Identification Number:
NL 00720 TN 13
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. 13, 09/24/2019

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

OSE

Effective Date

09/24/2019

Background

We are updating the Program Operations Manual System (POMS) sections in NL00720 effective with the Manual Adjustment Credit and Award Process System (MADCAP) August 2019 release.

Language changes for notices in the attached sections are a direct result of the updates requested by the Office of General Council (OGC), Office of Income Security Programs (OISP), and Office Electronic Services and Technology (OEST) .

Summary of Changes

NL 00720.095 CLO Closeout - CLOR05

We increased the number of fill-in choices for fill-in 1 and fill-in 4 .

 

NL 00720.180 HIB Health Insurance Benefit – HIB170 and HIB171

Language and fill-in modifications for HIB170 and HIB171 are a direct result of the updates requested by OISP and OEST in support of the Unprocessed Medical Cessation project. We replaced “checks” with "payments" in the first sentence for UTI HIB170 and HIB171. Additional changes for HIB170 include removal of the words “hospital and medical insurance coverage” and revisions to fill-ins 3, 4, and 5. Language changes for HIB171 include the addition of "Part A" and "Part B" in the first sentence and revisions to fill-in 3 .

 

NL 00720.245 OPT Overpayment – OPT263 and OPT294

OGC and OISP revised the language used in OPT263 and OPT294. Per OGC's request, we updated the language in the Universal Text Identifier (UTI) OPT 263 to reflect "a crime" instead of "crimes". Also, we updated the language in the first sentence of OPT294 and reduced the number of fill-ins from three to two.

NL 00720.095 CLO Closeout

CLO002 GENERAL CLOSEOUT FOR AWARDS (G19)

(System Generated)

Caption: Other Social Security 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) - Systems Generated
Choice 1: This benefit is the only benefit
Choice 2: These benefits are the only benefits
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she

CLO029 AD, B TO D, AND AB TO AD CONVERSION HIGHER BENEFITS POSSIBLE ON PRIOR SPOUSE'S RECORD (B35)

(Requested)

Caption: Other Social Security Benefits

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) - Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was
Fill-in (2) - Systems Generated
Choice 1: You
Choice 2: He
Choice 3: She

CLOR05 CLOSE OUT ANOTHER CLAIM PENDING (B56)

(Requested)

Caption: Other Social Security Benefits

This  (1)  benefit is the only benefit we can pay  (2)  at this time. We will let you know if  (3)  eligible for  (4)  benefits.  (5)  cannot receive any other type of benefits based on the application  (6)  filed.


Fill-in values:
Fill-in (1) - Requested As A One Position Alpha Character
Choice 1: (A) retirement
Choice 2: (B) wife's
Choice 3: (C) husband's
Choice 4: (D) widow's
Choice 5: (E) widower's
Choice 6: (F) mother's
Choice 7: (G) father's
Choice 8: (H) disabled widow's
Choice 9: (I) disabled widower's
Choice 10: (J) disabled divorced widow's
Choice 11: (K) disabled divorced widower's
Choice 12: (L) child's
Choice 13: (M) children
Choice 14: (N) parent
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (3) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (4) - Requested As A One Position Alpha Character
Choice 1: (A) retirement
Choice 2: (B) wife's
Choice 3: (C) husband's
Choice 4: (D) widow's
Choice 5: (E) widower's
Choice 6: (F) mother's
Choice 7: (G) father's
Choice 8: (H) disabled widow's
Choice 9: (I)disabled widower's
Choice 10: (J) disabled divorced widow's
Choice 11: (K) disabled divorced widower's
Choice 12: (L) child's
Choice 13: (M) children
Choice 14: (N) parent
Fill-in (5) - Systems Generated
Choice 1: You
Choice 2: He
Choice 3: She
Fill-in (6) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she

CLOR11 AWARD CLOSEOUT OTHER POTENTIAL CLAIM GIVEN 6-MONTH CLOSEOUT (B11)

(Requested)

Caption: Other Social Security Benefits

The  (1)  benefit is the only kind of benefit  (2)   (3)  entitled to receive, with the possible exception of  (4)  benefits. You told us when you applied for  (5)  benefits  (6)   (7)  that you did not wish to apply for  (8)  benefits  (9)  at that time.

If you change your mind, you need to apply for these benefits. The application date can make a difference in the amount we pay. If you apply within 6 months of the date of this letter, we may be able to use the date of your application for  (10)  benefits as the date of your application for  (11)  benefits.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: retirement
Choice 2: disability
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: Beneficiary name
Fill-in (3) - Systems Generated
Choice 1: are
Choice 2: is
Fill-in (4) - Requested As A One Position Alpha Character
Choice 1: (A) retirement
Choice 2: (B) disability
Choice 3: (C) spouse’s
Choice 4: (D) widow’s
Choice 5: (E) widower’s
Choice 6: (F) mother’s
Choice 7: (G) father’s
Choice 8: (H) child’s
Choice 9: (I) parent’s
Choice 10: (J) disabled widow’s
Choice 11: (K) disabled widower’s
Choice 12: (L) disabled divorced widow’s
Choice 13: (M) disabled divorced widower’s
Fill-in (5) - Systems Generated
Choice 1: retirement
Choice 2: disability
Fill-in (6) - Systems Generated
Choice 1: for
Choice 2: null
Fill-in (7) - Systems Generated
Choice 1: Beneficiary name
Choice 2: null
Fill-in (8) - Requested As A One Position Alpha Character
Choice 1: (A) retirement
Choice 2: (B) disability
Choice 3: (C) spouse’s
Choice 4: (D) widow’s
Choice 5: (E) widower’s
Choice 6: (F) mother’s
Choice 7: (G) father’s
Choice 8: (H) child’s
Choice 9: (I) parent’s
Choice 10: (J) disabled widow’s
Choice 11: (K) disabled widower’s
Choice 12: (L) disabled divorced widow’s
Choice 13: (M) disabled divorced widower’s
Fill-in (9) - Systems Generated
Choice 1: for him
Choice 2: for her
Choice 3: null
Fill-in (10) - Systems Generated
Choice 1: retirement
Choice 2: disability
Fill-in (11) - Requested As A One Position Alpha Character
Choice 1: (A) retirement
Choice 2: (B) disability
Choice 3: (C) spouse’s
Choice 4: (D) widow’s
Choice 5: (E) widower’s
Choice 6: (F) mother’s
Choice 7: (G) father’s
Choice 8: (H) child’s
Choice 9: (I) parent’s
Choice 10: (J) disabled widow’s
Choice 11: (K) disabled widower’s
Choice 12: (L) disabled divorced widow’s
Choice 13: (M) disabled divorced widower’s

CLOR12 AWARD CLOSEOUT POTENTIAL AUXILIARY AND FAMILY CLAIM GIVEN 6-MONTH CLOSEOUT (B12)

(Requested)

Caption: Other Social Security Benefits

The  (1)  benefit is the only kind of benefit  (2)   (3)  family are entitled to receive, with the possible exception of  (4)  benefits. You told us when you applied for  (5)  benefits  (6)   (7)  that  (8)  did not wish to apply for  (9)  benefits at that time.

If  (10)  mind,  (11)  to apply for these benefits. The application date can make a difference in the amount we pay. If  (12)  within 6 months of the date of this letter, we may be able to use the date of the application for  (13)  benefits  (14)   (15)  as the date of application for  (16)  benefits.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: retirement
Choice 2: disability
Fill-in (2) - Systems Generated
Choice 1: you and your family
Choice 2: Number Holder's Fullname
Fill-in (3) - Systems Generated
Choice 1: and his
Choice 2: and her
Choice 3: null
Fill-in (4) - Requested As A One Position Alpha Character
Choice 1: (A) wife's
Choice 2: (B) husband's
Choice 3: (C) child's
Fill-in (5) - Systems Generated
Choice 1: retirement
Choice 2: disability
Fill-in (6) - Systems Generated
Choice 1: for
Choice 2: null
Fill-in (7) - Systems Generated
Choice 1: Number Holder's fullname
Choice 2: null
Fill-in (8) - Requested As A One Position Alpha Character
Choice 1: (A) you
Choice 2: (B) your wife
Choice 3: (C) your husband
Choice 4: (D) your child
Fill-in (9) - Requested As A One Position Alpha Character
Choice 1: (A) wife's
Choice 2: (B) husband's
Choice 3: (C) child's
Fill-in (10) - Requested As A One Position Alpha Character
Choice 1: (A) you change your
Choice 2: (B) your wife changes her
Choice 3: (C) your husband changes his
Choice 4: (D) your child changes his
Choice 5: (E) your child changes her
Fill-in (11) - Systems Generated
Choice 1: you need
Choice 2: he needs
Choice 3: she needs
Fill-in (12) - Requested As A One Position Alpha Character
Choice 1: (A) you apply
Choice 2: (B) your wife applies
Choice 3: (C) your husband applies
Fill-in (13) - Systems Generated
Choice 1: retirement
Choice 2: disability
Fill-in (14) - Systems Generated
Choice 1: for
Choice 2: null
Fill-in (15) - Systems Generated
Choice 1: Number Holder's Surname
Fill-in (16) - Requested As A One Position Alpha Character
Choice 1: (A) wife's
Choice 2: (B) husband's
Choice 3: (C) child's

CLOR13 LUMP-SUM DEATH PAYMENT AWARD CLOSEOUT OTHER POTENTIAL CLAIM GIVEN 6-MONTH CLOSEOUT (B13)

(Requested)

Caption: Other Social Security Benefits

The lump-sum death payment is the only kind of payment  (1)   (2)  entitled to receive, with the possible exception of  (3)  benefits. You told us when you applied for the lump-sum death payment  (4)   (5)  that you did not wish to apply for  (6)  benefits  (7)  at that time.

If you change your mind, you need to apply for these benefits. The application date can make a difference in the amount we pay. If you apply within 6 months of the date of this letter, we may be able to use the date of the application for  (8)  benefits.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you
Choice 2: Fullname
Fill-in (2) - Systems Generated
Choice 1: are
Choice 2: is
Fill-in (3) - Systems Generated
Choice 1: retirement
Choice 2: disability
Fill-in (4) - Systems Generated
Choice 1: for
Choice 2: null
Fill-in (5) - Systems Generated
Choice 1: Surname
Choice 2: null
Fill-in (6) - Systems Generated
Choice 1: wife's
Choice 2: husbands
Choice 3: child's
Fill-in (7) - Systems Generated
Choice 1: for him
Choice 2: for her
Choice 3: null
Fill-in (8) - Systems Generated
Choice 1: wife's
Choice 2: husband's
Choice 3: child's

CLOR20 AUXILIARY CLAIMANT NOT INSURED ON OWN RECORD (Q04)

(Requested)

Caption: Your Benefits

Benefits are not payable on your own record because you have not worked long enough under Social Security. To qualify, you need credit for  (1)  calendar quarters of work. You now have  (2)  . If you earn the additional quarters, please contact any Social Security office.


Fill-in values:
Fill-in (1) - Requested As A Number
Choice 1: required QCs
Fill-in (2) - Requested As A Number
Choice 1: acquired QCs

NL 00720.180 HIB Health Insurance Benefits

HIB002 TEMPORARY SUBSTITUTION OF NOTICE FOR HEALTH INSURANCE CARD (H23)

(Requested/Generated)

Caption: Information About Medicare

 (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) - Systems Generated
Choice 1: You
Choice 2: Beneficiary's Name
Fill-in (2) - Systems Generated
Choice 1: You should
Choice 2: He should
Choice 3: She should
Fill-in (3) - Systems Generated
Choice 1: you need
Choice 2: he needs
Choice 3: she needs
Fill-in (4) - Systems Generated
Choice 1: you have
Choice 2: he has
Choice 3: she has
Fill-in (5) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

HIB003 MEDICAL CLAIMANT ENROLLED BEFORE INITIAL ENROLLMENT PERIOD (H42)

(Requested)

Caption: Information About Medicare

 (1)  not entitled to  (2)  under Medicare because  (3)  application was filed too soon.  (4)  may apply again at any time during the period  (5)  through  (6)  .  (7)  must apply in the first three months of this period to make sure Medicare starts in the month  (8)   (9)  age 65.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: You are
Choice 2: She is
Choice 3: He is
Fill-in (2) - Systems Generated
Choice 1: medical insurance coverage
Fill-in (3) - Systems Generated
Choice 1: your
Choice 2: her
Choice 3: his
Fill-in (4) - Systems Generated
Choice 1: You
Choice 2: She
Choice 3: He
Fill-in (5) - Systems Generated
Choice 1: Month and Year
Fill-in (6) - Systems Generated
Choice 1: Month and Year
Fill-in (7) - Systems Generated
Choice 1: You
Choice 2: She
Choice 3: He
Fill-in (8) - Systems Generated
Choice 1: you
Choice 2: she
Choice 3: he
Fill-in (9) - Systems Generated
Choice 1: reach
Choice 2: reaches

HIB004 MEDICAL CLAIMANT ENROLLED AFTER IEP AND BEFORE GENERAL ENROLLMENT PERIOD (H43)

(Requested)

Caption: Information About Medicare

 (1)  not entitled to  (2)  under Medicare because  (3)  application was filed too late.  (4)  should have filed before  (5)  . However,  (6)  g 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) - Systems Generated
Choice 1: You are
Choice 2: She is
Choice 3: He is
Fill-in (2) - Systems Generated
Choice 1: medical insurance coverage
Fill-in (3) - Systems Generated
Choice 1: your
Choice 2: her
Choice 3: his
Fill-in (4) - Systems Generated
Choice 1: You
Choice 2: She
Choice 3: He
Fill-in (5) - Systems Generated
Choice 1: Month and Year
Fill-in (6) - Systems Generated
Choice 1: you
Choice 2: she
Choice 3: he

HIB011 PREMIUM BILLING FOR HOSPITAL INSURANCE ONLY (H46)

(Requested)

Caption: Information About Medicare

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


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your
Choice 2: her
Choice 3: his
Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: HPAC amount
Fill-in (3) - Requested As A One Position Alpha Character
Choice 1: (A) this premium
Choice 2: (B) the combined premium for hospital and medical insurance
Choice 3: (C) premiums

HIB015 CIVIL SERVICE BUY-IN (H31)

(Requested/Generated)

Caption: Information About Medicare

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


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

HIB019 BENEFICIARY IS NOT ENTITLED TO MEDICARE PART A FOR FREE BUT ELIGIBLE TO BUY MEDICARE PART A (HOSPITAL INSURANCE) FOR A FEE

(Requested)

Caption: None

 (1)  cannot get Medicare Part A (hospital insurance) for free. However,  (2)  may be able to buy Medicare Part A for  (3)  a month. Please contact us for more information.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (3) - Systems Generated
Beneficiary's monthly cost for Part A

HIB021 DUAL ENTITLEMENT AUXILIARY/SURVIVOR AWARD AFTER PRIMARY - MEDICARE ENTITLEMENT PREVIOUSLY ESTABLISHED (H84)

(Requested)

Caption: Information About Medicare

This letter does not affect  (1)  Medicare benefits.


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

HIB033 HI COVERAGE - NO SMI ELECTED - PROVISIONAL BENEFITS CASE (P06)

(Requested)

Caption: Information About Medicare

 (1)  will have Medicare hospital insurance (Part A) coverage while  (2)  receiving these provisional benefits.  (3)  coverage will begin  (4)  .  (5)  hospital insurance (Part A) is free. If  (6)  provisional benefits end because  (7)  received 6 months of payments, then  (8)  Medicare coverage will end at the same time. If  (9)  provisional benefits end for any other reason, then  (10)  will get another letter telling  (11)  about  (12)  Medicare coverage.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: You
Choice 2: Beneficiary's name
Fill-in (2) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (3) - Systems Generated
Choice 1: You
Choice 2: His
Choice 3: Her
Fill-in (4) - Systems Generated
Choice 1: Month CCYY (date Medicare coverage begins)
Fill-in (5) - Systems Generated
Choice 1: Your
Choice 2: His
Choice 3: Her
Fill-in (6) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (7) - Systems Generated
Choice 1: you have
Choice 2: he has
Choice 3: she has
Fill-in (8) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (9) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (10) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (11) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (12) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

HIB036 SMI COVERAGE ELECTED DURING PROVISIONAL PERIOD - PROVISIONAL BENEFITS CASE (P07)

(Requested)

Caption: Information About Medicare

 (1)  will have Medicare hospital insurance (Part A) and medical insurance (Part B) coverage while  (2)  receiving these provisional benefits.  (3)  coverage will begin  (4)  .  (5)  hospital insurance (Part A) is free.  (6)  medical insurance (Part B) premium will be deducted from the monthly payment. If  (7)  provisional benefits end because  (8)  received 6 months of payments, then  (9)  Medicare coverage will end at the same time. If  (10)  provisional benefits end for any other reason, then  (11)  will get another letter telling  (12)  about  (13)  g Medicare coverage.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: You
Choice 2: Beneficiary's Name
Fill-in (2) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (3) - Systems Generated
Choice 1: Your
Choice 2: His
Choice 3: Her
Fill-in (4) - Systems Generated
Choice 1: Month CCYY (date Medicare coverage begins)
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 have
Choice 2: he has
Choice 3: she has
Fill-in (9) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (10) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (11) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (12) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (13) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

HIB039 INITIAL PREMIUM BILLING BENEFITS SUSPENDED OR DEFERRED STATUS MATURING BEYOND CURRENT YEAR (H60)

(Requested/Generated)

Caption: Information About Medicare

We will charge a monthly premium for  (1)  medical insurance under Medicare. 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 payment is due.


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

HIB040 MEDICARE COVERAGE WILL CONTINUE BASED ON EXTENDED MEDICARE PROVISIONS - PROVISIONAL BENEFITS CASE (P08)

(Requested)

Caption: Information About Medicare

 (1)  Medicare coverage will continue while  (2)  receiving these provisional benefits.  (3)  hospital insurance (Part A) is free. If  (4)  medical insurance (Part B)  (5)  will no longer get a bill for the premium.  (6)  premium will be deducted from the monthly payment.  (7)  Medicare coverage may end if we deny  (8)  request for reinstatement.  (9)  will get another letter telling  (10)  if  (11)  Medicare coverage will end.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Your
Choice 2: Beneficiary's Name
Fill-in (2) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (3) - Systems Generated
Choice 1: Your
Choice 2: His
Choice 3: Her
Fill-in (4) - Systems Generated
Choice 1: you have
Choice 2: he has
Choice 3: she has
Fill-in (5) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
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: your
Choice 2: his
Choice 3: her
Fill-in (9) - Systems Generated
Choice 1: You
Choice 2: He
Choice 3: She
Fill-in (10) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (11) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

HIB041 HI TERMINATION DUE TO DIB CESSATION OR MARRIAGE OF DAC (H80)

(Requested/Generated)

Caption: Information About Medicare

Since  (1)   (2)  no longer entitled to monthly Social Security benefits, we are stopping  (3)  hospital insurance coverage under Medicare.  (4)  hospital insurance coverage ends on the last day of  (5)  .  (6)  g Medicare card will no longer be valid after coverage ends, so please tear it up.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary name
Choice 2: you
Fill-in (2) - Systems Generated
Choice 1: is
Choice 2: are
Fill-in (3) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (4) - Systems Generated
Choice 1: Your
Choice 2: His
Choice 3: Her
Fill-in (5) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (6) - Systems Generated
Choice 1: Beneficiary's Name possessive
Choice 2: Your

HIB043 MEDICARE COVERAGE WILL CONTINUE BASED ON ESRD - PROVISIONAL BENEFITS CASE (P09)

(Requested)

Caption: Information About Medicare

 (1)  already entitled to  (2)  because  (3)  enrolled based on a kidney condition. If  (4)  medical insurance (Part B)  (5)  will no longer get a bill for the premium.  (6)  premium will be deducted from the monthly payment.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: You are
Choice 2: Beneficiary's Name + is
Fill-in (2) - Requested As A One Position Alpha Character
Choice 1: (A) hospital insurance (Part A)
Choice 2: (B) hospital insurance (Part A) and medical insurance (Part B)
Fill-in (3) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (4) - Systems Generated
Choice 1: you have
Choice 2: he has
Choice 3: she has
Fill-in (5) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (6) - Systems Generated
Choice 1: Your
Choice 2: His
Choice 3: Her

HIB045 MEDICARE CLOSED PERIOD - PROVISIONAL BENEFITS CASE (P10)

(Requested)

Caption: Information About Medicare

 (1)   (2)  coverage under Medicare from  (3)  through  (4)  . The Medicare coverage has ended because  (5)  no longer receiving provisional benefits.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: You have
Choice 2: She has
Choice 3: He has
Fill-in (2) - Requested As A One Position Alpha Character
Choice 1: (A) hospital insurance (Part A)
Choice 2: (B) hospital insurance (Part A) and medical insurance (Part B)
Fill-in (3) - Systems Generated
Choice 1: MM/CCYY (date Medicare coverage begins)
Fill-in (4) - Systems Generated
Choice 1: MM/CCYY (date Medicare coverage begins)
Fill-in (5) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is

HIB052 SMI REFUSAL PROCEDURE (H24)

(Requested)

Caption: Information About Medicare

If you do not want medical insurance, please complete the enclosed card and return it to us in the envelope we have provided. You will need to do this by the date shown on the card. If you decide you do not want the insurance, we will return any premiums that you have paid.

HIB061 HMO ENROLLMENT CIVIL SERVICE INVOLVEMENT (H54)

(Requested)

Caption: Information About Medicare

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


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

HIB092 HMO DISENROLLMENT. PRIVATE PREMIUM PAYMENT WILL CONTINUE. PENALTY INVOLVED. (H56)

(Requested)

Caption: Information About Medicare

 (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) - Systems Generated
Choice 1: Beneficiary Name, possessive
Choice 2: Your
Fill-in (2) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Choice 4: the
Fill-in (3) - Systems Generated
Choice 1: He
Choice 2: She
Choice 3: You
Choice 4: Beneficiary's Name

HIB093 HMO DISENROLLMENT. STATE WILL CONTINUE TO PAY PREMIUMS (H55)

(Requested)

Caption: Information About Medicare

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


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: the State
Choice 2: an organization
Fill-in (2) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Fill-in (3) - Systems Generated
Choice 1: hospital and medical
Choice 2: medical

HIB095 CHANGE IN DATE OF ENTITLEMENT TO SMI (H13)

(Requested or Systems Generated)

Caption: Information About Medicare

We have changed the date of  (1)  entitlement to  (2)  insurance under Medicare.  (3)  new entitlement date is  (4)  . We will take any premiums due for the insurance out of  (5)  next payment.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your
Choice 2: Beneficiary Name possessive
Fill-in (2) - Requested As A One Position Alpha Character
Choice 1: (A) hospital
Choice 2: (B) medical
Choice 3: (C) hospital and medical
Fill-in (3) - Systems Generated
Choice 1: Your
Choice 2: His
Choice 3: Her
Fill-in (4) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (5) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

HIB139 HEALTH INSURANCE – PENALTY FOR LATE ENROLLMENT (H21-2)

(Requested/Generated)

Caption: Information About Medicare

This medical insurance premium includes a penalty because  (1)  enrolled later than  (2)  could have.


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

HIB152 SMI DECLINED DURING IEP OR SMI DECLINED WHEN OFFERED THROUGH EQUITABLE RELIEF (H05)

(Requested/Generated)

Caption: Information About Medicare

 (1)   (2)  through  (3)  to enroll in Medicare Part B (medical insurance).

People who have Part B pay a monthly premium. If  (4)  not sign up for Part B when  (5)  first eligible,  (6)  may have to pay a late enrollment penalty for as long as  (7)  Part B.  (8)  monthly premium may go up 10 percent for each full 12-month period that  (9)  could have had Part B coverage, but did not sign up for it. Usually  (10)  will not have to pay a late enrollment penalty if ( (11)  ) up during a special enrollment period.

If  (12)  to sign up for Part B after  (13)  ,  (14)  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  (15)  up in the general enrollment period,  (16)  Part B coverage will start July 1 of the year  (17)  up.

 (18)  may also be able to sign up during a special enrollment period.  (19)  can do this if  (20)  one of the conditions listed below:

  •  (21)  covered under a group health plan through  (22)  current work or  (23)  spouse's current work,

  •  (24)  covered under a large group health plan through  (25)  current work or any family member's current work.

 (26)  may sign up for medical insurance at any time  (27)  covered under the group health plan. However,  (28)  may wait and sign up during the 8-month period that begins when the work ends or  (29)  coverage under the plan ends, whichever occurs first.  (30)  may also sign up if the type of plan  (31)  changes.

NOTE: COBRA and Retiree health coverage do not count as health insurance based on current employment.

Deciding when to sign up for Part B may depend on how  (32)  health insurance works with Medicare. For example, a group health plan is usually not the primary insurance if the employer has less than 20 employees. In this case, it is important to have Medicare coverage, and you may want to sign up now.

If  (33)  help deciding what to do, please contact  (34)  employee benefits office or contact us.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Beneficiary's full name
Choice 2: You
Fill-in (2) - Systems Generated
Choice 1: has
Choice 2: have
Fill-in (3) - Requested As A Date In Format Shown Below
Choice 1: Show HI-START plus 3 months MM/CCYY
Fill-in (4) - Systems Generated
Choice 1: you do
Choice 2: he does
Choice 3: she does
Fill-in (5) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (6) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (7) - Systems Generated
Choice 1: you have
Choice 2: he has
Choice 3: she has
Fill-in (8) - Systems Generated
Choice 1: Your
Choice 2: His
Choice 3: Her
Fill-in (9) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (10) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (11) - Systems Generated
Choice 1: you sign
Choice 2: he signs
Choice 3: she signs
Fill-in (12) - Systems Generated
Choice 1: you want
Choice 2: he wants
Choice 3: she wants
Fill-in (13) - Systems Generated
Show HI-START plus 3 months MM/CCYY
Fill-in (14) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (15) - Systems Generated
Choice 1: you sign
Choice 2: he signs
Choice 3: she signs
Fill-in (16) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (17) - Systems Generated
Choice 1: you sign
Choice 2: he signs
Choice 3: she signs
Fill-in (18) - Systems Generated
Choice 1: Beneficiary's full name
Choice 2: You
Fill-in (19) - Systems Generated
Choice 1: You
Choice 2: He
Choice 3: She
Fill-in (20) - Systems Generated
Choice 1: you meet
Choice 2: he meets
Choice 3: she meets
Fill-in (21) - Systems Generated
Choice 1: You are
Choice 2: He is
Choice 3: She is
Fill-in (22) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill (23) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (24) Systems Generated
Choice 1: You are
Choice 2: He is
Choice 3: She is
Fill-in (25) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (26) Systems Generated
Choice 1: You
Choice 2: He
Choice 3: She
Fill-in (27) Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (28) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (29) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (30) Systems Generated
Choice 1: You
Choice 2: He
Choice 3: She
Fill-in (31) Systems Generated
Choice 1: you have
Choice 2: he has
Choice 3: she has
Fill-in (32) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (33) Systems Generated
Choice 1: you need
Choice 2: he needs
Choice 3: she needs
Fill-in (34) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

HIB157 CHILDREN'S HEALTH INSURANCE PROGRAM (H18)

(Requested/Generated)

Caption: Health Insurance For Children

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) - Systems Generated
Choice 1: www.insurekidsnow.gov

HIB170 MONTHLY BENEFITS TERMINATED - HI/SMI CONTINUES - LAF U (H90)

(Requested/Generated)

Caption: Information About Medicare

Even though  (1)  no longer receiving monthly payments,  (2)  will still have  (3)  coverage under Medicare. (4)   (5) 


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Disabled Beneficiary's name is (not possessive)
Choice 2: you are
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (3) - Systems Generated
Choice 1: Part A (hospital insurance)
Choice 2: Part A (hospital insurance) and Part B (medical insurance)
Fill-in (4) - Systems Generated
Choice 1: Please keep the Medicare Card.
Choice 2: Null
Fill-in (5) - Systems Generated
Choice 1:There is a monthly premium for Medicare Part B. Because we stopped monthly payments, we will bill you every 3 months for premiums.
Choice 2: There is a monthly premium for Medicare Part B. Because we stopped monthly payments, we will bill him every 3 months for premiums.
Choice 3: There is a monthly premium for Medicare Part B. Because we stopped monthly payments, we will bill her every 3 months for premiums.
Choice 4: Null

HIB171 CRD ENTITLEMENT MONTHLY BENEFITS TERMINATED HI/SMI CONTINUES STATE BUY-IN CONTINUES (H91)

(Requested/Generated)

Caption: Information About Medicare

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) - Systems Generated
Choice 1: Disabled Beneficiary's Name is (not-possessive)
Choice 2: you are
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (3) - Systems Generated
Choice 1: Please keep the Medicare card.
Choice 2: Null
Fill-in (4) - Systems Generated
Choice 1: you live
Choice 2: he lives
Choice 3: she lives
Fill-in (5) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

HIB175 SMI PREMIUMS/ARREARAGE DEDUCTED FROM PMA ORCMA

(System Generated)

Caption: Information About Medicare

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


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: of plus the total amount of past-due premiums
Choice 2: Null
Fill-in (1) - Systems Generated
Choice 1: Beneficiary's full name (possessive)
Choice 2: your

HIB182 IRMAA – MEDICARE PART B PREMIUM BASED ON INCOME (HA9)

(Requested/Generated)

Caption: Information About Medicare

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) - Systems Generated
Choice 1: your
Choice 2: Beneficiary's Name Possessive
Fill-in (2) - Systems Generated
Choice 1: you have
Choice 2: she has
Choice 3: he has
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: she
Choice 3: he
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: her
Choice 3: his
Fill-in (5) - Systems Generated
Choice 1: your
Choice 2: her
Choice 3: his
Fill-in (6) - Systems Generated
Choice 1: your
Choice 2: her
Choice 3: his
Fill-in (7) - Systems Generated
Choice 1: you pay your
Choice 2: he pays his
Choice 3: she pays her

HIB183 IRMAA – BENEFICIARY/PAYEE – PRIOR NOTICE RECEIVED EXPLAINING IRMAA (HB1)

(Requested/Generated)

Caption: Information About Medicare

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


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

HIB184 ADVISES BENEFICIARY/PAYEE THAT WE WILL CONTINUE TO BILL FOR PART B PREMIUMS (HB4)

(Requested/Generated)

Caption: Information About Medicare

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


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

HIB185 IRMAA CMA ADJUSTED DUE TO CHANGE IN PART B PREMIUM AMOUNT (HB3)

(Requested/Generated)

Caption: Information About Medicare

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) - Requested As A Date in Format Shown Below
Choice 1: Using the PCI, show the calendar date in which the COM check will be paid
MM/DD/CCYY
Choice 2: Using the PCI, show the calendar date in which the DPD check will be paid
MM/DD/CCYY
Fill-in (2) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your

HIB186 ADVISES ATTAINER/NEW FILER THAT IRMAA MAY APPLY BASED ON INCOME LEVEL (HB5)

(Requested/Generated)

Caption: Information About Medicare

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)  g . 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) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Amount
Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Amount
Fill-in (3) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Fill-in (4) - Systems Generated
Choice 1: he has
Choice 2: she has
Choice 3: you have
Fill-in (5) - Requested As A Date in Format Shown Below
Choice 1: SMI start Date MM/CCYY

HIB187 MEDICAL PREMIUM DEDUCTIONS CONTINUE (G24)

(System Generated)

Caption: Information About Medicare

We will continue to deduct Medicare premiums from  (1)  monthly checks.


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

HIB188 SMI REFUSAL (H01)

(Requested/Generated)

Caption: Your Benefits

 (1)  told us that  (2)  want medical insurance under Medicare. We will send  (3)  a new Medicare card in a few days. It will show that  (4)  g entitled to only hospital insurance.

We will stop taking premiums for medical insurance out of  (5)  checks. If we have taken out any premiums for months when  (6)  not entitled to medical insurance, we will return the money to  (7)  .


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: You
Choice 2: Beneficiary's Name
Fill-in (2) - Systems Generated
Choice 1: you do not
Choice 2: he does not
Choice 3: she does not
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (4) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (5) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (6) - Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was
Fill-in (7) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her

HIB189 RAILROAD JURISDICTION (H02)

(Requested/Generated)

Caption: Information About Medicare

The Railroad Retirement Board is handling  (1)  hospital and medical insurance under Medicare.


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

HIB190 REENTITLEMENT TO DIB - NEW 24 MONTH WAITING PERIOD NEEDED (H04)

(Requested)

Caption: Information About Medicare

Our records show that  (1)  had an earlier disability. The earlier disability is not the same as  (2)  disability now. Since the disabilities are different,  (3)  will need to wait 24 months for Medicare to begin. We will tell you in another letter when  (4)  can get Medicare.


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

HIB191 HI AND SMI DATE OF ENTITLEMENT (H11)

(Requested/Generated)

Caption: Information About Medicare

 (1)  entitled to hospital and medical insurance under Medicare beginning  (2)  .


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: You are
Choice 2: Beneficiary's Name is
Fill-in (2) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY

HIB192 SUSPENSION OF 24 MONTH WAITING PERIOD - BENE DIAGNOSED WITH ALS (H16)

(Requested)

Caption: Information About Medicare

Because of a change in the law people receiving disability benefits because of Amyotrophic Lateral Sclerosis (ALS) no longer have to wait 24 months for Medicare coverage. We have therefore changed  (1)  entitlement dates to hospital insurance (Part A) and medical insurance (Part B) to  (2)  .


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

HIB193 SMI PREMIUM AMOUNTS AND EFFECTIVE DATES (H21)

(Requested/Generated)

Caption: Information About Medicare

We charge a monthly premium for  (1)  medical insurance. The rates are shown below:

Beginning Date Amount

 (2)   (3) 

NOTE: To allow multiple repetitions of the date and premium rates in Fill-ins 2 and 3, HIB259 is automatically generated.


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

HIB194 STATE BUY-IN (H30)

(Requested/Generated)

Caption: Information About Medicare

The State where  (1)  will pay the premiums for  (2)  Medicare coverage beginning  (3)  .  (4)  may receive a refund for some of the premiums  (5)  may have paid, if the State is responsible for paying them.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you live
Choice 2: Beneficiary's Name lives
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (4) - Systems Generated
Choice 1: You
Choice 2: He
Choice 3: She
Fill-in (5) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she

HIB195 PRIVATE GROUP BUY-IN (H32)

(Requested/Generated)

Caption: Information About Medicare

Beginning  (1)  , we will send the bills for  (2)  medical insurance premiums to the organization which  (3)  selected. Although we will send the bills to them,  (4)  will still be responsible for making sure that  (5)  premiums are paid. If the organization decides that it will no longer pay the premiums, we will start sending the premium bills to  (6)  again.

 (7)  may receive a refund for some of the premiums  (8)  g may have paid, if the organization is responsible for paying them.


Fill-in values:
Fill-in (1) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: Beneficiary's Name possessive
Fill-in (3) - Systems Generated
Choice 1: you have
Choice 2: he has
Choice 3: she has
Fill-in (4) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (5) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (6) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (7) - Systems Generated
Choice 1: You
Choice 2: He
Choice 3: She
Fill-in (8) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she

HIB196 TERMINATION OF PRIVATE GROUP BUY-IN (H40)

(Requested/Generated)

Caption: Information About Medicare

An organization has been paying  (1)  medical insurance premiums while  (2)  not receiving checks. Since we have started to pay  (3)  checks each month, we will take the premiums out of  (4)  checks beginning  (5)  .


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 were
Choice 2: he was
Choice 3: she was
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY

HIB197 TERMINATION OF CIVIL SERVICE BUY-IN (H41)

(Requested/Generated)

Caption: Information About Medicare

 (1)  medical insurance premiums were taken out of  (2)  civil service annuity. Since we have started to pay  (3)  checks each month, we will take the premiums out of  (4)  Social Security checks beginning  (5)  .


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
Choice 2: him
Choice 3: her
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY

HIB198 OPENING PARAGRAPH - AUXILIARY MQGE APPLICANT ON NUMBER HOLDER'S WAGE RECORD (H44)

(Requested)

Caption: None

This notice refers to  (1)  claim for  (2)  based on  (3)  Government employment.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your
Choice 2: Beneficiary's Name possessive
Fill-in (2) - Requested As A One Position Alpha Character
Choice 1: (A) Medicare
Choice 2: (B) Medicare as a disabled individual
Fill-in (3) - Systems Generated
Choice 1: Number Holder's name (possessive)

HIB199 BILLING FOR BOTH HI AND SMI PREMIUMS (H45)

(Requested)

Caption: Information About Medicare

The monthly premium for  (1)  medical insurance is  (2)  . The monthly premium for  (3)  hospital insurance is  (4)  . We will bill  (5)  each month for the combined premium for hospital and medical insurance.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your
Choice 2: Beneficiary's Name possessive
Fill-in (2) - Systems Generated
Choice 1: Amount of SMI premium
Fill-in (3) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (4) - Systems Generated
Choice 1: Amount of HI premium
Fill-in (5) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her

HIB200 FULLY INSURED FOR MEDICARE AT AGE 65 (H47)

(Requested)

Caption: Information About Medicare

Based on  (1)  earnings and on the date of birth,  (2)  g worked long enough under Social Security to qualify for Medicare coverage at age 65.


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 have
Choice 2: he has
Choice 3: she has

HIB212 HI START DATE PRIOR TO AGE 65 - HI AWARD ACTION TAKEN IN AGE 65 ATTAINMENT MONTH OR LATER (H48)

(Requested)

Caption: Information About Medicare

Now that  (1)  65 years old,  (2)  Medicare coverage is no longer based on  (3)  disability.  (4)  Medicare coverage does not change because  (5)  65. Work does not affect  (6)  Medicare eligibility. This is because work restrictions only apply to Medicare beneficiaries under age 65 and disabled. If  (7)  condition improves, and  (8)  to return to work, it is not necessary to notify Social Security.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you are
Choice 2: Beneficiary's Name is
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
Fill-in (4) - Systems Generated
Choice 1: Your
Choice 2: Beneficiary's Name possessive
Fill-in (5) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (6) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (7) - Systems Generated
Choice 1: your
Choice 2: Beneficiary's Name possessive
Fill-in (8) - Systems Generated
Choice 1: you decide
Choice 2: he decides
Choice 3: she decides

HIB213 TOTALIZATION MONTHLY BENEFITS AWARDED TO U.S. RESIDENT BETWEEN AGE 50 AND AGE 64 AND 9 MONTHS. (NO MEDICARE ENTITLEMENT ON ANOTHER SSN) (H50)

(Requested)

Caption: Information About Medicare

If  (1)  to be entitled to Medicare insurance when  (2)  age 65,  (3)  will need to apply for it. The separate application is necessary because  (4)  monthly benefits are based on a combination of U.S. and foreign Social Security credits. Please get in touch with us 3 months before  (5)  65 for more information about Medicare insurance.  (6)  may have to pay for this insurance.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you wish
Choice 2: Beneficiary's Name wishes
Fill-in (2) - Systems Generated
Choice 1: you reach
Choice 2: he reaches
Choice 3: she reaches
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: Beneficiary's Name possessive
Fill-in (5) - Systems Generated
Choice 1: you become
Choice 2: he becomes
Choice 3: she becomes
Fill-in (6) - Systems Generated
Choice 1: You
Choice 2: He
Choice 3: She

HIB214 TOTALIZATION MONTHLY BENEFITS AWARDED TO U.S. RESIDENT AT LEAST AGE 64 AND 9 MONTHS OR ALREADY ENTITLED TO DIB BENEFITS FOR 24 MONTHS — WORKER (NO FREE HI ENTITLEMENT ON ANOTHER SSN) (H51)

(Requested)

Caption: Information About Medicare

 (1)  not entitled to free Medicare hospital insurance under the Social Security agreement. We can use only U.S. Social Security credits to entitle someone to this insurance. This is true even though we have used foreign credits to pay monthly benefits.

 (2)  a total of  (3)  credits of work under the U.S. Social Security system to be entitled to free hospital insurance.  (4)   (5)  credits.  (6)   (7)  more credits to become entitled.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: You are
Choice 2: Beneficiary's Name is
Fill-in (2) - Systems Generated
Choice 1: You need
Choice 2: He needs
Choice 3: She needs
Fill-in (3) – Requested As A Number
Choice 1: Number of quarters needed to be insured for HI
Fill-in (4) - Systems Generated
Choice 1: You have
Choice 2: He has
Choice 3: She has
Fill-in (5) – Requested As A Number
Choice 1: Number of quarters earned
Fill-in (6) - Systems Generated
Choice 1: You need
Choice 2: He needs
Choice 3: She needs
Fill-in (7) – Requested As A Number
Choice 1: Number of quarters needed

HIB215 HI AND SMI TERMINATION DUE TO DIB CESSATION AFTER 25TH MONTH (H82)

(Requested/Generated)

Caption: Information About Medicare

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) - Systems Generated
Choice 1: he is
Choice 2: she is
Choice 3: you are
Fill-in (2) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Fill-in (3) - Requested As A One Position Alpha Character
Choice 1: (A) hospital
Choice 2: (B) hospital and medical
Fill-in (4) - Systems Generated
Choice 1: His
Choice 2: Her
Choice 3: Your
Fill-in (5) - Requested As A One Position Alpha Character
Choice 1: (A) hospital
Choice 2: (B) hospital and medical
Fill-in (6) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (7) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your

HIB216 TOTALIZATION MONTHLY BENEFIT AWARDED TO U.S. RESIDENT AT LEAST AGE 64 AND 9 MONTHS OR ENTITLED TO DISABILITY BENEFITS FOR 24 MONTHS AUXILIARY OR SURVIVOR (NO FREE HI ENTITLEMENT ON ANOTHER SSN) (H52)

(Requested)

Caption: Information About Medicare

 (1)  not entitled to free Medicare hospital insurance under the Social Security agreement. We can use only U.S. Social Security credits to entitle someone to this insurance. This is true even though we have used foreign credits to pay monthly benefits.

For  (2)  to be entitled to free hospital insurance,  (3)  needed to have earned  (4)  credits of work under the U.S. system. However, only  (5)  g credits were earned.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: You are
Choice 2: Beneficiary's Name is
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (3) - Requested As A Language
Choice 1: Name of worker
Fill-in (4) – Requested A Number
Choice 1: Number of quarters needed to be insured for HI
Fill-in (5) - Requested As A Number
Choice 1: Number of quarters earned

HIB217 INITIAL PREMIUM BILLING DUE TO ONE-CHECK-ONLY ADJUSTMENT PLUS SUSPENSION (H61)

(Requested/Generated)

Caption: Information About Medicare

We are taking medical insurance premiums out of the check  (1)  will receive. We will bill  (2)  every 3 months for future premiums, and will send  (3)  the bill shortly before payment is due.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her

HIB218 FINAL PREMIUM ADJUSTMENT DUE TO TERMINATION OF BENEFITS (CAN BE USED FOR CONVERSION FROM T TO A.) (H62)

(Requested/Generated)

Caption: Information About Medicare

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) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (1) - Systems Generated
Choice 1: Null
Choice 2: through MM/CCYY

HIB219 PREMIUM ADJUSTMENT DUE TO DEFERRED ACTION THAT WILL MATURE IN CURRENT YEAR (H63)

(Requested/Generated)

Caption: Information About Medicare

We will change  (1)  next check to account for medical insurance premiums that are due or already paid.


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

HIB220 INITIAL PREMIUM ADJUSTMENT DUE TO SMI ENTITLEMENT (H64)

(Requested/Generated)

Caption: Information About Medicare

We are taking medical insurance premiums due through  (1)  out of the check  (2)  will receive around  (3)  . These premiums total  (4)  . We will deduct medical insurance premiums 1 month in advance.


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

HIB221 PREMIUM ADJUSTMENT DUE TO CURRENT SMI ENTITLEMENT AND PRIOR PERIOD OF SMI ENTITLEMENT (H65)

(Requested/Generated)

Caption: Information About Medicare

We will  (1)  the payment  (2)  will receive shortly after  (3)  by  (4)  because of medical insurance premiums. When we figured the amount of  (5)  payment, we took into account all the medical insurance premiums which were previously paid or still due. We will deduct medical insurance premiums 1 month in advance.


Fill-in values:
Fill-in (1) - Requested As A One Position Alpha Character
Choice 1: (A) reduce
Choice 2: (B) increase
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (3) - Requested As A Date In Format Shown Below
Choice 1: MM/DD/CCYY
Fill-in (4) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Amount (PDA)
Fill-in (5) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

HIB223 SUBSEQUENT PREMIUM AND PINQ RECORD ADJUSTMENT (H66)

(System Generated)

Caption: Information About Medicare

We will  (1)  the payment  (2)  will receive after  (3)  by  (4)  because of medical insurance premiums which were  (5)  .


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: increase
Choice 2: reduce
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (3) - Systems Generated
Choice 1: MM/DD/CCYY
Fill-in (4) - Systems Generated
Choice 1: Amount (PDA)
Fill-in (5) - Requested As A One Position Alpha Character
Choice A: already paid
Choice B: owed

HIB224 PREMIUM AND PINQ RECORD ADJUSTMENT DUE TO RESUMPTION OF BENEFITS (H67)

(Requested/Generated)

Caption: Information About Medicare

We are  (1)   (2)  next payment by  (3)  because of the medical insurance premiums  (4)  . After that we will take premiums out of  (5)  regular checks each month.


Fill-in values:
Fill-in (1) - Requested As A One Position Alpha Character
Choice 1: (A) reducing
Choice 2: (B) increasing
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: Beneficiary's Name possessive
Fill-in (3) - Requested As A Money Amount in Format $$$$$.¢¢
Choice 1: Amount
Fill-in (4) - Requested As A One Position Alpha Character
Choice 1: (A) you owe
Choice 2: (B) he owes
Choice 3: (C) she owes
Choice 4: (D) already paid
Fill-in (5) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

HIB228 SMI PREMIUM CHANGED TO VARIABLE RATE DUE TO DELAYED DECEMBER COM PROCESSING (H72)

(Requested)

Caption: Information About Medicare

We have determined that the premium amount of  (1)  , which  (2)  now being charged, should be reduced to  (3)  effective with January of this year. This reduction in  (4)  premium is being made because the increase in  (5)  premium as of January 1st resulted in a decrease in  (6)  monthly Social Security check. The law permits us to reduce the Part B premium amount as necessary (but not below the amount  (7)  paid in December of last year) if the yearly change in the premium would cause the Social Security checks  (8)  this year to be lower than the checks  (9)  last year.


Fill-in values:
Fill-in (1) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: SMI premium rate
Fill-in (2) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (3) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: New variable SMI rate
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (6) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (7) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (8) - Systems Generated
Choice 1: you receive
Choice 2: he receives
Choice 3: she receives
Fill-in (9) - Systems Generated
Choice 1: you received
Choice 2: he received
Choice 3: she received

HIB229 REVIEW REQUESTED VARIABLE SMI PREMIUM APPLIES (H73)

(Requested)

Caption: Information About Medicare

As  (1)  requested, we reviewed the amount of the premium  (2)  each month for medical insurance. We've decided that  (3)  premium should have been  (4)  since January  (5)  . Because we've been charging  (6)   (7)  , it caused  (8)  to get less money in  (9)  Social Security check. This is why we'll lower  (10)  premium.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2) - Systems Generated
Choice 1: you pay
Choice 2: he pays
Choice 3: she pays
Fill-in (3) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (4) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Variable premium for SMI, plus surcharge amount
Fill-in (5) - Requested As A Date In Format Shown Below
Choice 1: CCYY
Fill-in (6) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (7) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Current base premium for SMI, plus surcharge, if applicable
Fill-in (8) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (9) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (10) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

HIB231 ERRONEOUS SMI TERMINATION EQUITABLE RELIEF GIVEN (H75)

(Requested)

Caption: Information About Medicare

We stopped  (1)  Medical insurance coverage under Medicare in  (2)  by mistake. We are sorry if our error caused  (3)  any inconvenience. We have corrected the mistake, and are starting  (4)  coverage again beginning  (5)  .

It might be to  (6)  advantage to start  (7)  medical coverage at an earlier date. We can start the coverage beginning  (8)  . However,  (9)  would have to pay the premiums for this insurance. The total amount of premiums from  (10)  through  (11)  is  (12)  .

If  (13)  coverage to start at the earlier date, please let us know within 60 days.  (14)  will need to tell us whether  (15)  to pay us directly for the premiums or have us take the money for the premiums out of  (16)  checks.

If  (17)  would like to have coverage beginning  (18)  , but it would be a hardship for  (19)  g to pay the premiums at one time, please let us know.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your
Choice 2: Beneficiary's Name possessive
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: him
Choice 3: her
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (6) - Systems Generated
Choice 1: your
Choice 2: Beneficiary's Name, possessive
Fill-in (7) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (8) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (9) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (10) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (11) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (12) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Premium amount due
Fill-in (13) - Systems Generated
Choice 1: you want
Choice 2: he wants
Choice 3: she wants
Fill-in (14) - Systems Generated
Choice 1: You
Choice 2: He
Choice 3: She
Fill-in (15) - Systems Generated
Choice 1: you want
Choice 2: he wants
Choice 3: she wants
Fill-in (16) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (17) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (18) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (19) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her

HIB232 PART B PREMIUM SURCHARGE ROLLBACK (H78)

(Requested)

Caption: Information About Medicare

We reduced the premium  (1)  paying for  (2)  medical insurance under Medicare. This is because of  (3)  health insurance coverage under an employer's health plan.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

HIB233 PART B ENROLLEE BENEFITS SUSPENDED FOR WORK (H79)

(Requested)

Caption: Information About Medicare

 (1)  not getting benefits because  (2)  working, so  (3)  to know some special facts about Medicare.  (4)  to consider these facts if  (5)  working for an employer who has 20 or more employees:

  • If  (6)  covered under  (7)  employer's group health plan, it will pay first for  (8)  g health care needs.

  • Medicare will not pay any expenses that the group health plan pays for.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: You are
Choice 2: Beneficiary's Name is
Fill-in (2) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (3) - Systems Generated
Choice 1: you need
Choice 2: he needs
Choice 3: she needs
Fill-in (4) - Systems Generated
Choice 1: You only need
Choice 2: He only needs
Choice 3: She only needs
Fill-in (5) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (6) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (7) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (8) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

HIB234 SMI WITHDRAWAL (H81)

(Requested/Generated)

Caption: Information About Medicare

 (1)  asked that we stop  (2)  medical insurance coverage under Medicare. This coverage ends the last day of  (3)  . If  (4)  g hospital insurance coverage, it will continue.

 (5) 

If  (6)  in the future that  (7)  would like to have medical insurance coverage again, please get in touch with us.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: You
Choice 2: Beneficiary's Name
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (4) - Systems Generated
Choice 1: you have
Choice 2: he has
Choice 3: she has
Fill-in (5) - Requested As A One Position Alpha Character
Choice 1: (A) We will stop taking premiums out of your Social Security checks. We will change your next payment to account for any premiums still due or any which you have already paid.
Choice 2: (B) Null
Fill-in (6) - Systems Generated
Choice 1: you decide
Choice 2: he decides
Choice 3: she decides
Fill-in (7) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she

HIB235 INELIGIBLE FOR HI/SMI DIB CESSATION PRIOR TO 25TH MONTH (H83)

(System Generated)

Caption: Information About Medicare

Since  (1)  no longer entitled to monthly Social Security benefits,  (2)  will not be eligible for Medicare insurance. Please disregard any information we may have given  (3)  about Medicare.


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

HIB236 PREMIUM ADJUSTMENT DUE TO SMI TERMINATION (H85)

(Requested/Generated)

Caption: Information About Medicare

Because we stopped  (1)  medical insurance, under Medicare, we will change the payment  (2)  will receive around  (3)  by  (4)  to account for premiums which were  (5)  g .


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: he
Choice 3: she
Fill-in (3) - Requested As A Date In Format Shown Below
Choice 1: MM/DD/CCYY
Fill-in (4) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Money amount
Fill-in (5) - Requested As A One Position Alpha Character
Choice 1: (A) still due
Choice 2: (B) already paid

HIB237 DISABILITY CESSATION PREMIUMS DUE FOR FUTURE MONTH(S) (H86)

(Requested/Generated)

Caption: Information About Medicare

Premiums for medical insurance under Medicare are paid 1 month in advance. Since you have only paid  (1)  premiums through  (2)  , you owe  (3)  to pay for the remaining premiums.

Please make your check or money order payable to the “Centers for Medicare & Medicaid Services”. Include  (4)  Medicare number on your check or money order. Send your payment to:

Centers for Medicare & Medicaid Services
Medicare Premium Collection Center
PO BOX 790355
St. Louis, MO 63179-0355

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

HIB238 INTRODUCTORY UTI FOR HEALTH PLAN PREMIUMS AND MEDICARE PRESCRIPTION DRUG PLAN COSTS (H88)

(Requested/Generated)

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

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) - Systems Generated
Choice 1: Beneficiary's full 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

HIB239 CRD ENTITLEMENT MONTHLY BENEFITS TERMINATED HI ENTITLEMENT CONTINUES (H92)

(Requested/Generated)

Caption: Information About Medicare

Even though  (1)  no longer receiving monthly checks,  (2)  will still have hospital insurance coverage under Medicare. Please keep  (3)  Medicare card.


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

HIB240 ADDRESS CHANGED TO FOREIGN COUNTRY ENTITLED TO HI ONLY (H95)

(Requested)

Caption: Information About Medicare

In most cases, Medicare will only pay for hospital services which  (1)  in the United States. Since  (2)  living outside the U.S., Medicare will not pay for hospital services unless  (3)  to the U.S. for services.


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

HIB241 FOREIGN ADDRESS GENERAL MEDICARE ELIGIBILITY (H96)

(Requested)

Caption: Information About Medicare

In most cases, Medicare will only pay for hospital and medical services which  (1)  in the United States.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you receive
Choice 2: Beneficiary's Name receives

HIB242 AUXILIARY BENEFICIARY AGE 65 OR OVER TERMINATED T3, T8 OR T9 NEW HEALTH INSURANCE CARD SMI ONLY (H98)

(Requested/Generated)

Caption: Information About Medicare

Even though  (1)  no longer receiving monthly checks and  (2)  not have hospital insurance coverage under Medicare,  (3)  will still have medical insurance coverage. We will send  (4)  a new Medicare card, which will show that  (5)  medical insurance only.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you are
Choice 2: Beneficiary's name is
Fill-in (2) - Systems Generated
Choice 1: do
Choice 2: does
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (5) - Systems Generated
Choice 1: you now have
Choice 2: he now has
Choice 3: she now has

HIB243 3RD PARTY BUY-IN FOR AUXILIARY BENEFICIARY AGE 65 OR OVER TERMINATED T3, T8 or T9 (H99)

(Requested/Generated)

Caption: Information About Medicare

We charge monthly premiums for  (1)  medical insurance under Medicare.  (2)  will continue to pay these premiums.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: your
Choice 2: Beneficiary's Name possessive
Fill-in (2) - Requested As A One Position Alpha Character
Choice 1: (A) The State where you live
Choice 2: (B) The organization you choose

HIB244 DIB CESSATION OVERPAYMENT AND PREMIUMS DUE FOR A FUTURE MONTH (H87)

(Requested/Generated)

Caption: Information About Medicare

 (1)  overpayment includes the Medicare medical insurance premiums of  (2)  which we took out of  (3)  checks during the time when  (4)  overpaid. Also,  (5)  not paid  (6)  premiums for  (7)  . For this reason, when  (8)  back  (9)  overpayment  (10)  should include  (11)  to pay for all premiums due.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Your
Choice 2: Beneficiary's Name possessive
Fill-in (2) - Requested As A Money Amount in Format $$$$$.¢¢
Choice 1: Amount
Fill-in (3) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (4) - Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was
Fill-in (5) - Systems Generated
Choice 1: you have
Choice 2: he has
Choice 3: she has
Fill-in (6) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (7) - Requested As A Date In Format Shown Below
Choice 1: MMCCYY
Fill-in (8) - Systems Generated
Choice 1: you pay
Choice 2: he pays
Choice 3: she pays
Fill-in (9) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (10) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (11) - Requested As A Money Amount in Format $$$$$.¢¢
Choice 1: Amount

HIB249 EQUITABLE RELIEF FOR V-SMI CASES ONLY (HC2)

(Requested/Generated)

Caption: Information About Medicare

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)  g ;

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) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (2) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (3) - Requested As A Money Amount in Format $$$$$.¢¢
Choice 1: Amount
Fill-in (4) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (5) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (6) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (7) - Requested As A Money Amount in Format $$$$$.¢¢
Choice 1: Amount
Fill-in (8) - Requested As A Money Amount in Format $$$$$.¢¢
Choice 1: Amount

HIB250 CHANGE IN RESIDENCE AFFECTS PREMIUM AMOUNT CATASTROPHIC LEGISLATION (H76)

(System Generated)

Caption: Information About Medicare

Beginning  (1)  we are changing  (2)  monthly Medicare premium rate to  (3)  because of  (4)  change in residence.


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

HIB251 WORK REINSTATEMENT NO SMI (H77)

(Requested)

Caption: Information About Medicare

 (1)  getting benefits because  (2)  stopped working, so  (3)  to know some special facts about Medicare.  (4)  to consider these facts if  (5)  covered under an employer group health plan while  (6)  working:

  1. 1. 

     (7)  may enroll for medical insurance under Medicare up until 8 months after  (8)  working.

  2. 2. 

    If  (9)  for medical insurance during the 8 months,  (10)  coverage will start sooner than if  (11)  until the regular enrollment time of January through March.

  3. 3. 

    Also,  (12)  may have to pay a premium penalty if  (13)  a full 12 months when  (14)  could have been, but  (15)  not, covered by Medicare. We do not count months of employer group health plan coverage when figuring the 12-month period.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: You are
Choice 2: Beneficiary name is
Fill-in (2) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (3) - Systems Generated
Choice 1: you need
Choice 2: he needs
Choice 3: she needs
Fill-in (4) - Systems Generated
Choice 1: You only need
Choice 2: He only needs
Choice 3: She only needs
Fill-in (5) - Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was
Fill-in (6) - Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was
Fill-in (7) - Systems Generated
Choice 1: You
Choice 2: He
Choice 3: She
Fill-in (8) - Systems Generated
Choice 1: you stop
Choice 2: he stops
Choice 3: she stops
Fill-in (9) - Systems Generated
Choice 1: you enroll
Choice 2: he enrolls
Choice 3: she enrolls
Fill-in (10) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (11) - Systems Generated
Choice 1: you wait
Choice 2: he waits
Choice 3: she waits
Fill-in (12) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (13) - Systems Generated
Choice 1: you have
Choice 2: he has
Choice 3: she has
Fill-in (14) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (15) - Systems Generated
Choice 1: were
Choice 2: was

HIB252 EQUITABLE RELIEF UNTIMELY PROCESSING (H49)

(Requested/Generated)

Caption: Information About Medicare

We did not give  (1)  earlier medical insurance because we did not process it timely. If  (2)  to have these benefits earlier,  (3)  can choose medical insurance benefits beginning  (4)  . If  (5)  this benefit to start earlier,  (6)  must do the following things within 60 days after the date of this notice:

  • tell us in writing that  (7)  the medical insurance benefits beginning  (8)  ;

  • pay us  (9)  (this covers the premiums due from  (10)  through  (11)  ); or,

  • tell us we can withhold this amount from the check.

If  (12)  the benefits beginning  (13)  but  (14)  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) - Systems Generated
Choice 1: Beneficiary name
Choice 2: you
Fill-in (2) - Systems Generated
Choice 1: you want
Choice 2: he wants
Choice 3: she wants
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (5) - Systems Generated
Choice 1: you want
Choice 2: he wants
Choice 3: she wants
Fill-in (6) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (7) - Systems Generated
Choice 1: you want
Choice 2: he wants
Choice 3: she wants
Fill-in (8) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (9) - Requested As A Money Amount in Format $$$$$.¢¢
Choice 1: Total amount of medical insurance premiums
Fill-in (10) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (11) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (12) - Systems Generated
Choice 1: you want
Choice 2: he wants
Choice 3: she wants
Fill-in (13) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (14) - Systems Generated
Choice 1: find
Choice 2: finds

HIB254 CHANGE IN DATE OF ENTITLEMENT TO HI AND SMI (H14)

(Requested/Generated)

Caption: Information About Medicare

We have changed the date of  (1)  entitlement to hospital and medical insurance under Medicare.  (2)  new entitlement date is  (3)  . We will take any premiums due for the insurance out of  (4)  g next check.


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) - Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

HIB255 CHANGE IN DATE OF ENTITLEMENT TO HI (H15)

(Requested/Generated)

Caption: Information About Medicare

We have changed the date of  (1)  entitlement to hospital insurance under Medicare.  (2)  new entitlement date is  (3)  .


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

HIB256 FUTURE MEDICARE COVERAGE (H07)

(Requested/Generated)

Caption: Information About Medicare

 (1)  may be able to buy Medicare coverage in the future. If  (2)  a citizen of the United States,  (3)  can buy Medicare as soon as  (4)  to this country. If  (5)  not a citizen,  (6)  can buy Medicare only after  (7)  lived in the United States for five years in a row. These must be the five years right before  (8)  for Medicare. Also, as an alien  (9)  must be lawfully admitted for permanent residence.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: You
Choice 2: Beneficiary's name
Fill-in (2) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4) - Systems Generated
Choice 1: you return
Choice 2: he returns
Choice 3: she returns
Fill-in (5) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (6) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (7) - Systems Generated
Choice 1: you have
Choice 2: he has
Choice 3: she has
Fill-in (8) - Systems Generated
Choice 1: you apply
Choice 2: he applies
Choice 3: she
Fill-in (9) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she

HIB257 WHAT HOSPITAL INSURANCE WILL PAY (H27)

(Requested/Generated)

Caption: Information About Medicare

Hospital insurance will pay most hospital bills and certain post-hospital expenses. Medical insurance will help pay much of the medical expenses incurred for physicians and other medical services. This notice shows whether  (1)  entitled to hospital insurance only, medical insurance only, or both hospital and medical insurance. Benefits are payable if covered services were rendered on or after the entitlement date shown.  (2)  will receive by mail a health insurance card and a booklet explaining how to use the card, what services are covered, and the methods of claiming benefits for covered services. If  (3)  planning changes in any other hospital or medical insurance  (4)  , remember that Social Security health insurance coverage will be effective with the dates shown on this notice.

If  (5)  help with medical expenses before  (6)  health insurance coverage begins, or if  (7)  aid in meeting medical expenses not covered by  (8)  health insurance,  (9)  may want to get in touch with the nearest social services office to see whether  (10)  eligible under a program of medical assistance.

Notify any Social Security office immediately if  (11)   (12)  address so that  (13)  health insurance card and any claims or informational material may reach  (14)  promptly.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you are
Choice 2: Beneficiary's name + is
Fill-in (2) - Systems Generated
Choice 1: You
Choice 2: He
Choice 3: She
Fill-in (3) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (4) - Systems Generated
Choice 1: you now have
Choice 2: he now has
Choice 3: she now has
Fill-in (5) - Systems Generated
Choice 1: you need
Choice 2: he needs
Choice 3: she needs
Fill-in (6) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (7) - Systems Generated
Choice 1: you need
Choice 2: he needs
Choice 3: she needs
Fill-in (8) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (9) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (10) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (11) - Systems Generated
Choice 1: you change
Choice 2: he changes
Choice 3: she changes
Fill-in (12) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (13) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (14) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her

HIB258 OPENING INTRO WHEN BENEFICIARY IS ENTITLED TO MEDICARE BENEFITS UNDER TITLE XVIII

(Requested/Generated)

Caption: None

This certifies that  (1)  entitled under Title XVIII of the Social Security Act to the Medicare benefits shown, beginning with the date indicated.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you are
Choice 2: Beneficiary's name + is

HIB259 SMI PREMIUM AMOUNTS AND EFFECTIVE DATES (H21 DETAIL LINE)

(Systems Generated)

Caption: Information About Medicare

 (1)   (2) 

NOTE: This UTI is automatically generated whenever HIB193 is requested/generated and there is more than one row of data to display in Fill-ins two and three under the headers in the chart.


Fill-in values:
Fill-in (1) - Systems Generated As A Date In Format Shown Below
Choice 1: MM/CCYY
Fill-in (2) - Systems Generated As A Money Amount In Format $$$$$.¢¢
Choice 1: Amount of SMI premium

HIB260 IRMAA

(System Generated)

Caption: Information About Medicare

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) - Systems Generated
Choice 1: Name possessive
Choice 2: your

HIB261 IRMAA

(System Generated)

Caption: Information About Medicare

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


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Total Amount in $$$$$¢¢ format
Fill-in (2) - Systems Generated
Choice 1: MM/CCYY
Fill-in (3) - Systems Generated
Choice 1: null
Choice 2: and
Choice 3: through
Fill-in (4) - Systems Generated
Choice 1: null
Choice 2: MM/CCYY

HIB262 IRMAA D

(System Generated)

Caption: Information About Medicare

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


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Total Amount in $$$$$¢¢ format
Fill-in (2) - Systems Generated
Choice 1: MM/CCYY
Fill-in (3) - Systems Generated
Choice 1: null
Choice 2: and
Choice 3: through
Fill-in (4) - Systems Generated
Choice 1: null
Choice 2: MM/CCYY

HIB263 IRMAA B and D

(System Generated)

Caption: Information About Medicare

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


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Total Amount in $$$$$¢¢ format

HIB264 IRMAA Waiver Request

(System Generated)

Caption: Information About Medicare

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) - Systems Generated
Choice 1: he owes
Choice 2: she owes
Choice 3: you owe
Fill-in (2) - Systems Generated
Choice 1: he owes
Choice 2: she owes
Choice 3: you owe
Fill-in (3) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
Fill-in (4) - Systems Generated
Choice 1: MM/CCYY (COM + 2 months)

HIB265 IRMAA Deduction

(System Generated)

Caption: Information About Medicare

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) - Systems Generated
Choice 1: 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: MM/CCYY (COM)

HIB266 IRMAA B Deduction

(System Generated)

Caption: Information About Medicare

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


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Amount in $$$$$¢¢ format

HIB267 IRMAA D Deduction

(System Generated)

Caption: Information About Medicare

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


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Amount in $$$$$¢¢ format

HIB268 IRMAA Partial Recovery

(System Generated)

Caption: Information About Medicare

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) - Systems Generated
Choice 1: MM/CCYY (COM)
Fill-in (2) - Systems Generated
Choice 1: Amount in $$$$$¢¢ format

HIB269 IRMAA Total Withholding

(System Generated)

Caption: Information About Medicare

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


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Name possessive
Choice 2: your
Fill-in (2) - Systems Generated
Choice 1: he owes
Choice 2: she owes
Choice 3: you owe

HIB270 IRMAA PART B Arrearage

(System Generated)

Caption: Information About Medicare

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) - Systems Generated
Choice 1: MM/CCYY (COM)
Fill-in (2) - Systems Generated
Choice 1: Amount in $$$$$.¢¢ format

HIB271 IRMAA D and/or B Installment Payment

(System Generated)

Caption: Information About Your Installment Payment

As you requested, we will withhold  (1)  from  (2)  monthly Social Security payments beginning  (3)  for past due Medicare amounts owed. We will withhold  (4)  each month until you have paid all of the past due Medicare amounts you owe.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Amount in $$$$$.¢¢ format
Fill-in (2) - Systems Generated
Choice 1: Name possessive
Choice 2: your
Fill-in (3) - Systems Generated
Choice 1: MM/CCYY (COM)
Fill-in (4) - Systems Generated
Choice 1: Amount in $$$$$.¢¢ format

HIBR60 MEDICAL INSURANCE INFORMATION PRIMARY IS IMPRISONED OR CONFINED (H03)

(Requested)

Caption: Information About Medicare

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 re-enroll 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 re-enroll. 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 a 3-month period and will be sent to you shortly before the payment is due.


Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you receive
Choice 2: Beneficiary's Name receives
Fill-in (2) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (3) - Requested As A One Position Alpha Character
Choice 1: (A) imprisoned
Choice 2: (B) confined in a institution
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (6) - Systems Generated
Choice 1: prison
Choice 2: the institution
Fill-in (7) - Systems Generated
Choice 1: You
Choice 2: He
Choice 3: She
Fill-in (8) - Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (9) - Systems Generated
Choice 1: prison
Choice 2: the institution
Fill-in (10) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (11) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

NL 00720.245 OPT Overpayment

OPT028 NEW OVERPAYMENT AMOUNT INCLUDES PRIOR OVERPAYMENT (M05)

(Requested)

Caption: Your Benefits

However, the total overpayment is  (1)  , which includes a prior overpayment of  (2)  .


Fill-in values:
Fill-in (1) - Requested As A Money Amount In Format $$$$$.¢¢
Total overpayment
Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
Current balance of prior overpayment

OPT107 OVERPAYMENT RECOVERED FROM ONE MONTH'S BENEFIT (A57)

(Requested)

Caption: Your Benefits

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) – Systems Generated
Choice 1: null
Fill-in (2) – Systems Generated
Choice 1: null
Fill-in (3) – Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Choice 4: Beneficiary's name
Fill-in (4) – Systems Generated
month and year (MM/CCYY)
Fill-in (5) – Systems Generated
Choice 1: overpaid
Choice 2: incorrectly paid
Fill-in (6) – Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Choice 4: Beneficiary's name
Fill-in (7) – Systems Generated
month and year (MM/CCYY)

OPT122 BENEFICIARY OVERPAID DUE TO SUSPENSION/TERMINATION (M13)

(Requested)

Caption: Your Benefits

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


Fill-in values:
Fill-in (1) – Systems Generated
Choice 1: Beneficiary's Name (possessive)
Choice 2: your
Fill-in (2) – Systems Generated
MM/CCYY
Fill-in (3) – Systems Generated
Choice 1: he was
Choice 2: she was
Choice 3: you were
Fill-in (4) Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Amount of overpayment

OPT127 UNDERPAYMENT USED TO REDUCE/RECOVER AN OVERPAYMENT (M03)

(Requested)

Caption: Your Benefits

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


Fill-in values:
Fill-in (1) - Requested As A Money Amount in Format $$$$$.¢¢
Amount used for recovery
Fill-in (2) - Requested As A One Position Alpha Character or Language
Choice 1: (A) your
Choice 2: Name of Beneficiary
Fill-in (3) - Requested As A One Position Alpha Character
Choice 1: (A) all
Choice 2: (B) part

OPT132 DIRECT DEPOSIT — JOINT ACCOUNT — RECOVERY OF PAYMENTS MADE AFTER DEATH (A16)

(Requested)

Caption: Your Benefits

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) Requested As A Money Amount In Format $$$$$.¢¢
Amount of overpayment
Fill-in (2) Requested
Full name of the deceased beneficiary, possessive
Fill-in (3) Requested As A Date In Format Shown Below
Month(s) and year(s) of incorrect payment
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (4) Systems Generated
Choice 1: you
Choice 2: Beneficiary's first name
Fill-in (5) Requested
Month(s) and year(s) of incorrect payment
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (6) Systems Generated
Choice 1: Beneficiary's name is
Choice 2: you are
Fill-in (7) Systems Generated
Choice 1: Beneficiary's name is
Choice 2: you are
Fill-in (8) Requested
Amount of overpayment

OPT148 CROSS PROGRAM RECOVERY - T16 UNDERPAYMENT USED TO RECOVER T2 OVERPAYMENT (B88)

(System Generated)

Caption: Your Benefits

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


Fill-in values:
Fill-in (1)
Amount of SSI under payment
Fill-in (2)
Choice 1: Beneficiary's Name possessive
Choice 2: your

OPT149 CROSS PROGRAM RECOVERY - T16 UNDERPAYMENT NOT USED TO REDUCED/RECOVER A T2 OVERPAYMENT (B89)

(System Generated)

Caption: What We Will Pay

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 Name
Choice 2: your

OPT151 OVERPAYMENT LIABILITY INFORMATION TO A REPRESENTATIVE PAYEE FOR OVERPAID BENEFICIARY (A27)

(Requested)

Caption: Your Benefits

As representative payee, you are personally liable for repayment unless you used the overpaid funds for the benefit of  (1)  , and the overpayment was made through no fault of your own.


Fill-in values:
Fill-in (1) – Systems Generated
Name(s) of beneficiary (ies)

OPT152 REPAY BENEFITS WITHHELD - PROTEST OF OVERPAYMENT RECEIVED TIMELY (LAF D to C ) (A44)

(Requested)

Caption: Your Benefits

We are paying  (1)  again beginning  (2)  because  (3)  asked us to review our overpayment decision. If we later find that our decision was correct, or that we cannot waive the overpayment,  (4)  will have to pay back the  (5)  which  (6)  . Someone from the local Social Security office will contact  (7)  to discuss the overpayment.


Fill-in values:
Fill-in (1) – Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2) - Requested As A Date In Format Shown Below
Date payments resumed MM/CCYY
Fill-in (3) – Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4) – Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (5) – Requested As A Money Amount In Format $$$$$.¢¢
Amount of overpayment
Fill-in (6) – Systems Generated
Choice 1: you owe
Choice 2: he owes
Choice 3: she owes
Fill-in (7) – Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her

OPT153 OVERPAYMENT WITHHELD FROM BENEFITS IS REPAID — PROTEST RECEIVED TIMELY (A46)

(Requested)

Caption: Your Benefits

 (1)  asked us to review our overpayment decision. While we review  (2)  case, we are sending  (3)  the money we withheld from  (4)  checks.

If we later find that our decision was correct, or that we cannot waive the overpayment,  (5)  will have to pay back the  (6)  which  (7)  . Someone from the local Social Security office will contact  (8)  to discuss the overpayment.


Fill-in values:
Fill-in (1) – Systems Generated
Choice 1: You
Choice 2: Beneficiary's Name
Fill-in (2) – Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) – Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (4) – Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) – Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (6) Requested As A Money Amount In Format $$$$$.¢¢
Amount of overpayment-
Fill-in (7) – Systems Generated
Choice 1: you owe
Choice 2: he owes
Choice 3: she owes
Fill-in (8) – Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her

OPT154 OVERPAYMENT PROTESTED - BENEFITS RESUMED AND WITHHELD BENEFITS REPAID - FOREIGN CLAIMS (A47)

(Requested)

Caption: Your Benefits

We are paying  (1)  again beginning  (2)  because  (3)  asked us to review our overpayment decision. If we later find that our decision was correct, or that we cannot waive the overpayment,  (4)  will have to pay back the  (5)  which  (6)  .


Fill-in values:
Fill-in (1) – Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (2) – Requested As A Date In Format Shown Below
Date payments resumed MM/CCYY
Fill-in (3) – Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4) – Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (5) – Requested As A Money Amount In Format $$$$$.¢¢
Amount of overpayment
Fill-in (6) – Systems Generated
Choice 1: you owe
Choice 2: he owes
Choice 3: she owes

OPT155 OVERPAYMENT PROTESTED - BENEFITS RESUMED - MONEY WITHHELD NOT REPAID - FOREIGN CLAIMS (A48)

(Requested)

Caption: Your Benefits

We are paying  (1)  again beginning  (2)  because  (3)  asked us to review our overpayment decision. For now, we are still withholding the money which we already subtracted from  (4)  checks.

If we later find that our decision was correct, or that we cannot waive the overpayment,  (5)  will have to pay back the  (6)  which  (7)  .


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2) – Requested As A Date In Format Shown Below
Date payments resumed MM/CCYY
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (6) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the remaining overpayment
Fill-in (7) Systems Generated
Choice 1: you owe
Choice 2: he owes
Choice 3: she owes

OPT156 OVERPAYMENT PROTESTED AFTER RECOVERY COMPLETED/STOPPED - REPAY BENEFITS WITHHELD - FOREIGN CLAIMS (A49)

(Requested)

Caption: Your Benefits

 (1)  asked us to review our overpayment decision. While we review  (2)  case, we are sending  (3)  the money we withheld from  (4)  checks. If we later find that our decision was correct, or that we cannot waive the overpayment,  (5)  will have to pay back the  (6)  which  (7)  .


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's Name
Fill-in (2) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (4) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (6) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the overpayment
Fill-in (7) Systems Generated
Choice 1: you owe
Choice 2: he owes
Choice 3: she owes

OPT158 INTRODUCTORY STATEMENT FOR CAT A-A22 NOTICE WHEN OVERPAYMENT ESTABLISHED AND ALIEN TAXATION INVOLVED (ADMINISTRATIVE ADJUSTMENT) (F70)

(Requested)

Caption: None

We are writing to give  (1)  new information about the  (2)  benefits which  (3)  on this Social Security record. In the rest of this letter, we will tell  (4)  :

  • How we paid  (5)   (6)  too much in benefits; and

  • What to do if  (7)  we are wrong about the overpayment.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2) Requested As A One Position Alpha Character
Choice 1: (A) disability
Choice 2: (B) retirement
Choice 3: (C) survivor
Choice 4: (D) auxiliary
Fill-in (3) Systems Generated
Choice 1: you receive
Choice 2: he receives
Choice 3: she receives
Fill-in (4) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (5) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (6) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the overpayment
Fill-in (7) Systems Generated
Choice 1: you think
Choice 2: he thinks
Choice 3: she thinks

OPT159 A21 NOTICE OVERPAYMENT RECOVERY (G51)

(System Generated)

Caption: Your Benefits

As we told  (1)  in our previous letter, we are withholding  (2)  benefits to recover the overpayment of  (3)  .


Fill-in values:
Fill-in (1)
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2)
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3)
Amount of the overpayment

OPT161 INTRODUCTORY PARAGRAPH E31 AND E32 NOTICES (G70)

(System Generated)

Caption: None

We are writing to give  (1)  new information about the  (2)  benefits which  (3)  on this Social Security record. In the rest of this letter, we will tell  (4)  :

  • How we paid  (5)   (6)  too much in benefits; and

  • What to do if  (7)  we are wrong about the overpayment.


Fill-in values:
Fill-in (1)
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2)
Choice 1: disability
Choice 2: retirement
Choice 3: survivor
Fill-in (3)
Choice 1: you receive
Choice 2: he receives
Choice 3: she receives
Fill-in (4)
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (5)
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (6)
Amount of the overpayment
Fill-in (7)
Choice 1: you think
Choice 2: he thinks
Choice 3: she thinks

OPT162 E31 AND E34 NOTICES MBP GREATER THAN OVERPAYMENT (G71)

(System Generated)

Caption: Your Benefits

We plan to collect the overpayment from the check which  (1)  will receive around  (2)  . We will reduce  (3)  check to  (4)  . We will send  (5)   (6)  regular monthly benefit amount again beginning  (7)  .


Fill-in values:
Fill-in (1)
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (2)
MM/DD/CCYY
Fill-in (3)
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (4)
Amount of the check
Fill-in (5)
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (6)
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (7)
MM/CCYY

OPT163 E34 NOTICE INTRODUCTORY PARAGRAPH (G72)

(System Generated)

Caption: None

We are writing to give  (1)  new information about Social Security benefits on this record. We paid  (2)   (3)  too much in Social Security benefits. In the rest of this letter, we will tell you:

  • How we paid too much in benefits, and

  • What to do if you think we are wrong about the overpayment.


Fill-in values:
Fill-in (1)
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (2)
Beneficiary's name
Fill-in (3)
Amount of the Overpayment

OPT164 OVERPAYMENT RECOVERY PROPOSED AGAINST OTHER BENEFICIARY E34 NOTICE (G73)

(System Generated)

Caption: None

We cannot recover the overpayment from the person who was overpaid. For this reason, we will withhold the money from the checks of other persons who are paid on the same Social Security record.

OPT165 CHECK PARAGRAPH FUTURE WITHHOLDING OF OVERPAYMENT (G91)

(System Generated)

Caption: Your Benefits

We will pay  (1)  a monthly check of  (2)  until we start to collect the overpayment.


Fill-in values:
Fill-in (1)
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (2)
PMA or CMA in $$$$$.¢¢ format

OPT166 PREVIOUS CHECK WAS INCORRECT AMOUNT (M02)

(Requested)

Caption: Your Benefits

The check  (1)  received for  (2)  in  (3)  should have been for  (4)  . Therefore we paid  (5)   (6)  more in benefits than  (7)  due.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2) – Requested As A Money Amount In Format $$$$$.¢¢
Amount of check
Fill-in (3) Requested As A Date In Format Shown Below
MM/CCYY
Fill-in (4) Requested As A Money Amount In Format $$$$$.¢¢
Amount that should have been paid
Fill-in (5) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (6) Requested As A Money Amount In Format $$$$$.¢¢
Amount of overpayment
Fill-in (7) Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was

OPT167 OVERPAYMENT RECOVERED (M06)

(Requested)

Caption: Your Benefits

We have recovered all of the money  (1)  owed because of an overpayment.


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

OPT168 OVERPAYMENT BALANCE (M08)

(Requested)

Caption: Your Benefits

The total amount of the overpayment is  (1)  .


Fill-in values:
Fill-in (1) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the overpayment

OPT169 INCORRECT BENEFIT CAUSED INCORRECT PAYMENT, OVERPAYMENT OR UNDERPAYMENT (M10)

(Requested)

Caption: Your Benefits

Since we paid  (1)   (2)  for  (3)  , we paid  (4)   (5)   (6)  than  (7)  due.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount paid
Fill-in (3) Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (4) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (5) - Requested As A Money Amount In Format $$$$$.¢¢
Amount of the overpayment
Fill-in (6) - Requested As A One Position Alpha Character
Choice 1: (A) more
Choice 2: (B) less
Fill-in (7) Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was

OPT170 BENEFITS DEFERRED TO RECOVER AN INCORRECT PAYMENT/OVERPAYMENT (M11)

(Requested)

Caption: Your Benefits

We are withholding all of  (1)  benefits for  (2)  and  (3)  of  (4)  benefits for  (5)  to recover the  (6)  that was not due


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: your
Choice 2: Beneficiary's Name possessive
Fill-in (2) Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (3) Requested As A Money Amount In Format $$$$$.¢¢
Amount of final adjustment
Fill-in (4) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) Requested As A Date In Format Shown Below
MM/CCYY of final adjustment
Fill-in (6) Requested As A Money Amount In Format $$$$$.¢¢
Amount of overpayment or incorrect payment

OPT171 OTHER BENEFICIARY OVERPAID DUE TO WORK (M12)

(Requested)

Caption: Your Benefits

We paid  (1)   (2)  too much in benefits because of work and earnings in  (3)  .


Fill-in values:
Fill-in (1) - Requested As A Language
Name of overpaid beneficiary
Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
Amount of overpayment
Fill-in (3) - Requested As A Date In Format Shown Below
CCYY

OPT179 PAID VS. PAYABLE (M01)

(Requested)

Caption: Your Benefits

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


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount
Fill-in (3) Requested As A Date in Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (4) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (5) Requested As A Money Amount In Format $$$$$.¢¢
Correct Amount
Fill-in (6) Requested As A Date in Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (7) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (8) Requested As A Money Amount In Format $$$$$.¢¢
Amount
Fill-in (9) Systems Generated
Choice 1: more
Choice 2: less
Fill-in (10) Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was

OPT180 FOREIGN REFUND REQUEST ADJUSTMENT PROPOSED OVERPAYMENT EXCEEDS MBP (F24)

(System Generated)

Caption: How To Pay Us Back

You should refund this overpayment within 30 days. Please make your check or money order payable to “Social Security Administration” and send it to us in the enclosed envelope.

Always include  (1)  Social Security claim number on the check or money order.

Please send your check or money order in United States currency or in local currency equal to the United States dollars. When you pay us in local currency, we use the exchange rate in effect at the time we get your payment. If this causes a difference between the amount you pay us and the amount you owe us, we will let you know. If you cannot mail your payment directly to us, please contact your Federal Benefits Unit for help in making the refund. Visit  (2)  for a list of Federal Benefits Units.

If we do not receive your refund within 30 days, we plan to recover the overpayment by withholding  (3)  full benefit each month beginning with the benefit  (4)  would normally receive about  (5)  . We will continue to withhold  (6)  benefit until the overpayment is fully recovered.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: your
Choice 2: Beneficiary Name possessive
Fill-in (2) Systems Generated
Fill-in (3) Systems Generated
Choice 1: your
Choice 2: Beneficiary Name possessive
Fill-in (4) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (5) Systems Generated
MM/DD/CCYY
Fill-in (6) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

OPT181 (M07) DUPLICATE CHECK OVERPAYMENT

(Requested)

Caption: Your Benefits

We sent  (1)  two checks for  (2)  , both in the amount of  (3)  and both checks were cashed. Since  (4)  due only one check, we paid  (5)   (6)  too much in benefits.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (2) Requested As A Date in Format Shown Below
MM/CCYY
Fill-in (3) Requested As A Money Amount In Format $$$$$.¢¢
Amount
Fill-in (4) Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was
Fill-in (5) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (6) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the overpayment

OPT182 PRIOR OVERPAYMENT — WORK MONTHS PREVENTED RECOVERY (A29)

(Requested)

Caption: Your Benefits

Our records show that we paid  (1)   (2)  too much in  (3)  . In our previous letter, we told  (4)  that we would withhold benefits in  (5)  to recover  (6)  amount. But  (7)  recent report shows that  (8)  worked during  (9)  . Because of that work, no benefits were payable for that period. Since we could not use benefits for those months to recover the amount  (10)  owed,  (11)  us  (12)  .


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: Beneficiary's name
Choice 2: you
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the overpayment
Fill-in (3) Requested As A Date in Format Shown Below
Year of prior overpayment in CCYY
Fill-in (4) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (5) Requested As A Date in Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (6) Requested As A One Position Alpha Character
Choice 1: (A) this
Choice 2: (B) part of this
Fill-in (7) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (8) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (9) Requested As A Date in Format Shown Below
Choice 1: month and year of work MM/CCYY
Choice 2: months and years of work MM/CCYY through MM/CCYY
Fill-in (10) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (11) Systems Generated
Choice 1: you still owe
Choice 2: he still owes
Choice 3: she still owes
Fill-in (12) Requested As A Money Amount In Format $$$$$.�¢
Overpayment Amount

OPT262 OVERPAYMENT ESTABLISHED DUE TO INCORRECT COMPUTATION, A LEGALLY DEFINED OVERPAYMENT OR TO RECOVER A SKELETON DUE PROCESS OVERPAYMENT

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because the payment amount was incorrect. We corrected  (3)  record, which caused (4)  benefit amount to decrease.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) 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

OPT263 OVERPAYMENT ESTABLISHED DUE TO SUBVERSIVE ACTIVITY

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because  (3)  convicted of a crime against the United States.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was

OPT264 OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY DID NOT HAVE A CHILD IN THEIR CARE

(Requested)

Caption: Your Benefits

 (1)  received (2)  too much in benefits because  (3)  a child in  (4)  care who receives benefits from us.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you no longer have
Choice 2:he no longer has
Choice 3: she no longer has
Fill-in (4) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

OPT265 OVERPAYMENT ESTABLISHED BECAUSE A WARRANT FOR THE BENEFICIARY'S ARREST EXISTS

(Requested)

Caption: Your Benefits

 (1)  received (2)  too much in benefits. We should not have paid  (3)  because of a warrant for  (4)  arrest.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.��
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you
Choice 2:him
Choice 3: her
Fill-in (4) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

OPT266 OVERPAYMENT ESTABLISHED BECAUSE OF STATE OR FEDERAL ASSISTANCE

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because (3)  received State or Federal assistance.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she

OPT267 OVERPAYMENT CAUSED BY REPRESENTATIVE PAYEE MISUSE OF BENEFITS

(Requested)

Caption: Your Benefits

 (1)  received (2)  too much in benefits because  (3)  misused funds while acting as a representative payee.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she

OPT268 OVERPAYMENT CAUSED BY DISABILITY CESSATION

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because we cannot pay benefits after  (3)  disability ends.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Requested As A One Position Alpha Character or Wage Earner's Name for Choice 4
Choice 1: (A) your
Choice 2: (B) his
Choice 3: (C) her
Choice 4: Wage Earner's name (possessive)

OPT269 OVERPAYMENT ESTABLISHED DUE TO RECEIPT OF PROVISIONAL BENEFITS ON A CLAIM THAT WAS LATER DENIED

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because  (3)  received temporary benefits while we were making a decision on  (4)  claim that we later denied.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (3) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

OPT270 OVERPAYMENT ESTABLISHED DUE TO CROSS-BENEFIT ADJUSTMENT

(Requested)

Caption: Your Benefits

We moved  (1)  overpayment of  (2)  to  (3)  for collection.


Fill-in values:
Fill-in (1) Requested As A Alpha Character or the Beneficiary's Name
Choice 1: (A) another person's
Choice 2: Beneficiary's full name (possessive)
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: Beneficiary’s full name

OPT271 OVERPAYMENT ESTABLISHED DUE TO CHANGE IN THE AMOUNT OR COMMENCEMENT OF THE GOVERNMENT PENSION OFFSET

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because we must offset  (3)  benefit payments due to  (4)  receipt of a government pension.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (4) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

OPT272 OVERPAYMENT ESTABLISHED DUE TO CROSS-BENEFIT ADJUSTMENT

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because (3)  received a pension based on work not covered by Social Security taxes.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Requested As A One Position Alpha Character or Wage Earner's name for Choice 4
Choice 1: (A) you
Choice 2: (B) he
Choice 3: (C) she
Choice 4: Wage Earner's name (not possessive)

OPT273 OVERPAYMENT ESTABLISHED DUE TO RECEIPT OF PAYMENTS AFTER CONFINEMENT TO A MENTAL INSTITUTION BECAUSE OF A COURT ORDER

(Requested)

Caption: Your Benefits

 (1)  received (2)  too much in benefits because  (3)  received payments after being confined to an institution because of a court order.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she

OPT274 OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY WAS AN ALIEN LIVING OUTSIDE THE UNITED STATES WHILE RECEIVING BENEFITS

(Requested)

Caption: Your 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.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (3) Systems Generated
Choice 1: you are
Choice 2: he was
Choice 3: she was

OPT275 OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY WORKED OUTSIDE THE US IN A JOB NOT COVERED UNDER SOCIAL SECURITY TAXES

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because  (3)  worked outside the United States in a job not covered by United States Social Security taxes.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she

OPT276 OVERPAYMENT ESTABLISHED DUE TO PRISONER SUSPENSION

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because of  (3)  criminal conviction and confinement in a correctional institution for more than 30 days.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

OPT277 OVERPAYMENT ESTABLISHED DUE TO DEATH RECLAMATION, REPRESENTATIVE PAYEE ELECTRONIC FUNDS TRANSFER (EFT) AFTER DEATH OR REPRESENTATIVE PAYEE DEATH

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because we cannot pay benefits for the month of death or later.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.��
Amount of the Overpayment

OPT278 OVERPAYMENT ESTABLISHED DUE TO PERMANENT DEDUCTIONS RESULTING FROM THE ANNUAL EARNINGS TEST

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because of  (3)  work and earnings.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

OPT279 OVERPAYMENT ESTABLISHED DUE TO DEATH SUPER-ENDORSEMENT

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because  (3)  signed and cashed a check for the month of death or later.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she

OPT280 OVERPAYMENT ESTABLISHED DUE TO A CHANGE IN MARITAL STATUS

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because of a change in  (3)  marital status.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

OPT281 OVERPAYMENT ESTABLISHED DUE TO ENTITLEMENT TO WORKERS' COMPENSATION, PUBLIC DISABILITY OR BOTH

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because of  (3)  receipt of workers’ compensation, public disability payments, or both of these payments.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

OPT282 OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY CONTINUED TO RECEIVE BENEFITS AFTER THE AGE OF 18

(Requested)

Caption: Your Benefits

 (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 elementary or high school student.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment

OPT283 OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY CONTINUED TO RECEIVE BENEFITS AFTER AGE 19 OR 22

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because we do not pay benefits once a full-time student reaches age 19 , unless  (3)  blind or 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.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is

OPT284 OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY IS NO LONGER IN FULL-TIME SCHOOL ATTENDANCE

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because we do not pay benefits once a student stops going to school full-time.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.��
Amount of the Overpayment

OPT285 OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY REFUSED TO ACCEPT VOCATIONAL REHABILITATION

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because we should not have paid benefits when (3)  refused vocational rehabilitation services.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she

OPT286 OVERPAYMENT ESTABLISHED DUE TO UNPAID ATTORNEY FEES

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because of unpaid attorney's fees.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment

OPT287 OVERPAYMENT ESTABLISHED RAILROAD RETIREMENT BOARD EARNINGS WERE INCORRECTLY USED TO ESTABLISH THE BENEFICARY'S ENTITLEMENT

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because  (3)  received incorrect payments from the Railroad Retirement Board.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she

OPT288 OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICARY WAS NOT A UNITED STATES (U.S.) CITIZEN OR LAWFULLY PRESENT IN THE U.S.

(Requested)

Caption: Your Benefits

 (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.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (4) Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was

OPT289 OVERPAYMENT ESTABLISHED BECAUSE THE MONTH OF ENTITLEMENT WAS INCORRECT

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because of a change in the month  (3)  benefits started.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

OPT290 OVERPAYMENT ESTABLISHED DUE TO MULTIPLE ENTITLEMENTS

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because  (3)  received payments on two or more records for the same month(s).


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she

OPT291 OVERPAYMENT ESTABLISHED BECAUSE INSURED STATUS WAS NOT MET

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because  (3)  worked long enough under Social Security to receive monthly benefits.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you have not
Choice 2: he has not
Choice 3: she has not

OPT292 OVERPAYMENT ESTABLISHED BECAUSE THE BENFICIARY MISUSED FUNDS WHILE SERVING AS A REPRESENTATIVE PAYEE

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because  (3)  misused benefits that  (4)  received as the representative payee for another person.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she

OPT293 OVERPAYMENT CAUSED BY SUBSTANTIAL GAINFUL WORK ACTIVITY (SGA) DURING THE EXTENDED PERIOD OF ELIGIBILITY (EPE) OR DISABILITY CESSATION DUE TO SGA

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because of  (3)  work activity.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Requested As A One Position Alpha Character or the Wage Earner's Name for Choice 4
Choice 1: (A) your
Choice 2:(B) his
Choice 3:(C) her
Choice 4: Wage Earmer's name (possessive)

OPT294 OVERPAYMENT ESTABLISHED VIA CROSS PROGRAM RECOVERY (CPR) TO RECOVER A TITLE VIII SPECIAL VETERANS BENEFITS (SVB) PAID IN EXCESS

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in Special Veterans Benefit (SVB) payments.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.��
Amount of the Overpayment

OPT295 OVERPAYMENT CAUSED DUE TO INCORRECT PAYMENTS FOR MEDICARE SERVICES

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because of incorrect payments for Medicare services.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment

OPT296 OVERPAYMENT ESTABLISHED BECAUSE THE BENEFCIARY WAS CONVICTED OF A CRIME OR IMPRISONED FOR MORE THAN 30 DAYS DUE TO FELONIOUS HOMICIDE

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because of (3)  criminal conviction and imprisonment for more than 30 days.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

OPT297 OVERPAYMENT CAUSED BY WINDFALL OFFSET

(Requested)

Caption: Your Benefits

 (1)  received (2)  too much in benefits because  (3)  received Supplemental Security Income (SSI) payments  (4)   (5)  .


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4) Systems Generated
Choice 1: from
Choice 2: in
Fill-in (5) Systems Generated
Choice 1: MM/CCYY through MM/CCYY
Choice 2: MM/CCYY

OPT298 OVERPAYMENT ESTABLISHED BECAUSE MORE THAN ONE PAYMENT WAS CASHED FOR THE SAME MONTH

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because we should not have paid two payments for the same month(s).


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment

OPT299 OVERPAYMENT ESTABLISHED DUE TO INVALID FAMILY RELATIONSHIPS

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because  (3)  did not meet the relationship requirements to receive benefits.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she

OPT300 OVERPAYMENT ESTABLISHED BECAUSE OF INVALID ENTITLEMENT

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because  (3)  did not qualify for benefits.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she

OPT301 OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY WAS DEPORTED

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because  (3)  deported from the United States.


Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was

NL 00720 TN 13 - Manual Adjustment, Credit and Award Process (MADCAP) Beneficiary Notice Print Program - 9/24/2019