720.390 WAV Waiver

WAV - Waiver

WAV001 OVERPAYMENT RECONSIDERATION AND WAIVER INFORMATION - INITIAL OVERPAYMENT NOTICE -REFUND REQUESTED, ADJUSTMENT NOT PROPOSED (A07) (F07)

(System Generated)

Caption: Do You Think We Are Wrong About The Overpayment?

You have certain rights with respect to this overpayment and its recovery.

1. Right to Appeal: If you disagree in any way with this overpayment determination, you have the right, within 60 days of the date you receive this notice, to request that the determination be reconsidered. If you request this independent review of the overpayment determination, please submit any additional information you have which pertains to the overpayment.

2. Right to Request Waiver: You also have the right to request a determination concerning the need to recover the overpayment. An overpayment must be refunded or withheld from benefits unless both of the following are true:

a. The overpayment was not your fault in any way, and

b. You could not meet your necessary living expenses if we

recovered the overpayment, or recovery would be unfair for some

other reason.

If you request waiver, we may need a statement of your assets and monthly income and expenses.

If you request reconsideration and/or waiver within 30 days, the overpayment will not have to be recovered until the case is reviewed. This review is described in more detail on the attached form SSA-3105, Important Information About Your Appeal and Waiver Rights. Please contact us if you need help completing the forms for requesting reconsideration(SSA-561-U2, Request for Reconsideration) and/or waiver (SSA-632-BK, Request for Waiver of Overpayment Recovery or Change in Repayment Options.)

If you have any additional questions, please contact us, and have this letter with you so that we may help you more quickly.

WAV002 OVERPAYMENT RECONSIDERATION AND WAIVER INFORMATION- INITIAL OVERPAYMENT NOTICE, ADJUSTMENT PROPOSED (A09)

(Requested/Generated)

Caption: Do You Think We Are Wrong About The Overpayment?

You have certain rights with respect to this overpayment and its recovery.

1. Right to Appeal: If you disagree in any way with this overpayment determination, you have the right, within 60 days of the date you receive this notice, to request that the determination be reconsidered. If you request this independent review of the overpayment determination, please submit any additional information you have which pertains to the overpayment.

2. Right to Request Waiver: You also have the right to request a determination concerning the need to recover the overpayment. An overpayment must be refunded or withheld from benefits unless both of the following are true:

a. The overpayment was not your fault in any way, and

b. You could not meet your necessary living expenses if we

recovered the overpayment, or recovery would be unfair for some

other reason.

If you request waiver, we may need a statement of your assets and monthly income and expenses.

If you request reconsideration and/or waiver within 30 days, the planned withholding of your benefit to recover the overpayment will not take place until your case is reviewed. This review is described in more detail on the attached form SSA-3105, Important Information About Your Appeal and Waiver Rights. Please contact us if you need help completing the forms for requesting reconsideration (SSA-561-U2, Request for Reconsideration) or waiver (SSA-632-BK, Overpayment Recovery Questionnaire).

If you have any additional questions, please contact us, and have this letter available so that we can help you more quickly.

WAV002 FOREIGN RECONSIDERATION & WAIVER RIGHTS INITIAL OVERPAYMENT NOTICE ADJUSTMENT PROPOSED (F09)

(System Generated)

Caption: Do You Think We Are Wrong About The Overpayment?

You have certain rights with respect to this overpayment and its recovery.

1. Right to Appeal: If you disagree in any way with this overpayment determination, you have the right, within 60 days of the date you receive this notice, to request that the determination be reconsidered. If you request this independent review of the overpayment determination, please submit any additional information you have which pertains to the overpayment.

2. Right to Request Waiver: You also have the right to request a determination concerning the need to recover the overpayment. An overpayment must be refunded or withheld from benefits unless both of the following are true:

a. The overpayment was not your fault in any way, and

b. You could not meet your necessary living expenses if we

recovered the overpayment, or recovery would be unfair for some

other reason.

If you request waiver, we may need a statement of your assets and monthly income and expenses.

If you request reconsideration and/or waiver within 30 days, the planned withholding of your benefit to recover the overpayment will not take place until your case is reviewed. This review is described in more detail on the attached form SSA-3105, Important Information About Your Appeal, Waiver Rights and Repayment Options. Please contact us if you need help completing the forms for requesting reconsideration (SSA-561-U2, Request for Reconsideration) and/or waiver (SSA-632-BK, Overpayment Recovery Questionnaire).

If you have any additional questions, please contact us, and have this letter available so that we can help you more quickly.

Unless we hear from you within 30 days, we will withhold your payment as shown above.

WAV005 CROSS PROGRAM RECOVERY – WAIVER REQUEST FOR SSI OVERPAYMENT (B83)

(Requested/Generated)

Caption: Your Benefits

You may not have to pay us back. Sometimes we can waive the collection of an overpayment, which means you won't have to pay us back. For us to waive the collection of the overpayment, two things have to be true.

  • It wasn't your fault that you got too much SSI money.

AND

  • Paying us back would mean you can't pay  (1)  bills for food, clothing, housing, medical care or other necessary expenses, or it would be unfair for some other reason

If you think these are true about you, contact any Social Security office. You can ask for waiver at any time by completing the waiver form and returning it to us. The form is called Request for Waiver of Recovery or Change in Repayment Rate, Form SSA-632-BK. We will be happy to help you fill out the form. If you ask for waiver after that time, we will stop collecting the overpayment while we decide if we can waive collection.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

NL 00720.410 WEP Windfall Elimination Provision

WEP001 WINDFALL ELIMINATION PROVISION (A04)

(Requested)

Caption: Your Benefits

We reduced  (1)  Social Security benefits starting  (2)  . This is the first month that  (3)  received a pension based on work not covered by Social Security taxes.

When  (4)  this type of pension, we may apply the Windfall Elimination Provision to  (5)  Social Security benefits. This changes the way we figure  (6)  benefit amount.  (7)  benefit amount is less than it would be if  (8)  not receiving the pension.

To learn more about how non-covered pensions affect Social Security benefits, please view our factsheet titled “Windfall Elimination Provision.” located at  (9)  online.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Number Holder's name possessive
Choice 2: your
Fill-in (2) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4) - Systems Generated
Choice 1: you receive
Choice 2: he receives
Choice 3: she receives
Fill-in (5) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (6) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (7) - Systems Generated
Choice 1: Your
Choice 2: His
Choice 3: Her
Fill-in (8) - Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was
Fill-in (9) - Systems Generated

WEP004 NUMBER HOLDER’S MONTHLY BENEFIT IS CHANGING BECAUSE WINDFALL ELIMINATION PROVISION (WEP) NO LONGER APPLIES

(Requested)

Caption: Your Benefits

We changed  (1)  benefit amount starting  (2)  . The Windfall Elimination Provision no longer reduces  (3)  benefits. We stopped applying this provision because  (4)  :

  • Reached 30 years of substantial earnings covered by Social Security taxes, or

  • Stopped receiving a pension based on work not covered by Social Security taxes.

To learn more about how non-covered pensions affect Social Security benefits, please view our factsheet titled, ” Windfall Elimination Provision,” at  (5)  online.


Fill-in values:
Fill-in (1) Systems generated
Choice 1: your
Choice 2: Number Holder's name possessive
Fill-in (2) - Requested as a Date in Format Shown Below
MM/CCYY
Fill-in (3) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (4) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (5) - Systems Generated

NL 00720 TN 25 - Manual Adjustment, Credit and Award Process (MADCAP) Beneficiary Notice Print Program - 9/12/2022