Identification Number:
NL 00730 TN 39
Intended Audience:See Transmittal Sheet
Originating Office:Systems
Title:Title II Redesign (T2R) Notices Title II Postentitlement (PE) Actions
Type:POMS Full Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part NL – Notices, Letters and Paragraphs
Chapter 007 – Letters and Paragraphs for Title II, Title XVI, and Title XVIII
Subchapter 30 – Title II Redesign (T2R) Notices Title II Postentitlement (PE) Actions
Transmittal No. 39, 12/15/2022

Audience

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

Originating Component

OEIS

Effective Date

Upon Receipt

Background

We are updating Program Operations Manual System (POMS) sections in NL 00730 to incorporate updates made to the processing of the Change of Address (COA) Confirmation notice, existing Universal Text Identifiers (UTIs) and the creation of new UTIs in the attached sections as a direct result of the of the T2R COA conversion to Customer Communication Management platform, IT MOD Update Notice Referral Language, and Consolidated Appropriations Act of 2021 (CAA 2021) initiatives.

Summary of Changes

NL 00730.005 Title II Redesign (T2R) Automated Notices

  • Updated Subsection B to include the T2R Change of Address Confirmation notice’s enhancement that allows the beneficiary to view the T2R COA notice online via their “MySSA” account and the new message center alert that advises the beneficiary of its availability

 

NL 00730.030 Title II Redesign (T2R) Standalone Change of Address Confirmation Notices

  • Updated Section B - replaced references of UTIs with Snippets as we will be using language from new Customer Communications Management (CCM) architecture instead of legacy Language Development Facility (LDF) to generate the formatted Notices

  • Added new snippet MESH03 and replaced SSAH05 with HDR053

  • Updated description for SSAH01 and MESH06

  • Removed REFC07 and replaced REF001, REF003, REF008 and REF185 with REF210, REF196, REF211 and REF197 respectively

  • Updated COA015, replaced "please call or visit any Social Security office right away." with “please contact us using the information below.”


NL 00730.102 “A” Paragraphs and Captions

  • Updated ALS020, replaced fourth bullet "You can file an appeal with any Social Security office. You must ask for an appeal in writing. Please use our “Request for Reconsideration” form, SSA-561. You may go to our website at (1) to find the form SSA-561. You can also contact us by phone, mail, or come into an office to request the form. If you need help to fill out the form, we can help you by phone or in person." with “You must ask for an appeal in writing. Please use our "Request for Reconsideration" form, SSA-561-U2. You may go to our website at (1) to locate the form. You can also contact us to request the form, or if you need help filling out the form.” Updated ALS020 Fill-in (1) to replace “www.socialsecurity.gov/online/” with “www.ssa.gov/forms/”

  • Updated ALS020 Fill-in (1) to replace “www.socialsecurity.gov/online/” with “www.ssa.gov/forms/”

 

NL 00730.116 “H” Paragraphs and Captions

  • Updated HBN001, removed "If you should have any questions concerning this Notice of Medicare Premium Payment Due, please write or visit any Social Security Office. "

  • Added five new captions and UTIs HIBC14, HIBC16, HIBC18, HIBC20, HIBC21, HIB316, HIB317, HIB318, HIB327 and HIB331.

  • Updated HIB183, changed Fill-in choices to "your" and Beneficiary's name to make them gender neutral.

  • Updated HIB184, removed the pronoun based choices for Fill-ins 1 and 2 and made "you" part of the fixed text to make the language gender neutral. Replaced Fill-in 1 with two choices to include the new Medicare Part B Immunosuppressive Drug coverage, Choice 1 is "Part B (Medical insurance)" and Choice 2 is "Part B Immunosupressive Drug Coverage."

  • Updated HIB186, modified the fixed text to include the new "Medicare Part B Immunosuppressive Drug Coverage."

 

NL 00730.126 “M” Paragraphs and Captions

  • Updated the third sentence in the third paragraph of MHP053 - replaced "visit (12), call 1-800-772-1213 (TTY 1-800-325-0778) or visit the nearest Social Security office. " with "contact us. "

  • Removed Fill-in (12) from Fill-in Values for MHP053

 

NL 00730.136 “R” Paragraphs and Captions

  • Removed REF001, REF003, REF008, REF018, REF056 and REF185 and replaced them with the new REF210, REF196, REF211, REF208 and REF209, REF198 and REF197 UTIs respectively

  • Updated REF020, removed third and fourth sentences and added "Visit www.ssa.gov for a copy of the pamphlet. " at the end of the second sentence

  • Updated Fill-in 2 and Fill-in 4 of REF020 to replace Choice 2 and removed Choice 3

  • Removed Fill-in (6), (7) and (8) from Fill-in values for REF020

 

NL 00730.146 "W" Paragraphs and Captions

  • Updated the fifth paragraph of WAV001 - replaced "The people in any Social Security office will be glad to help you complete " with "P lease contact us if you need help completing ."

  • Updated the sixth paragraph of WAV001 - replaced "Even if you do not want to request reconsideration or waiver, please call, write or visit any Social Security office if you have questions or need more information. Please take this letter with you if you do visit an office. " with "I f you have any additional questions, please contact us, and have this letter with you so that we may help you more quickly. "

  • Updated last paragraph of WEP003 - replaced "see our factsheet titled “Windfall Elimination Provision". You can get this factsheet at (9) online. You can also call, write, or visit us to get the factsheet.” with “view our factsheet titled “Windfall Elimination Provision,” that you can get at (9) online. ”

  • Updated value for Fill-in 9 of WEP003 - replaced "www.socialsecurity.gov/pubs/EN-05-10045.pdf ” with “www.ssa.gov/pubs ”

  • Updated last paragraph of WEP004 - replaced “see our factsheet titled” Windfall Elimination Provision.” You can get this factsheet at (5) online. You can also call, write, or visit us to get the factsheet. ” with “view our factsheet titled, "Windfall Elimination Provision," at (5) online. ”

  • Updated value for Fill-in 5 of WEP004 - replaced "www.socialsecurity.gov/pubs/EN-05-10045.pdf ” with “www.ssa.gov/pubs”

 

NL 00730.149 Fact and Worksheets

  • Updated BRR013 - removed last sentence and added “using the contact information below” at the end of first sentence

 

NL 00730.005 Title II Redesign (T2R) Automated Notices

A. Language in Title II Redesign (T2R) notices

NOTICE LANGUAGE:

The T2R notice process generates automated notices in both English and Spanish. When the language (LANG) field on the updated Master Beneficiary Record (MBR) = Spanish (S), the T2R notice process will generate both a Spanish and English notice. We send both versions of the notice to the beneficiary. We print the Spanish notice first, followed by the English notice.

ENCLOSURE LANGUAGE:

When we generate “enclosures,” the name of the enclosure appears on the first page of the Spanish notice. If there is a Spanish version, the beneficiary receives only the Spanish enclosure. If there is no Spanish version, we include the English version.

REFUND ENVELOPES:

Although some refund envelopes (e.g. CMS Refund Envelope) have both a Spanish and English version, policy requires that we use only the English version of the envelope.

B. Actions generating automated notices

The T2R system produces a notice when we update the MBR in the following situations:

  • Medicare Part A (hospital insurance or HI) - and Part B (medical insurance or SMI) enrollments, withdrawals, and terminations

  • Reducing the Part B premiums because of the Medicare Modernization Act;

  • Part B premium deductions start for cases where the Railroad Retirement Board has jurisdiction;

  • Maturing actions when Part B premium or Voluntary Tax Withholding (VTW) deductions are involved;

  • Deductions of Medicare health premiums (Part C) and Medicare prescription drug premiums (Part D) from SSA benefits;

  • Part B premium changes from Income Related Monthly Adjustment Amount (IRMAA); and

  • The Part B premium is greater than the Monthly Benefit Amount (MBA) and a suspension of monthly benefits occurs. We send an automated billing notification.

Beginning with T2R Release 3 in June 2004, we expanded T2R to include post entitlement processing. T2R generates notices for student awards, disabled child awards, parent awards, entitlement conversions based on full retirement age (FRA), other age attainments and death of the number holder (NH). For some entitlement conversion situations, T2R will convert the old Payment Identification Code (OLD-PIC) to a NEW-PIC. However, because of a suspension for a developmental reason, we cannot tell the beneficiary of the new type of benefit. If T2R resumes benefits, it only addresses the resumption of benefits. It does not explain the new type of benefit based on the prior entitlement conversion.

T2R generates notices for suspensions, terminations, voluntary tax withholding, workers compensation, public disability benefits, direct deposit, domestic to foreign address changes, payee changes, death terminations, and other post entitlement actions that update the MBR.

T2R generates a notice when the beneficiary’s MBA changes for any effective date. Policy requires this notification of the MBA change even if the Monthly Benefit Credited (MBC) does not change. T2R addresses reasons for MBA changes, including:

  • benefits to another entitled person stop due to death or another reason,

  • benefits to an auxiliary decrease due to the entitlement of another beneficiary,

  • cost of living increase,

  • adjusted reduction factor (ARF) or delayed retirement credits (DRCs) are applied,

  • workers’ compensation and public disability benefits are factored in,

  • an incorrect MBA determined by the T2R RATES business process, and

  • a zero MBA when the Primary Insurance Amount (PIA) equals the MAX and the History Reason for Suspension or Termination (HRFST) is Technical Entitlement (TECENT).

We generate a T2R notice for suspense-to-suspense status (Ledger Account File (LAF) S to LAF S) when the MBA changes. For example, if pre MBR LAF = S and post MBR LAF = S and the only change is an MBA change because another beneficiary terminated, the T2R notice will address the MBA change(s) for each effective date. The T2R notice will not repeat the reason the beneficiary is in suspense. The notice states benefits will not be paid at this time. Whenever an effective date in MBR History Data (HIST) shows a HRFST posted, but not posted for the same effective date on the pre MBR, the T2R notice does give the new suspension reason.

With the November 2005 Release, based on legislation, T2R generates notices relating to:

  • fugitive felon suspensions,

  • garnishment and levy deductions, and

  • CDR Failure to Cooperate suspensions and terminations.

Beginning with the November 2007 release, T2R generates an overpayment Payment Stub for new T2 overpayments. The Payment Stub appears after the signature page in the notice (NL 00730.200).

In August 2012, the Automated Job Stream 3 (AJS3) software was retired and functionality rolled into T2R. T2R enhanced notices have the ability to report details on work and earnings and the potential effects of those earnings on benefits.

In August 2014, T2R incorporated functionality of another system, Automated Job Stream 1 (AJS1). After we fold all AJS1 functionality into T2R, T2R will provide information on Primary Insurance Amount (PIA) changes that have an effect on benefits. Effective August 2014, T2R notices also provide information when:

  • we apply the Windfall Elimination Provision (WEP) for the first time or remove it, or

  • we transfer a death underpayment to another beneficiary on the same account.

In August 2014, T2R started generating automated a standalone “Change of Address Confirmation” (COA) notice when someone inputs a change of address through the internet. In August 2020, the Telephone Interactive Voice Response System was added as an additional source for reporting a change of address thus invoking the "Change of Address Confirmation" (COA) notice. In October 2022, the T2R COA notice was enhanced to make the notice available online in the beneficiary's "MySSA" account. The Customer Communication Management (CCM) system now creates the notice and a message to alert the beneficiary of its availability in the Message Center of their "MySSA" account. The notice:

  • Lets the beneficiary or representative payee know that we changed the address on our records because of a request made on the Internet at “MySSA” or over the phone using the interactive voice system.

  • Gives steps to take if beneficiary or representative payee didn’t request the address change

  • Goes to the old address on the record

  • Does not disclose other details about the beneficiary’s account; and

  • Does not display the beneficiary’s Social Security number

In February 2015, T2R started sending notices to beneficiaries who receive a Prior Month Accrual (PMA) check when they are in a terminated status on the Pre MBR and remain in a terminated status on the Post MBR.

 

NL 00730.030 Title II Redesign (T2R) Standalone Change of Address Confirmation Notices

A. Introduction

As part of SSA’s effort to reduce fraud, T2R sends a notice to the beneficiary or representative payee whenever an address is changed through the internet at “mySocialSecurity” or using the Telephone Interactive Voice Response System (IVR). The notice tells the beneficiary or representative payee to contact us if he or she didn’t change the address. We started sending out this notice in August 2014 as part of the Direct Deposit Fraud Program and added the option of changing the address via the telephone as part of the IVR Project in August 2020.

The Master Beneficiary Record (MBR) does not store both the beneficiary and representative payee’s addresses. Therefore, the T2R notice system only sends the notice to the old mailing address on the MBR, which may belong to a representative payee or beneficiary. The notice does not display a Social Security number, and we do not send a copy to attorneys.

The T2R notice system only produces complete notices for change of address confirmation, so no notices are completed through AURORA (manual notice system) or through any other manual process. If an incomplete notice generates, it will be removed from the file and written to an error log. The error log will be investigated by systems staff.

B. Sequence of notice

The Snippets used in the Change of Address notice generate in the following order:

Snippet

Type

Description

MESH03

Mandatory

Social Security Administration

SSAH01

Mandatory

Retirement, Survivors, and Disability Insurance

HDR053

Mandatory

Change of Address Confirmation

HDR026

Mandatory

Social Security Administration
P.O. Box 32905
Baltimore, Maryland 21241-2905

MESH06

Mandatory

Date

SSAH30

Mandatory

Addressee and Pre MBR Address

SNO002

Optional

Special Notice Option Text

SNO004

Optional

Special Notice Option Text

COA014

Mandatory

Text

COAC02

Mandatory

Caption

COA015

Mandatory

Text

COAC03

Mandatory

Caption

COA016

Mandatory

Text

REF210

Conditional

Text – uses Pre MBR ZIP

REF197

Conditional

Text – uses Pre MBR ZIP

REF196

Conditional

Text – uses Pre MBR ZIP

REF211

Conditional

Text – uses Pre MBR ZIP

SSAS02

Mandatory

Signature

NOTE: The type ‘Mandatory’ indicates that the Snippet must be included in every COA notice. The type ‘Conditional’ indicates that only one of the Snippets is selected based on the conditions of the particular situation, as in the case of the Referral Snippets. The type ‘Optional’ indicates that the Snippet is dependent on a particular condition, but is not a required condition or paragraph (e.g., the beneficiary has elected a particular Special Notice Option).

C. Snippets used in the notice

COA014 – T2R STANDALONE CHANGE OF ADDRESS NOTICE – ADVISES BENEFICIARY THAT WE CHANGED THE ADDRESS ON THE MASTER BENEFICIARY RECORD (MBR)

Thank you for notifying us about your change of address. We have updated (1) Social Security record. We are sending this letter to the address we previously had on file for you. We are doing this so we can make sure that you were the one who reported the address change. We will send any future letters to the new address. If you reported an address change, you do not need to respond to this letter.

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

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

COA015 – T2R STANDALONE CHANGE OF ADDRESS NOTICE – ADVISES BENEFICIARY TO CONTACT A SOCIAL SECURITY OFFICE IF NO ADDRESS CHANGE WAS REQUESTED

If you did not request this recent address change, please contact us using the information below.

COA016 – T2R STANDALONE CHANGE OF ADDRESS NOTICE – ADVISES BENEFICIARIES OF HOW TO VIEW RECORDS ONLINE AND HOW TO CREATE A “MY SOCIAL SECURITY” ONLINE ACCOUNT

(1) can view (2) Social Security records online with (3) “mySocial Security ” online account. If (4) not already have a “mySocial Security” account, we invite (5) to visit our website at (6) to create one.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

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

Fill-in (2)

Choice 1

your

Choice 2

her

Choice 3

his

Fill-in (3)

Choice 1

your

Choice 2

her

Choice 3

his

Fill-in (4)

Choice 1

you do

Choice 2

she does

Choice 3

he does

Fill-in (5)

Choice 1

you

Choice 2

her

Choice 3

him

Fill-in (6)

www.socialsecurity.gov

COAC02 – T2R STANDALONE CHANGE OF ADDRESS NOTICE – CAPTION

If You Did Not Change Your Address

COAC03 – T2R STANDALONE CHANGE OF ADDRESS NOTICE – CAPTION

Online Services

HDR026 – T2R STANDALONE CHANGE OF ADDRESS NOTICE – RETURN ADDRESS

Social Security Administration

P.O. Box 32905

Baltimore, MD 21241-2905

MESH06 - T2R STANDALONE CHANGE OF ADDRESS NOTICE – NOTICE DATE

Date: (1)

Fill-in values:

 

Fill-in (1)

T2R Post Entitlement Run Date + 7 days in format Month DD, CCYY

REF210 – T2R STAN DALONE CHANGE OF ADDRESS NOTICE – REFERRAL PARAGRAPH – DOMESTIC ADDRESS – T2/TSC NUMBER NOT PRESENT OR EQUALS THE NATIONAL NUMBER

Refer to NL 00730.136

REF197 – T2R STANDALONE CHANGE OF ADDRESS NOTICE – FOREIGN ADDRESS

Refer to NL 00730.136

REF196 – T2R STANDALONE CHANGE OF ADDRESS NOTICE – DOMESTIC ADDRESS

Refer to NL 00730.136

REF211 – T2R STANDALONE CHANGE OF ADDRESS NOTICE – DOMESTIC ADDRESS – NO T2/TSC AND NO LOC ON DOORS

Refer to NL 00730.136

SNO002 – T2R STANDALONE CHANGE OF ADDRESS NOTICE – SPECIAL NOTICE OPTIONS – BRAILLE, DATA CD, AUDIO CD OR LARGE PRINT

Refer to NL 00730.138

SNO004 – T2R STANDALONE CHANGE OF ADDRESS NOTICE – SPECIAL NOTICE OPTION – TELEPHONE CONTACT

Refer to NL 00730.138

SSAH30 – T2R STANDALONE CHANGE OF ADDRESS NOTICE – PAYMENT LEGEND AND ADDRESS

Refer to NL 00730.138

 

NL 00730.102 "A" Paragraphs and Captions

List of “A” Paragraphs and Captions

A. ACT Universal Text Identifier – Privacy Act

ACT003 – PAPERWORK/PRIVACY ACT NOTICE PRINTED WHEN PAYMENT STUB IS PRINTED

Privacy Act Statement

The Social Security Administration (SSA) has authority to collect the information requested on the PAYMENT STUB under section 204 of the Social Security Act. Giving us this information is voluntary. You do not have to do it. We will need this information only if you choose to make payment by credit card. You do not need to fill out the credit card information if you choose another means of payment (for example, by check or money order).

If you choose the credit card payment option, we will provide the information you give us to the banks handling your credit card account and SSA's account. This will allow you to repay your overpayment with your credit card. We may also provide this information to another person or government agency to comply with federal laws requiring the release of information from our records. You can find these and other routine uses of information provided to SSA listed in the Federal Register. If you want more information about this, you may call or write any Social Security office.

We may also use the information you give us when we match records by computer. Matching programs compare our records with those of other Federal, State, or local government agencies. Many agencies may use matching programs to find or prove that a person qualifies for benefits paid by the Federal government. The law allows us to do this even if you do not agree to it.

Explanations about these and other reasons why information you provide us may be used or given out are available in Social Security offices. If you want to learn more about this, contact any Social Security office.

B. ADJ Universal Text Identifiers – Adjustment

ADJ048 – UNDERPAYMENT TRANSFERRED FROM DECEASED BENEFICIARY TO SPOUSE

(1) will soon receive a payment of (2) because we owed money to (3). This payment is in addition to any monthly payments (4) may receive.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

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

Fill-in (2)

Amount of underpayment transferred from deceased beneficiary to spouse

Fill-in (3)

 

Choice 1

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) of deceased beneficiary (if Beneficiary Identification Code (BIC) is A)

Choice 2

your spouse

Choice 3

his spouse

Choice 4

her spouse

Choice 5

NOT USED BY T2R

Name of deceased beneficiary (non-possessive)

Fill-in (4)

 

Choice 1

you

Choice 2

he

Choice 3

she

C. AET Universal Text Identifier – Annual Earnings Test

AETC02 – CAPTION

You May Be Due More Benefits

AETC06 – CAPTION

What We Will Do

AETC07 – CAPTION

The Yearly Earnings Limit

AETC08 – CAPTION

A Special Rule That Applies To Earnings In One Year

AETC09 – CAPTION

If Your Expected Earnings Change

AETC10 – CAPTION

If You Work For Wages

AETC11 – CAPTION

If You Are Self-Employed

AETC12 – CAPTION

If You Work For Wages and Are Self-Employed

AETC14 – CAPTION

How We Calculate Earnings

If You Work For Wages and Are Self-Employed

AETH01 – HEADER

How Work Affects Your Social Security

AETH02 – HEADER

How To Estimate Earnings

AET036 – INFORMATIONAL PARAGRAPH TO THE BENEFICIARY ABOUT HOW EARNINGS HAVE AFFECTED HIS OR HER SOCIAL SECURITY BENEFITS

Please read the rest of this letter carefully. In it, we explain the changes we are making to (1) benefits. We also tell you how (2) earnings have affected (3) benefits and what to do if you disagree with any of our decisions.

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

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

Fill-in (2)

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

AET037 – REFER TO WORKSHEET HEADER NL 00730.149D

AET038 – PROVIDES THE LAST MONTHLY EARNINGS TEST YEAR’S INCOME LIMITS AND THE BENEFICIARY'S NON-SERVICE MONTHS FOR THE LAST MONTHLY EARNINGS TEST YEAR

In addition, you told us that (1) did not (2) more than (3) a month and did not work over 45 hours a month in self-employment (4) (5).

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

you

Fill-in (2)

 

Choice 1

expect to earn

Choice 2

earn

Fill-in (3)

 

Choice 1

Full Retirement Age (FRA) year exempt amount divided by 12 in the format $$$$$.¢¢

EXAMPLE:

If the FRA year = 2012, then the exempt amount = $38, 880. Divide the exempt amount by 12.

$38,880 12 = 3240

(show this amount in Fill-in (3))

Choice 2

Pre-Full Retirement Age (FRA) year exempt amount divided by 12 in the format $$$$$.¢¢

EXAMPLE:

If the PRE-FRA year = 2012 and the exempt amount = $14,640,

Divide $14,640 12 =1220 (show this amount in Choice 2)

Fill-in (4)

 

Choice 1

from

Choice 2

in

Choice 3

through

Fill-in (5)

 

Choice 1

First non-service month

Choice 2

and

Choice 3

comma (,)

AET039 – INTRODUCTORY PARAGRAPH FOR THE BENEFICIARY ABOUT THE ANNUAL EARNINGS LIMIT FOR SPECIFIC YEARS

The earnings limit for (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11). If (12) over the allowed amount for the year, we withhold $1 in benefits for every (13) (14) above the limit. We have enclosed a worksheet to show how we applied the earnings limit to (15) earnings to figure (16) benefits.

For more information about the earnings limit, see the enclosed fact sheet called, "How Work Affects Your Social Security."

Fill-in values:

 

Fill-in (1)

 

Choice 1

CCYY plus ”is”

Fill-in (2)

 

Choice 1

Annual Earnings Test (AET) amount for this Year of Earnings Report (YOER) in the format $$$$$$.¢¢

Fill-in (3)

 

Choice 1

and for

Choice 2

comma (,)

Choice 3

Null

Fill-in (4)

 

Choice 1

CCYY plus ”is”

Choice 2

Null

Fill-in (5)

 

Choice 1

Annual Earnings Test (AET) amount for this Year of Earnings Report (YOER) in the format $$$$$$.¢¢

Choice 2

Null

Fill-in (6)

 

Choice 1

and for

Choice 2

comma (,)

Choice 3

Null

Fill-in (7)

 

Choice 1

CCYY plus ”is”

Choice 2

Null

Fill-in (8)

 

Choice 1

Annual Earnings Test (AET) amount for this Year of Earnings Report (YOER) in the format $$$$$$.¢¢

Choice 2

Null

Fill-in (9)

 

Choice 1

and for

Choice 2

Null

Fill-in (10)

 

Choice 1

CCYY plus ”is”

Choice 2

Null

Fill-in (11)

 

Choice 1

Annual Earnings Test (AET) amount for this Year of Earnings Report (YOER) in the format $$$$$$.¢¢

Choice 2

Null

Fill-in (12)

 

Choice 1

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) plus “works and earns”

Choice 2

“you” plus “work and earn”

Fill-in (13)

 

Choice 1

$2

Choice 2

$3

Choice 3

$2 or $3

Fill-in (14)

 

Choice 1

he earns

Choice 2

she earns

Choice 3

you earn

Fill-in (15)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (16)

 

Choice 1

his

Choice 2

her

Choice 3

your

AET040 – PARAGRAPH TO A NON-RESPONDER (NRP) WITH A MID-YEAR MAILER INDICATOR ON THE MASTER BENEFICIARY RECORD (MBR) EXPLAINING THAT SINCE HE OR SHE DID NOT PROVIDE AN ESTIMATE OF EARNINGS FOR THE CURRENT YEAR, WE WILL USE LAST YEAR'S EARNINGS AS THE CURRENT YEAR ESTIMATE

Earlier we asked you to estimate (1) earnings for (2). We need this estimate to decide how much Social Security benefits to pay (3) for (4). We have not heard from you. Unless you contact us with a new estimate, we will use the same estimate we used in (5) to decide (6) benefits for (7).

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

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

Fill-in (2)

Current Operating Year (COY) in the format CCYY

Fill-in (3)

 

Choice 1

you

Choice 2

him

Choice 3

her

Fill-in (4)

Current Operating Year (COY) in the format CCYY

Fill-in (5)

Current Operating Year (COY) – 1 (the last year for which we have an estimate) in the format CCYY

Fill-in (6)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (7)

Current Operating Year (COY) in the format CCYY

AET041 – PARAGRAPH TO A NON-RESPONDER (NRP) WITH NO MID-YEAR MAILER INDICATOR ON THE MASTER BENEFICIARY RECORD (MBR) EXPLAINING THAT SINCE HE OR SHE DID NOT PROVIDE AN ESTIMATE OF EARNINGS FOR THE CURRENT YEAR. WE WILL USE LAST YEAR’S EARNINGS AS THE CURRENT YEAR ESTIMATE.

We base the amount of Social Security benefits (1) due on (2) estimated earnings. In (3), (4) earnings estimate was (5). Unless you contact us with a new estimate, we will use that same estimate to decide (6) benefits for (7).

Fill-in values:

 

Fill-in (1)

 

Choice 1

you are

Choice 2

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

Fill-in (2)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (3)

Current Operating Year (COY) – 1 (the last year for which we have an estimate in the format CCYY

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (5)

Post-MBR Amount of Reported Earnings (AORE) from the last estimate in the format $$$$$¢¢

Fill-in (6)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (7)

Current Year in the format CCYY

AET042 – PARAGRAPH TO A WORKING BENEFICIARY THAT SINCE HE OR SHE DID NOT PROVIDE AN ESTIMATE OF EARNINGS FOR THE CURRENT YEAR, WE WILL USE THE EARNINGS REPORTED BY HIS OR HER EMPLOYER LAST YEAR AS THE CURRENT YEAR ESTIMATE.

In (1), we based the amount of (2) Social Security benefits on earnings of (3) that (4) employer reported. We will use the same amount of earnings to decide (5) benefits in (6). That is, unless you contact us with a new estimate of (7) expected earnings for (8).

Fill-in values:

 

Fill-in (1)

Current Operating Year (COY) – 1 in the format CCYY

Fill-in (2)

 

Choice 1

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

Choice 2

your

Fill-in (3)

Post-MBR Amount of Reported Earnings (AORE) in the format $$$$$.¢¢

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (6)

Current Operating Year (COY) in the format CCYY

Fill-in (7)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (8)

Current Operating Year (COY) in the format CCYY

AET043 – REQUEST TO BENEFICIARY ASKING THEM TO NOTIFY SOCIAL SECURITY ADMINISTRATION IF HIS OR HER WORK ESTIMATE IS NOT CORRECT

(1) work plans may have changed and we want to make sure that we are paying (2) correctly. So, please check (3), and let us know right away if you think (4) will earn more or less than (5) in (6).

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

Your

Fill-in (2)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (3)

 

Choice 1

his estimate

Choice 2

her estimate

Choice 3

your estimate

Choice 4

his expected earnings

Choice 5

her expected earnings

Choice 6

your expected earnings

Fill-in (4)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (5)

Amount of Reported Earnings (AORE) in the format $$$$$.¢¢

Fill-in (6)

The Year of Earnings Report (YOER) in the format CCYY

AET044 – EXPLAINS TO A DIVORCED AUXILIARY SPOUSE THAT A FORMER SPOUSE'S WORK NO LONGER AFFECTS BENEFITS

(1) told us (2) divorce was final in (3). Once (4) been divorced for 2 years, (5) former spouse’s work no longer affects (6) benefits. Therefore, beginning (7), we will no longer withhold or reduce (8) benefits because of (9) former spouse's work.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

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

Fill-in (2)

 

Choice 1

your

Choice 2

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

Choice 3

his

Choice 4

her

Fill-in (3)

Marriage End Date (MARR-END-REL-D)

Fill-in (4)

 

Choice 1

you have

Choice 2

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

Choice 3

he has

Choice 4

she has

Fill-in (5)

 

Choice 1

your

Choice 2

his

Choice 3

her

Choice 4

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

Fill-in (6)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (7)

Effective date of change in the format Month CCYY

Fill-in (8)

 

Choice 1

your

Choice 2

his

Choice 3

her

Choice 4

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

Fill-in (9)

 

Choice 1

your

Choice 2

his

Choice 3

her

AET045 – REFER TO WORKSHEET HEADER NL 00730.149A

AET046 – REFER TO WORKSHEET HEADER NL 00730.149A

AET047 – REFER TO WORKSHEET HEADER NL 00730.149A

AET048 – REFER TO WORKSHEET HEADER NL 00730.149B

AET049 – REFER TO WORKSHEET HEADER NL 00730.149B

AET050 – REFER TO WORKSHEET HEADER NL 00730.149B

AET051 – REFER TO WORKSHEET HEADER NL 00730.149D

AET052 – REFER TO WORKSHEET HEADER NL 00730.149D

D. AGE Universal Text Identifier – Age

AGE002 – EXPLANATION OF FULL RETIREMENT AGE (FRA) ATTAINMENT WHEN BORN ON THE FIRST DAY OF THE MONTH

Because (1) born on the first day of the month, we consider (2) (3) the month before.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

you were

Fill-in (2)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (3)

 

Choice 1

Null

Choice 2

to have reached full retirement age

E. ALS Universal Text Identifiers – Appeals

ALSC04 – CAPTION

If You Disagree With The Decision

ALSC06 – CAPTION

Do You Think We Are Wrong About The Overpayment

ALS017 – APPEALS LANGUAGE FOR MONTHLY BENEFIT PAYABLE (MBP) CHANGE DUE TO A THIRD-PARTY ACTION

If you disagree with the change we have made to (1) monthly payment, you have the right to appeal. We will review your case and look at any new facts you have. A person who did not make the first decision will decide your case.

  • You have 60 days to ask for an appeal.

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

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

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

ALS020 – GENERAL APPEALS LANGUAGE

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

  • You have 60 days to ask for an appeal in writing.

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

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

  • You must ask for an appeal in writing. Please use our "Request for Reconsideration" form, SSA-561-U2. You may go to our website at (1) to locate the form. You can also contact us to request the form, or if you need help filling out the form.

Fill-in values:

 

Fill-in (1)

www.ssa.gov/forms/

ALS100 – PAYMENTS WILL CONTINUE WHILE THE APPEAL OF MEDICAL CESSATION IS PENDING

(1) entitled to have (2) payments continued until we notify (3) of the appeal decision made on (4) case. If (5)(6) appeal, (7) may have to pay some, or all, of this money back unless we are able to waive repayment.

Fill-in values:

 

Fill-in (1)

 

Choice 1

You are

Choice 2

Disabled Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) plus "is"

Fill-in (2)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (3)

 

Choice 1 you
Choice 2 him
Choice 3 her

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (5)

 

Choice 1

you lose

Choice 2

he loses

Choice 3

she loses

Fill-in (6)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (7)

 

Choice 1

you

Choice 2

he

Choice 3

she

F. ANP Universal Text Identifier – Outside the U.S.

ANP003 – BENEFICIARY OUTSIDE U.S. (Pub-05-10137)

Please read the enclosed pamphlet, “Social Security: Your Payments While You Are Outside the United States.” It explains what (1) will need to do to start receiving payments again.

Fill-in values:

 

Fill-in (1)

 

Choice 1

“Mr.” plus Beneficiary’s Last Name (BLN)

Choice 2

“Ms.” plus Beneficiary’s Last Name (BLN)

Choice 3

you

G. AST Universal Text Identifier – Equitable relief

ASTC02 – CAPTION

Information About (1) Installment Payment

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

Your

H. ATY Universal Text Identifiers – Representative Fee

ATYC01 – CAPTION

Information About Representatives Fees

ATYC03 – CAPTION

Information About Past-Due Benefits Withheld To Pay A Representative

ATY067 – SUPPLEMENTAL SECURITY INCOME OFFSET HAS BEEN DETERMINED – PAST DUE BENEFITS BEING RELEASED TO BENEFICIARY AND REPRESENTATIVE HAS NOT REGISTERED FOR DIRECT PAYMENT

If a representative, who is a (1), registers with us to receive direct fee payment, because of the law we usually withhold part of the past-due benefits to pay the fee we approve. Although (2) representative is a (3), he or she did not register for direct payment before we completed our work on (4) claim. For that reason, we did not withhold from (5) past-due benefits to pay the fee we approve. Therefore, the Social Security Administration is not involved in paying the fee. This is a matter between (6) and (7) (8).

Fill-in values:

 

Fill-in (1)

 

Choice 1

lawyer

Choice 2

participant in the non-attorney direct payment demonstration project

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

lawyer

Choice 2

participant in the demonstration project

Fill-in (4)

 

Choice 1

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

Choice 2

your

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (6)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (7)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (8)

 

Choice 1

lawyer

Choice 2

representative

ATY836 – EXPLANATION TO THE BENEFICIARY ABOUT THE WITHHOLDING OF REPRESENTATIVE FEES FROM PAST-DUE BENEFITS

Based on the law, we must withhold part of past-due benefits to pay an appointed representative. We cannot withhold more than 25 percent of past-due benefits to pay an authorized fee. We withheld (1) from (2) past-due benefits to pay (3) representative.

Fill-in values:

 

Fill-in (1)

Attorney fee amount in the format $$$$$$.¢¢

Fill-in (2)

 

Choice 1

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

Choice 2

your

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

 

NL 00730.116 “H” Paragraphs and Captions

A. List of “H” paragraphs and captions

HBN001 – AUTOMATED CMS BILLING NOTICE USED WITH HIB225

(appears after the signature page of the notice)

NOTICE OF MEDICARE PREMIUM PAYMENT DUE

CENTERS FOR MEDICARE & MEDICAID SERVICES

BILLING DATE: (1)

MEDICAL PREMIUMS FOR

PERIOD ENDING: (2)

CURRENT AMOUNT DUE: (3)

PAYMENT DUE BY: (4)

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

  • You must pay by check or money order. Include your Medicare number at the top of your check or money order. Make the check or money order payable to: CMS MEDICARE INSURANCE.

  • If you have changed your address, be sure to write your new address in the space provided below.

 

PLEASE DETACH AT DOTTED LINE

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

CMS-500A

 

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

Name: (7)

( ) Check here if your Make Checks Payable To:

address has changed. CMS MEDICARE INSURANCE

Show new address below.

Send To:

Medicare Premium Collection Center
P.O. Box 790355
St. Louis, MO 63179-0355

 

Fill-in values:

 

Fill-in (1)

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

Fill-in (2)

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

Fill-in (3)

SMI premiums due

Fill-in (4)

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

Fill-in (5)

Medicare Beneficiary Identification (MBI) Number

Fill-in (6)

SMI premiums due

Fill-in (7)

BGN plus BLN (not possessive)

B. “HDR” - Headings

HDR030 - DATE AND BENEFICIARY NOTICE CONTROL NUMBER

Fill-in values:

 

Fill-in (1)

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

Fill-in (2)

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

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

HIBC01 – CAPTION

Information About Medicare

HIBC02 – CAPTION

Health Insurance For Children

HIBC05 – CAPTION

Why (1) Cannot Quality For Medicare

Fill-in values:

 

Fill-in (1)

show the BGN plus BLN (not possessive)

 

HIBC14 – CAPTION

How to Apply for Immunosuppressive Drug Coverage

HIBC15 – CAPTION

To Cancel This Insurance

HIBC16 – CAPTION

If You Need Coverage for Immunosuppressive Drugs Only

HIBC18 – CAPTION

If You Need Help With Costs for the Immunosuppressive Drug Coverage

HIBC19 – CAPTION

Notice of Group Billing

HIBC20 – CAPTION

Apply for Medicare

HIBC21 – CAPTION

If You Need Health Coverage through Marketplace or Medicaid

HIB001 – ENTITLED TO HI AND/OR SMI

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

Your

Choice 2

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

Fill-in (2)

 

Choice 1

Part A (hospital insurance) starts

Choice 2

Part B (medical insurance) starts

Choice 3

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

Fill-in (3)

Date in format Month CCYY

Fill-in (4)

 

Choice 1

and Part B (medical insurance) starts

Choice 2

Null

Fill-in (5)

 

Choice 1

Date in format Month CCYY

Choice 2

Null

HIB002 - TEMPORARY SUBSTITUTION OF NOTICE FOR HEALTH INSURANCE CARD

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

BGN plus BLN (not possessive)

Fill-in (2)

 

Choice 1

You should

Choice 2

He should

Choice 3

She should

Fill-in (3)

 

Choice 1

you need

Choice 2

he needs

Choice 3

she needs

Fill-in (4 )

 

Choice 1

you have

Choice 2

he has

Choice 3

she has

Fill-in (5)

 

Choice 1

your

Choice 2

his

Choice 3

her

HIB005 – SMI PREMIUM BILLING

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

Your

Choice 2

His

Choice 3

Her

Fill-in (2)

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

Fill-in (3)

Date in MMCCYY format

Fill-in (4)

 

Choice 1

null

Choice 2

and

Fill-in (5)

 

Choice 1

null

Choice 2

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

HIB008 – SMI PREMIUM DEDUCTIONS

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (2)

 

Choice 1

next

Choice 2

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

HIB011 – HI PREMIUM BILLING

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (2)

Show the current HI premium rate in the format 999.99

Fill-in (3)

 

Choice 1

this premium

Choice 2

the combined premium for hospital and medical insurance

HIB013 – MEDICARE HI/SMI PREMIUM PENALTY

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

This medical insurance premium includes

Choice 2

This hospital insurance premium includes

Choice 3

These hospital and medical insurance premiums include

Fill-in (2)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

HIB015 – PREMIUMS DEDUCTED FROM CIVIL SERVICE ANNUITY

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (2)

 

Choice 1

him

Choice 2

her

Choice 3

you

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

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

Leave Blank

Choice 2

The State of

Fill-in (2)

show State name

Fill-in (3)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (4)

Show the TP START DATE in the format MMCCYY

Fill-in (5)

 

Choice 1

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

Choice 2

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

Choice 3

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

Choice 4

Null

Fill-in (6)

 

Choice 1

Leave Blank

Choice 2

The State of

Fill-in (7)

show State name

Fill-in (8)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (9)

Show the TP START date in the format MMCCYY

Fill-in (10)

 

Choice 1

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

Choice 2

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

Choice 3

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

Choice 4

Null

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

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

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

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

Leave Blank

Choice 2

The State of

Fill-in (2)

Show State name

Fill-in (3)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (4)

Show TP STOP date in the format MMCCYY

Fill-in (5)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (6)

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

Fill-in (7)

 

Choice 1

Leave Blank

Choice 2

The State of

Fill-in (8)

Show State name

Fill-in (9)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (10)

Show the TP STOP date in the format MMCCYY

Fill-in (5)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (12)

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

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

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

Leave Blank

Choice 2

The State of

Fill-in (2)

Show the State name

Fill-in (3)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (4)

 

Choice 1

MMCCYY

Choice 2

MMCCYY and MMCCYY

Choice 3

MMCCYY through MMCCYY

Fill-in (5)

 

Choice 1

Leave Blank

Choice 2

The State of

Fill-in (6)

Show the State name

Fill-in (7)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (8)

 

Choice 1

MMCCYY

Choice 2

MMCCYY and MMCCYY

Choice 3

MMCCYY through MMCCYY

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

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (2)

MMCCYY

Fill-in (3)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (4)

MMCCYY

Fill-in (5)

 

Choice 1

BGN plus BLN possessive

Choice 2

your

Fill-in (6)

MMCCYY

Fill-in (7)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (8)

MMCCYY

HIB034 –ADVISE THAT SMI DEDUCTION WILL START/CONTINUE

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

Fill-in values:

 

Fill-in (1)

 

Choice 1 start
Choice 2 continue

Fill-in (2)

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

Fill-in (3)

 

Choice 1

your

Choice 2

BGN plus BLN (possessive)

HIB038 – MEDICARE DISALLOWANCE CRIME AGAINST UNITED STATES

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (2)

 

Choice 1

he has

Choice 2

she has

Choice 3

you have

HIB042 – MEDICARE DISALLOWANCE FEHB ACT OF 1959

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (2)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Choice 4

he could be

Choice 5

she could be

Choice 6

you could be

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

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

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

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

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

Beneficiary Full Name plus the word “is”

Choice 2

You are

Fill-in (2)

 

Choice 1

medical

Choice 2

hospital

Choice 3

hospital and medical

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

he

Choice 2

she

Choice 3

you

HIB054 – HI AND/OR SMI PERIOD NOT PREVIOUSLY COVERED

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN the word “has”

Choice 2

Beneficiary First Name plus the word “has”

Choice 3

you have

Fill-in (2)

 

Choice 1

he believes

Choice 2

she believes

Choice 3

you believe

Fill-in (3)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

HIB060 – SUSPENSE FOR PRISON/MENTAL ADVISES OF SMI PREMIUMS

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

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

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN plus the word “receives”

Choice 2

you receive

Fill-in (2)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (3)

 

Choice 1

imprisoned

Choice 2

confined in an institution

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (6)

 

Choice 1

prison

Choice 2

the institution

Fill-in (7)

 

Choice 1

BGN plus BLN

Choice 2

You

Fill-in (8)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (9)

 

Choice 1

prison

Choice 2

the institution

Fill-in (10)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (11)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB061 – SMI PREMIUM CONTINUES DEDUCTION FROM CS ANNUITY

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

Beneficiary Full Name (possessive)

Choice 2

your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB066 – HI/SMI PREMIUMS ALREADY PAID

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

medical

Choice 2

hospital

Choice 3

hospital and medical

Fill-in (2)

 

Choice 1

BGN plus BLN plus “has”

Choice 2

BGN plus “has”

Choice 3

you have

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB067 – SMI PREMIUM BILLING

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB068 – HI/SMI EQUITABLE RELIEF

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

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

(13)

Fill-in values:

 

Fill-in (1)

 

Choice 1

he wants

Choice 2

she wants

Choice 3

you want

Fill-in (2)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (3)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (4)

 

Choice 1

Show the HI-NONEQRELST date in MMCCYY

Choice 2

Show the SMI-NONEQRELST date in MMCCYY

Fill-in (5)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (6)

 

Choice 1

he wants

Choice 2

she wants

Choice 3

you want

Fill-in (7)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (8)

 

Choice 1

Show the HI-NONEQRELST date in MMCCYY

Choice 2

Show the SMI-NONEQRELST date in MMCCYY

Fill-in (9)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (10)

 

Choice 1

Show the total amount for HI premiums calculated

Choice 2

Show the total amount for SMI premiums calculated

Choice 3

Show the combined total amount for HI and SMI premiums calculated

Fill-in (11)

 

Choice 1

Show the HI-NONEQRELST date in MMCCYY

Choice 2

Show the SMI-NONEQRELST date in MMCCYY

Fill-in (12)

Show the COM month in MMCCYY

Fill-in (13)

 

Choice 1

tell us we can withhold this amount from the check.

Choice 2

tell us to bill you for this amount.

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

Your

Fill-in (2)

 

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

Fill-in (3)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (6)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (7)

 

Choice 1

is

Choice 2

was

Fill-in (8)

 

Choice 1

Show the HI TERM date minus 1 month in MMCCYY

Choice 2

Show the SMI TERM date minus 1 month in MMCCYY

Fill-in (9)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (10)

 

Choice 1

he receives

Choice 2

she receives

Choice 3

you receive

Fill-in (11)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB070 – PREMIUM HI DWI CONTINUES SMI TERMINATES NON-PAYMENT

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (2)

 

Choice 1

medical

Choice 2

hospital

Fill-in (3)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (4)

 

Choice 1

medical

Choice 2

hospital

HIB071 – RRB JURIS STARTS AND COLLECTS MEDICARE PREMIUMS

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

HIB072 – RRB JURIS STARTS AND COLLECTS MEDICARE PREMIUMS

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN

Choice 2

You

Fill-in (2)

 

Choice 1

is

Choice 2

are

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (6)

 

Choice 1

him

Choice 2

her

Choice 3

you

HIB073 – RRB SENDS NEW MEDICARE CARD

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

Your

Fill-in (2)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB074 – NEW MEDICARE CARD

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (not possessive)

Choice 2

BGN (not possessive)

Choice 3

you

Fill-in (2)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (3)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

HIB075 – EQUITABLE RELIEF/HARDSHIP

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

he wants

Choice 2

she wants

Choice 3

you want

Fill-in (2)

 

Choice 1

Show the HI NONEQRELST date in MMCCYY

Choice 2

Show the SMI NONEQRELST date in MMCCYY

Fill-in (3)

 

Choice 1

find

Choice 2

finds

HIB076 – HI/SMI TERMINATION INFORMATIONAL

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

you do

Choice 2

he does

Choice 3

she does

Fill-in (2)

 

Choice 1

you are

Choice 2

he is

Choice 3

she is

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

you have

Choice 2

he has

Choice 3

she has

Fill-in (5)

 

Choice 1

Your

Choice 2

His

Choice 3

Her

Fill-in (6)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (7)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (8)

 

Choice 1

you sign

Choice 2

he signs

Choice 3

she signs

Fill-in (9)

 

Choice 1

you want

Choice 2

BGN plus BLN plus “wants”

Fill-in (10)

 

Choice 1

Part A

Choice 2

Part B

Choice 3

Part A and Part B

Fill-in (11)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (12)

 

Choice 1

you sign

Choice 2

he signs

Choice 3

she signs

Fill-in (13)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (14)

 

Choice 1

you enroll

Choice 2

he enrolls

Choice 3

she enrolls

HIB077 – SMI TERMINATION INFORMATIONAL

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

you do

Choice 2

he does

Choice 3

she does

Fill-in (2)

 

Choice 1

you are

Choice 2

he is

Choice 3

she is

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

you have

Choice 2

he has

Choice 3

she has

Fill-in (5)

 

Choice 1

Your

Choice 2

His

Choice 3

Her

Fill-in (6)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (7)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (8)

 

Choice 1

you sign

Choice 2

he signs

Choice 3

she signs

HIB078 – HI TERMINATION INFORMATIONAL

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

His

Choice 2

Her

Choice 3

Your

Fill-in (2)

 

Choice 1

he re-enrolls

Choice 2

she re-enrolls

Choice 3

you re-enroll

HIB079 – VOLUNTARY TERMINATION FOR PREMIUM HI OR SMI

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN plus the word “is”

Choice 2

BGN plus the word “is”

Choice 3

you are

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

medical

Choice 2

hospital

Fill-in (4)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (5)

 

Choice 1

hospital

Choice 2

medical

Fill-in (6)

 

Choice 1

His

Choice 2

Her

Choice 3

Your

Fill-in (7)

Show the HI TERM date minus 1 month in MMCCYY format

HIB080 – VOLUNTARY SMI TERMINATION CIVIL SERVICE INVOLVED

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

BGN (possessive)

Choice 3

your

Fill-in (2)

 

Choice 1

him

Choice 2

her

Choice 3

you

HIB082 – HI AND/OR SMI VOLUNTARY TERMINATION

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN

Choice 2

You

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (4)

 

Choice 1

Show the HI TERM date minus 1 month in MMCCYY format

Choice 2

Show the SMI TERM date minus 1 month in MMCCYY format

HIB083 – SPECIAL ENROLLMENT PERIOD DISABILITY

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

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

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (not possessive)

Choice 2

BGN (not possessive)

Choice 3

You

Fill-in (2)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

meets

Choice 2

meet

Fill-in (5)

 

Choice 1

He is

Choice 2

She is

Choice 3

You are

Fill-in (6)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (7)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (8)

 

Choice 1

He is

Choice 2

She is

Choice 3

You are

Fill-in (9)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (10)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (11)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (12)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (13)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (14)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (15)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (16)

 

Choice 1

he has

Choice 2

she has

Choice 3

you have

HIB084 – SPECIAL ENROLLMENT PERIOD AGED

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

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

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (not possessive)

Choice 2

BGN (not possessive)

Choice 3

You

Fill-in (2)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (3)

 

Choice 1

he meets

Choice 2

she meets

Choice 3

you meet

Fill-in (4)

 

Choice 1

His

Choice 2

Her

Choice 3

Your

Fill-in (5)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (6)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (7)

 

Choice 1

He has

Choice 2

She has

Choice 3

You have

Fill-in (8)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (9)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (10)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (11)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (12)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (13)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB085 – VOLUNTARY SMI TERMINATION CURRENT PAY

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

BGN (possessive)

Choice 3

your

HIB086 – VOLUNTARY HI/SMI TERMINATION PREMIUMS DUE

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (not possessive)

Choice 2

You

Fill-in (2)

 

Choice 1

owes

Choice 2

owe

Fill-in (3)

Show total past due amount in $999,999.99 format

Fill-in (4)

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

Fill-in (5)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (6)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (7)

 

Choice 1

your

Choice 2

his

Choice 3

her

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

(1) (2) coverage will continue.

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

Your

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

Choice 3

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

HIB088 – HI/SMI FOREIGN ADDRESS

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (2)

 

Choice 1

BGN plus BLN (not possessive)

Choice 2

BGN (not possessive)

Choice 3

you

Fill-in (3)

 

Choice 1

receives

Choice 2

receive

Fill-in (4)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (5)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (6)

 

Choice 1

he returns

Choice 2

she returns

Choice 3

you return

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN plus the word “is”

Choice 2

you are

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

hospital

Choice 2

hospital and medical

Fill-in (4)

Show HI-TERM date in MMCCYY format

Fill-in (5)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

HIB090 – TERMINATION ALL MEDICARE COVERAGE

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

Your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

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

Choice 2

Medicare Part B (medical insurance)

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB092 – STATE/LOCAL GOVT CONTINUES TO PAY SMI PREMIUM

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

Your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

He

Choice 2

She

Choice 3

You

HIB093 – STATE OR GROUP CONTINUES TO PAY SMI PREMIUMS

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

the State

Choice 2

an organization

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

hospital and medical

Choice 2

medical

HIB101 – MEDICARE STATE BUY-IN

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

Leave blank

Choice 2

The State of

Fill-in (2)

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

Fill-in (3)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (4)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (5)

TP START date in MMCCYY format

Fill-in (6)

 

Choice 1

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

Choice 2

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

Choice 3

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

Choice 4

NULL

HIB102 – STATE BUY-OUT

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

Leave blank

Choice 2

The State of

Fill-in (2)

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

Fill-in (3)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (4)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (5)

Show the TP STOP date in MMCCYY format

Fill-in (6)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (7)

Show the TP STOP date plus 1 month in MMCCYY format

HIB103 – LIMITED BUY-IN AND BUY-OUT

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

Leave blank

Choice 2

The State of

Fill-in (2)

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

Fill-in (3)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (4)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (5)

 

Choice 1

MMCCYY

Choice 2

MMCCYY and MMCCYY

Choice 3

MMCCYY through MMCCYY

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

he currently has

Choice 2

she currently has

Choice 3

you currently have

Choice 4

he does not currently have

Choice 5

she does not currently have

Choice 6

you do not currently have

Fill-in (2)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

HIB105 – RETRO BUYIN/BUYOUT PAST DUE PREMIUMS

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

he still owes

Choice 2

she still owes

Choice 3

you still owe

Fill-in (2)

MMCCYY

HIB106 – STATE BUYIN FOR SMI PREMIUM PENALTY ONLY

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (2)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

His

Choice 2

Her

Choice 3

Your

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (6)

MM/YYYY

Fill-in (7)

 

Choice 1

he

Choice 2

she

Choice 3

you

HIB107 – STATE STOPS PAYING SMI PREMIUM PENALTY

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

Your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

show date in MMCCYY format

Fill-in (5)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (6)

show date in MMCCYY format

HIB108 – GROUP PAYER BUY-OUT

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (2)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (3)

show date in MMCCYY format

Fill-in (4)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (5)

Show date in MMCCYY format

HIB109 – 3RD Party SMI PREMIUM DEDUCTED FROM MBA

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

Fill-in values:

 

Fill-in (1)

Medicare medical insurance premium

Fill-in (2)

SMI premium amount in $9999.99 format

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (5)

 

Choice 1

he disagrees

Choice 2

she disagrees

Choice 3

you disagree

Fill-in (6)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB110 – SMI PREMIUM DEDUCTED FROM MBA PAST DUE PREMIUMS

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

Fill-in values:

 

Fill-in (1)

Medicare medical insurance premium

Fill-in (2)

SMI premium amount in $9999.99 format

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

premium amount due in 99999.99 format

Fill-in (5)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (6)

 

Choice 1

he disagrees

Choice 2

she disagrees

Choice 3

you disagree

Fill-in (7)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB111 – BUY-IN AND REFUND OF MEDICARE PREMIUMS

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (2)

 

Choice 1

he

Choice 2

she

Choice 3

you

HIB112 – BUYIN PREMIUM NO LONGER DEDUCTED FROM MBA

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (2)

 

Choice 1

you

Fill-in (3)

 

Choice 1

you disagree

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB113 – BUY-OUT NOT IN PAY STATUS PREMIUM BILLING

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

BGN (possessive)

Choice 3

your

Fill-in (2)

 

Choice 1

Medicare hospital insurance premium

Choice 2

Medicare medical insurance premium

Choice 3

Medicare hospital and medical insurance premiums

Fill-in (3)

 

Choice 1

premium is

Choice 2

premiums total

Fill-in (4)

money amount in format 999,999.99

Fill-in (5)

 

Choice 1

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

Choice 2

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

Choice 3

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

Choice 4

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

Fill-in (6)

 

Choice 1

he does

Choice 2

she does

Choice 3

you do

HIB114 – BENEFITS TERM PROFRA MEDICARE CONTINUES

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

Your

Fill-in (2)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

HIB115 – HI/SMI BUY-OUT

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

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

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN plus “wants”

Choice 2

you want

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

he cancels

Choice 2

she cancels

Choice 3

you cancel

Fill-in (4)

 

Choice 1

he cancels

Choice 2

she cancels

Choice 3

you cancel

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (6)

 

Choice 1

he cancels

Choice 2

she cancels

Choice 3

you cancel

Fill-in (7)

 

Choice 1

he contacts

Choice 2

she contacts

Choice 3

you contact

Fill-in (8)

 

Choice 1

he waits

Choice 2

she waits

Choice 3

you wait

Fill-in (9)

 

Choice 1

he contacts

Choice 2

she contacts

Choice 3

you contact

HIB119 – BILLING TO CONFIRM GROUP PAYER

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

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN

Choice 2

You

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (4)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (5)

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (6)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (7)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (8)

 

Choice 1

him

Choice 2

her

Choice 3

you

HIB120 – BUY-OUT FOR HI AND SMI

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (2)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (3)

 

Choice 1

he cancels

Choice 2

she cancels

Choice 3

you cancel

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Choice 4

he has

Choice 5

she has

Choice 6

you have

Fill-in (2)

 

Choice 1

disabled

Choice 2

over age 65

Choice 3

end stage renal disease

HIB132 – ESRD TERMINATES AND RRB JURISDICTION

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB133 – ESRD TERMINATION - SAME HI/SMI TERMINATION DATES

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (not possessive)

Choice 2

you

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

Show HI-TERM date minus 1 month in MMCCYY format

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (not possessive)

Choice 2

you

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

Show HI-TERM date minus 1 month in MMCCYY format

Fill-in (4)

 

Choice 1

His

Choice 2

Her

Choice 3

Your

Fill-in (5)

Show SMI-TERM date minus 1 month in MMCCYY format

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

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

  • (4) regular dialysis, or

  • (5) a kidney transplant

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

12th

Choice 2

36th

Fill-in (2)

 

Choice 1

he gets a transplant

Choice 2

she gets a transplant

Choice 3

you get a transplant

Choice 4

regular dialysis stops

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

begins

Choice 2

begin

Fill-in (5)

 

Choice 1

gets

Choice 2

get

Fill-in (6)

 

Choice 1

he got a kidney transplant

Choice 2

she got a kidney transplant

Choice 3

you got a kidney transplant

Choice 4

his dialysis stopped

Choice 5

her dialysis stopped

Choice 6

your dialysis stops

Fill-in (7)

 

Choice 1

Show KDNY-TRNSDATE date in MMCCYY format

Choice 2

Show DLYS-STOP date in MMCCYY format

Fill-in (8)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (9)

Show HI-TERM date minus 1 month in format MMCCYY

Fill-in (10)

 

Choice 1

His

Choice 2

Her

Choice 3

Your

Fill-in (11)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB136 – TERMINATION OF ESRD COVERAGE

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

he resumes

Choice 2

she resumes

Choice 3

you resume

Fill-in (2)

 

Choice 1

gets

Choice 2

get

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB137 – ESRD TERMINATES SAME HI/SMI TERMINATION DATES

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

  • a kidney transplant, or

  • resume regular dialysis.

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

12th

Choice 2

36th

Fill-in (2)

 

Choice 1

regular dialysis stops

Choice 2

a kidney transplant

Fill-in (3)

 

Choice 1

he gets

Choice 2

she gets

Choice 3

you get

Fill-in (4)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (5)

 

Choice 1

stopped regular dialysis

Choice 2

received a kidney transplant

Fill-in (6)

 

Choice 1

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

Choice 2

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

HIB142 – CURRENT PAY TO SUSPENSE OR DEFERRED STATUS

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

HIB143 – SMI PENALTY RATE TO BASE RATE AT AGE 65

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (not possessive)

Choice 2

you

Fill-in (2)

 

Choice 1

qualifies

Choice 2

qualify

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

Show the SMI premium penalty rate

Fill-in (6)

Show the SMI premium base rate

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

You

Choice 2

He

Choice 3

She

Fill-in (2)

MMCCYY

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

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

The word 'Is' BGN plus BLN

Choice 2

Are you

Fill-in (2)

 

Choice 1

Is he

Choice 2

Is she

Choice 3

Are you

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

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

Fill-in values:

 

Fill-in (1)

www.insurekidsnow.gov

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (5)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (6)

 

Choice 1

he does

Choice 2

she does

Choice 3

you do

Fill-in (7)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (2)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (5)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (6)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (7)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (8)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

HIB162 – REFUSAL OVER AUTOMATIC ENROLLMENT

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (not possessive)

Choice 2

You

Fill-in (2)

 

Choice 1

he does

Choice 2

she does

Choice 3

you do

Fill-in (3)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

HIB163 – SMI REFUSAL CURRENT PAY REFUND OF PREMIUMS

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

You do

Choice 2

BGN plus BLN plus does

Fill-in (2)

 

Choice 1

you were

Choice 2

he was

Choice 3

she was

Fill-in (3)

 

Choice 1

you

Choice 2

him

Choice 3

her

HIB164 – SMI REFUSAL PREMIUM BILLING AND NO OPEN THIRD PARTY

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

he was

Choice 2

she was

Choice 3

you were

Fill-in (2)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (3)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (4)

 

Choice 1

he receives

Choice 2

she receives

Choice 3

you receive

Fill-in (5)

 

Choice 1

he

Choice 2

she

Choice 3

you

HIB165 – REFUSAL/WITHDRAWAL STATE BUY-IN ESTABLISHED

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

hospital

Choice 2

medical

Choice 3

hospital and medical

Fill-in (4)

 

Choice 1

he

Choice 2

she

Choice 3

you

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

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

(5)

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

you are

Fill-in (2)

 

Choice 1

you

Choice 2

he

Choice

she

Fill-in (3)

 

Choice 1

Part A (hospital insurance)

Choice 2

Part B (medical insurance)

Fill-in (4)

 

Choice 1

Please keep the Medicare card.

Choice 2

Null

Fill-in (5)

 

Choice 1

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

Choice 2

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

Choice 3

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

Choice 4

Null

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

you are

Fill-in (2)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (3)

 

Choice 1

Please keep the Medicare card.

Choice 2

Null

Fill-in (4)

 

Choice 1

you live

Choice 2

he lives

Choice 3

she lives

Fill-in (5)

 

Choice 1

your

Choice 2

his

Choice 3

her

HIB175 – SMI PREMIUMS/ARREARAGE DEDUCTED FROM PMA OR CMA

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

Fill-in values:

 

Fill-in (1)

 

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

Fill-in (2)

 

Choice 1

Beneficiary's full name (possessive)

Choice 2

your

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

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

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

  • the standard Part B premium amount,

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

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

BGN plus BLN (possessive)

Fill-in (2)

 

Choice 1

you have

Choice 2

she has

Choice 3

he has

Fill-in (3)

 

Choice 1

you

Choice 2

she

Choice 3

he

Fill-in (4)

 

Choice 1

your

Choice 2

her

Choice 3

his

Fill-in (5)

 

Choice 1

your

Choice 2

her

Choice 3

his

Fill-in (6)

 

Choice 1

your

Choice 2

her

Choice 3

his

Fill-in (7)

 

Choice 1

you pay your

Choice 2

he pays his

Choice 3

she pays her

HIB183 – USE WITH HIB182 WHEN IRMAA AFFECTS PART B RATE

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

Beneficiary's name (possessive)

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

Part B (Medical Insurance)

Choice 2

Part B Immunosuppressive Drug Coverage

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

using the PCI show the calendar date of the COM check

Choice 2

using the PCI show the calendar date of the DPD check

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB186 – SMI MATURITY AND NO IRMAA DATA ON POST MBR

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

Fill-in values:

 

Fill-in (1)

Show the IRMAA level 1 yearly amount for singles

Fill-in (2)

Show the IRMAA level 1 yearly amount for couples

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

he has

Choice 2

she has

Choice 3

you have

Fill-in (5)

show the SMI START date

HIB215 – T2 BENEFITS TERMINATE HI/SMI TERMINATES

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

hospital

Choice 2

hospital and medical

Fill-in (4)

 

Choice 1

His

Choice 2

Her

Choice 3

Your

Fill-in (5)

 

Choice 1

hospital

Choice 2

hospital and medical

Fill-in (6)

Show HI-TERM date in format MMCCYY

Fill-in (7)

 

Choice 1

his

Choice 2

her

Choice 3

your

HIB218 – REASON SMI PREMIUM/ARREARAGE IS BEING DEDUCTED

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (2)

 

Choice 1

Null

Choice 2

“through” plus date COM in Month CCYY format

HIB225 – HRFST LESSDO MBA LESS THAN SMI PREMIUM

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

Your

Fill-in (2)

Show the current SMI premium amount

Fill-in (3)

 

Choice 1

BGN plus BLN (not possessive)

Choice 2

you

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (6)

Show the first EFD in HIST Data that corresponds to LESSDO

Fill-in (7)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (8)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (9)

Show money amount for the remaining premiums

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (2)

Show the first EFD in HIST Data that corresponds to LESSDO

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

Show current SMI premium amount

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (6)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (7)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN plus the word “is”

Choice 2

you are

Fill-in (2)

he / she / you

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (3)

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

HIB249 – OFFER RELIEF FOR SMI PREMIUMS (VSMI RATES)

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

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

AND

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

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

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

Fill-in values:

 

Fill-in (1)

Show the SMI-NONEQRELST date

Fill-in (2)

Show the SMI-NONEQRELST date

Fill-in (3)

Show the total amount of the SMI premiums

Fill-in (4)

Show the SMI-NONEQRELST date

Fill-in (5)

Show the current operating month date

Fill-in (6)

Show the SMI-NONEQRELST date

Fill-in (7)

Show the current VSMI rate

Fill-in (8)

Show the current Part B premium rate

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

HIB261 – PREMIUM RELIEF ESTABLISHED DUE TO IRMAA B

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

Fill-in values:

 

Fill-in (1)

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

Fill-in (2)

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

Fill-in (3)

 

Choice 1

null

Choice 2

and

Choice 3

through

Fill-in (4)

 

Choice 1

Null

Choice 2

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

HIB262 – PREMIUM RELIEF ESTABLISHED DUE TO IRMAA D

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

Fill-in values:

 

Fill-in (1)

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

Fill-in (2)

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

Fill-in (3)

 

Choice 1

null

Choice 2

and

Choice 3

through

Fill-in (4)

 

Choice 1

Null

Choice 2

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

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

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

Fill-in values:

 

Fill-in (1)

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

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

he owes

Choice 2

she owes

Choice 3

you owe

Fill-in (2)

 

Choice 1

he owes

Choice 2

she owes

Choice 3

you owe

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

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

HIB265 – DEDUCTION OF CURRENT SMI PREMIUMS

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN possessive

Choice 2

your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

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

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

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

Fill-in values:

 

Fill-in (1)

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

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

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

Fill-in values:

 

Fill-in (1)

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

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

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

Fill-in values:

 

Fill-in (1)

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

Fill-in (2)

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

HIB269 – FULL WITHHOLDING CONTINUES UNTIL PREMIUMS PAID IN FULL

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (2)

 

Choice 1

he owes

Choice 2

she owes

Choice 3

you owe

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

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

Fill-in values:

 

Fill-in (1)

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

Fill-in (2)

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

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

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

Fill-in values:

 

Fill-in (1)

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

Fill-in (2)

 

Choice 1

BGN plus BLN (possessive)

Choice 2

your

Fill-in (3)

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

Fill-in (4)

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

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

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

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

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

HIB316 – ADDITIONAL SOURCES FOR OBTAINING HEALTH INSURANCE

For questions about Marketplace or Medicaid coverage, visit (1), or call the Marketplace Call Center at 1-800-318-2596 (TTY 1-855-889-4325).

Fill-in values:

 

Fill-in (1)

HealthCare.gov

HIB317 – HOW TO APPLY FOR HELP WITH THE COST OF IMMUNOSUPPRESSIVE DRUG COVERAGE

Contact your state Medicaid agency to find out if you qualify for help paying for the premium and cost-sharing for your immunosuppressive drug benefit. Visit Medicaid.gov to find contact information for your state.

HIB318 – HOW TO APPLY FOR IMMUNOSUPPRESSIVE DRUG COVERAGE

  • Call us toll-free at 1-877-465-0355 between 8:30 a.m. – 6:00 p.m. EST, Monday through Friday, to enroll over the phone.

  • You can also use "Application for Enrollment in Part B Immunosuppressive Drug Coverage" Form CMS-10798. You may go to CMS.gov to find the form. Mail the completed form to:

SOCIAL SECURITY ADMINISTRATION
OFFICE OF CENTRAL OPERATIONS
PO BOX 32914
BALTIMORE, MARYLAND 21298-2703

HIB327 – IMMUNOSUPPRESSIVE DRUG COVERAGE ELIGIBILITY

(1) may be eligible for a Medicare benefit called Part B Immunosuppressive Drug Coverage (Part B-ID) that helps pay for immunosuppressive drugs. This coverage is only for immunosuppressive drugs and not any other Medicare services or prescriptions. You may be eligible to enroll in Part B-ID, but you are only eligible for payment of immunosuppressive drugs under Part B-ID if you are eligible for those drugs under Medicare Part B.

You can only sign up for this benefit if (2) expect to get other health insurance such as:

  • Employer group health plan or individual health plan (including Marketplace)

  • TRICARE for Life

  • Medicaid or the State Children’s Health Insurance Program (CHIP) coverage that includes immunosuppressive drugs

  • Being enrolled in the patient enrollment system of the Department of Veterans Affairs (VA) or otherwise eligible to receive immunosuppressive drugs from the VA

    Fill-in values:

     

    Fill-in (1)

     

    Choice 1

    You

    Choice 2

    BGN plus BLN (non-possessive)

    Fill-in (2)

     

    Choice 1

    you do not have and do not

    Choice 2

    BGN plus BLN (non-possessive) + does not have and does not

HIB331 – APPLY FOR MEDICARE THREE MONTHS PRIOR TO TURNING 65

If (1) within three months of turning age 65 or older, contact Social Security to file an application for Medicare Part A and Part B. You must file an application to enroll in additional benefits under Medicare. Visit www.ssa.gov to file your application online or get the phone number for your local office.

Fill-in values:

 

Fill-in (1)

 

Choice 1

you are

Choice 2

BGN plus BLN (non-possessive) + is

 

NL 00730.126 “M” Paragraphs and Captions

List of “M” Paragraphs and Captions

A. “MAN” Universal Text Identifier - Manual

MAN001 – MANUAL NOTICE NEEDED TO EXPLAIN TITLE II REDESIGN ACTION(S)

MANUAL NOTICE NEEDED – (1)

Fill-in values:

 

Fill-in (1)

 

Choice 1

LIMITED GROUP PAYER

Choice 2

THIRD-PARTY WIPEOUT PROCESSED

Choice 3

MEDICARE CLAIM WITHDRAWAL PROCESSED

Choice 4

MBA LESS SMI PAST PREMIUMS

Choice 5

MULTIPLE 3RD PARTY CLOSED PERIODS

Choice 6

SPA OPA POSTED TO BOUD TERM TO TERM

Choice 7

SUSPENSION FOR WITHDRAWAL CLAIM

Choice 8

NEW OPA AND PRIOR OPA UNDER PROTEST

Choice 9

MULTIPLE FFEL CHANGED OCCURRENCES

Choice 10

WARRANT ISSUING AGENCY IS BLANK

Choice 11

MBR ORI AND WARRANTDT NO MATCH ON FFSCF

Choice 12

WC/PDB STOPS AND NO AMOF DATA PRESENT

Choice 13

FFEL SUSP NO CHANGE IN FFEL OCCURRENCES

Choice 14

ICF INPUT WC DATA DELETED ON POST-MBR

Choice 15

MULTIPLE ARD DATA LINES FOR SAME YEAR (YOER)

B. “MAR” Universal Text Identifiers - Marriage

MAR008 – MARRIAGE DOES NOT AFFECT SOCIAL SECURITY ADMINISTRATION BENEFITS

Thank you for telling us that (1) married. However, this marriage will not affect (2) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

you

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

MAR009 – DIVORCE DOES NOT AFFECT SOCIALSECURITY ADMINISTRATION BENEFITS

Thank you for telling us about (1) divorce. However, the divorce will not affect (2) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

C. “MHP” Universal Text Identifiers – Medicare Health Plan

MHPC02 – CAPTION

Information About (1) Health Plan Premiums

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

Your

MHPC03 – CAPTION

Information About (1) Medicare Prescription Drug Plan Costs

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

Your

MHPC04 – CAPTION

Information About (1) Health Plan Premiums and Medicare Prescription Drug Plan Costs

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

Your

MHP008 – MEDICARE ADVANTAGE PART B PREMIUM REDUCED

MONTH CCYY    MONTH CCYY    $$$$$$¢¢    $$$$$$¢¢

NOTE: The fill-ins for MHP008 will be repeated for each occurrence of MARD data that needs to be displayed in the notice.

Fill-in values:

 

Fill-in (1)

Medicare Advantage Reduction Start Date (MARD-START-REL) for the first occurrence of MARD data that has changed when comparing the pre- and post-MBRs

 

NOTE: for Fill-in (1), the date will be displayed in the numeric format showing the slash after the month and before the year (e.g., 01/2006)

Fill-in (2)

Medicare Advantage Reduction Stop Date (MARD-STOP-REL) that corresponds to the MARD start date

 

NOTE: the MARD stop date may not have a value if there is no stop date on the post-MBR

Fill-in (3)

Medicare Advantage Reduction Amount (MARD-AMOUNT) that corresponds to the start/stop occurrence

 

NOTE: If an MARD occurrence on the pre-MBR is wiped-out, then the value for this fill-in will be zero and displayed as 0.00

Fill-in (4)

Show the Part B premium after the Medicare Advantage Reduction Amount (MARD-AMOUNT) is applied.

 

NOTE: if the MARD occurrence displayed is for a wiped-out occurrence on the pre-MBR, the value for this fill-in will be the Part B SMI rate

NOTE: The decision to display MARD occurrence from the pre-MBR that is wiped-out was made by CMS notice policy when creating the revised language to use for Medicare Advantage reduction of Part B premium amount.

MHP009 – PART C HEALTH PLAN PREMIUMS DEDUCTION FROM SSA BENEFITS STARTS

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

you

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

MHP012 – PART C HEALTH PLAN PREMIUMS DEDUCTED FROM A PRIOR MONTHLY ACCRUAL (PMA) OR CURRENT MONTHLY ACCRUAL (CMA)

This represents all health plan premiums due to date.

MHP013 – SUPPLEMENTAL MEDICAL INSURANCE (SMI) PART B PREMIUM REDUCED

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

MHP014 – MEDICARE ADVANTAGE PART B PREMIUM REDUCED

Below we show the changes to the monthly deduction to (1) medical insurance (Part B) premium:

Start Date

Stop Date

Amount of Reduction

Amount of Premium After the Reduction

 

 

 

 

(2)

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

a blank line is required for Fill-in (2) for formatting purposes

MHP015 – PART C HEALTH PLAN PREMIUM DEDUCTED FROM MONTHLY BENEFIT PAYABLE (MBP) > $0.00

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

Fill-in values:

 

Fill-in (1)

For every Deductions Additions History (DAH) occurrence on the post-MBR with the Deductions Additions History Update Date (DAH-UPDDT) equal to the Run Date that has a Deductions Additions History Type of Payment Code (DAH-TOP) = MBP (M) and has a Deductions Additions History Item Code (DAH-ITEM) = 445, 450, 455 and/or 460, add the Deductions Additions History Amount (DAH-AMOUNT) for each of these occurrences together and show this total as the fill-in value

Fill-in (2)

 

Choice 1

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

Choice 2

your

MHP016 – PART C HEALTH PLAN PREMIUM DEDUCTION AMOUNT CHANGES

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

MHP017 – PART C HEALTH PLAN PREMIUMS NO LONGER DEDUCTED FROM SSA BENEFITS

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

MHP018 – ADVISES BENEFICIARY TO CONTACT THEIR HEALTH PLAN ABOUT PART C HEALTH PLAN OR ABOUT THE REDUCTION OF PART B PREMIUM AMOUNT

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

MHP027 – REFUND FOR PART C HEALTH PLAN PREMIUMS ONLY PAID IN THE PRIOR MONTH ACCRUAL AMOUNT (PAMT) OR CURRENT MONTH ACCRUAL AMOUNT (CAMT)

This payment includes a refund of (1) health plan premiums.

Fill-in values:

 

Fill-in (1)

 

Choice 1

his

Choice 2

her

Choice 3

your

MHP028 – REFUND FOR PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS PAID IN A PRIOR MONTH ACCRUAL AMOUNT (PAMT) OR CURRENT MONTH ACCRUAL AMOUNT (CAMT)

This payment includes a refund of (1) Medicare prescription drug plan costs.

Fill-in values:

 

Fill-in (1)

 

Choice 1

his

Choice 2

her

Choice 3

your

MHP029 – REFUND FOR PART C HEALTH PLAN PREMIUMS AND ALSO PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS

This payment includes a refund of (1) health plan premiums and (2) Medicare prescription drug plan costs.

Fill-in values:

 

Fill-in (1)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

MHP030 – REFUND FOR PART D ONLY MEDICARE PRESCRIPTION DRUG PLAN COSTS AND NO OTHER TITLE II REDESIGN PARAGRAPH GENERATED AS INTRODUCTORY PARAGRAPH

Based on the information we have (1) (2) due a refund for Medicare prescription drug plan costs.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

you

Fill-in (2)

 

Choice 1

is

Choice 2

are

MHP031 – REFUND FOR PART C ONLY HEALTH PLAN PREMIUMS AND NO OTHER TITLE II REDESIGN PARAGRAPH GENERATED AS INTRODUCTORY PARAGRAPH

Based on the information we have (1) (2) due a refund for health plan premiums.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

you

Fill-in (2)

 

Choice 1

is

Choice 2

are

MHP032 – REFUND FOR PART C HEALTH PLAN PREMIUMS AND ALSO REFUND FOR PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS AND NO OTHER TITLE II REDESIGN PARAGRAPH GENERATED AS INTRODUCTORY PARAGRAPH

Based on the information we have, (1) (2) due a refund for (3) health plan premiums and (4) Medicare prescription drug plan costs.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

you

Fill-in (2)

 

Choice 1

is

Choice 2

are

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

MHP033 – BENEFICIARY REQUESTS THAT ONLY PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS DEDUCTED FROM SOCIAL SECURITY ADMINISTRATION BENEFITS

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

you

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

MHP034 – BENEFICIARY REQUESTS THAT PART C HEALTH PLAN PREMIUMS AND ALSO PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS DEDUCTED FROM SOCIAL SECURITY ADMINISTRATION BENEFITS

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

you

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

MHP035 – PART C ONLY HEALTH PLAN PREMIUMS DEDUCTED FROM PRIOR MONTH ACCRUAL AMOUNT (PAMT) CHECK

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

Fill-in values:

 

Fill-in (1)

Total amount of the Part C health plan premiums deducted from the Prior Month Accrual Amount (PAMT) check; this amount includes any Part C arrearages show in Deductions Additions History (DAH) data from the PAMT

Fill-in (2)

 

Choice 1

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

Choice 2

your

Fill-in (3)

Run date plus 15 days as the date in the format Month DD, CCYY

MHP036 – PART D ONLY MEDICARE PRESCRIPTION DRUG PLAN COSTS DEDUCTED FROM PRIOR MONTH ACCRUAL AMOUNT (PAMT) CHECK

We deducted (1) for (2) Medicare prescription drug plan costs from the check you will receive on or about (3).

Fill-in values:

 

Fill-in (1)

Total amount of the Part D Medicare prescription drug plan costs deducted from the Prior Month Accrual Amount (PAMT) check; this amount includes any Part D arrearages show in Deductions Additions History (DAH) data from the PAMT

Fill-in (2)

 

Choice 1

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

Choice 2

your

Fill-in (3)

Run date plus 15 days as the date in the format Month DD, CCYY

MHP037 – PART C HEALTH PLAN PREMIUMS AND ALSO PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS DEDUCTED FROM PRIOR MONTH ACCRUAL AMOUNT (PAMT) CHECK

We deducted (1) for (2) health plan premiums and (3) for (4) Medicare prescription drug plan costs from the check you will receive on or about (5).

Fill-in values:

 

Fill-in (1)

Total amount of the Part C health plan premiums deducted from the Prior Month Accrual Amount (PAMT) check; this amount includes any Part C arrearages show in Deductions Additions History (DAH) data from the PAMT

Fill-in (2)

 

Choice 1

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

Choice 2

your

Fill-in (3)

Total amount of the Part D Medicare prescription drug plan costs deducted from the Prior Month Accrual Amount (PAMT) check; this amount includes any Part D arrearages show in Deductions Additions History (DAH) data from the PAMT

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

Run date plus 15 days as the date in the format Month DD, CCYY

MHP038 – PART C ONLY HEALTH PLAN PREMIUMS DEDUCTED FROM CURRENT AMOUNT (CAMT) CHECK

We deducted (1) for (2) health plan premiums from the check you will receive for (3) on or about (4).

Fill-in values:

 

Fill-in (1)

Total amount of the Part C health plan premiums deducted from the Current Amount (CAMT) check; this amount includes any Part C arrearages show in Deductions Additions History (DAH) data from the CAMT

Fill-in (2)

 

Choice 1

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

Choice 2

your

Fill-in (3)

Current Operating Month (COM) in the format Month CCYY

Fill-in (4)

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

MHP039 – PART D ONLY MEDICARE PRESCRIPTION DRUG PLAN COSTS DEDUCTED FROM CURRENT AMOUNT (CAMT) CHECK

We deducted (1) for (2) Medicare prescription drug plan costs from the check you will receive for (3) on or about (4).

Fill-in values:

 

Fill-in (1)

Total amount of the Part D Medicare prescription drug plan costs deducted from the Current Amount (CAMT) check; this amount includes any Part C arrearages show in Deductions Additions History (DAH) data from the CAMT

Fill-in (2)

 

Choice 1

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

Choice 2

your

Fill-in (3)

Current Operating Month (COM) in the format Month CCYY

Fill-in (4)

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

MHP040 – PART C HEALTH PLAN PREMIUMS AND ALSO PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS DEDUCTED FROM THE CURRENT MONTHLY ACCRUAL (CMA) CHECK

We deducted (1) for (2) Medicare approved health plan premiums and (3) for (4) Medicare prescription drug plan costs. We deducted these amounts from the payment (5) will receive for (6) on or about (7).

Fill-in values:

 

Fill-in (1)

Total amount of the Part C health plan premiums deducted from the Current Monthly Accrual (CMA) check; this amount includes any Part C arrearages show in Deductions Additions History (DAH) data from the CMA

Fill-in (2)

 

Choice 1

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

Choice 2

your

Fill-in (3)

Total amount of the Part D Medicare prescription drug plan costs deducted from the Current Amount (CAMT) check; this amount includes any Part C arrearages shown in Deductions Additions History (DAH) data from the Current Monthly Accrual (CMA)

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (6)

Current Operating Month (COM) in the format Month CCYY

Fill-in (7)

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

MHP041 – PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS FROM THE PRIOR MONTH ACCRUAL AMOUNT (PAMT) AND/OR CURRENT AMOUNT (CAMT)

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

MHP042 – PART C HEALTH PLAN PREMIUMS AND ALSO PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS FROM THE PRIOR MONTH ACCRUAL AMOUNT (PAMT) AND/OR CURRENT AMOUNT (CAMT)

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

MHP043 – PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS ONLY DEDUCTED FROM MONTHLY BENEFIT PAYABLE (MBP)

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

Fill-in values:

 

Fill-in (1)

Amount of the Part D Medicare prescription drug plan costs deducted from the Monthly Benefit Payable (MBP)

Fill-in (2)

 

Choice 1

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

Choice 2

your

MHP044 – PART C HEALTH PLAN PREMIUM AND PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS DEDUCTED FROM THE MONTHLY BENEFIT PAYABLE (MBP)

Each month, we will continue to deduct (1) for (2) health plan premiums and (3) for (4) Medicare prescription drug plan costs.

Fill-in values:

 

Fill-in (1)

Amount of the Part C health plan premium deducted from the Monthly Benefit Payable (MBP)

Fill-in (2)

 

Choice 1

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

Choice 2

your

Fill-in (3)

Amount of the Part D Medicare prescription drug plan costs deducted from the Monthly Benefit Payable (MBP)

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

MHP045 – CHANGE IN THE DEDUCTION AMOUNT FOR PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS FROM SOCIAL SECURITY ADMINISTRATION BENEFITS

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

MHP046 – CHANGE IN THE DEDUCTION AMOUNT FOR PART C HEALTH PLAN PREMIUM AND ALSO A CHANGE IN THE DEDUCTION AMOUNT FOR PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS

There has been a change in the amount withheld for (1) health plan premiums and (2) Medicare prescription drug plan costs.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

MHP047 – PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS ONLY NO LONGER DEDUCTED FROM SOCIAL SECURITY ADMINISTRATION BENEFITS

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

MHP048 – PART C HEALTH PLAN PREMIUMS AND ALSO PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS NO LONGER DEDUCTED FROM SOCIAL SECURITY ADMINISTRATION BENEFITS

We will no longer deduct money for (1) health plan premiums and (2) Medicare prescription drug plan costs from (3) monthly benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

MHP049 – REFERRAL LANGUAGE USED WHEN PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS ONLY ARE INVOLVED FOR ANY REASON

If you have any questions about (1) Medicare prescription drug plan costs, please contact (2) Medicare prescription drug plan.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

MHP050 – REFERRAL LANGUAGE USED WHEN PART C HEALTH PLAN PREMIUMS AND ALSO PART D MEDICARE PRESCRIPTION DRUG PLAN COSTS ARE BOTH INVOLVED FOR ANY REASON

Please contact (1) Medicare health plan or (2) Medicare prescription drug plan if (3) questions about (4) premiums or costs.

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

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

Fill-in (2)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (3)

 

Choice 1

you have

Choice 2

he has

Choice 3

she has

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

MHP053 – INITIAL ENTITLEMENT TO HOSPITAL INSURANCE (HI)/SUPPLEMENTAL MEDICAL INSURANCE (SMI) WITH NO CURRENT DEDUCTION FOR MEDICARE PART D OR INCOME RELATED MONTHLY ADJUSTMENT AMOUNT (IRMAA) D

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

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

If (10) limited income and resources, we encourage (11) to apply for the extra help that is available to assist with Medicare prescription drug costs.  The extra help can pay the monthly premiums, annual deductibles and prescription co-payments.  To learn more or apply, please contact us.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

you

Fill-in (2)

 

Choice 1

is

Choice 2

are

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (5)

www.medicare.gov

Fill-in (6)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (7)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (8)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (9)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (10)

 

Choice 1

he has

Choice 2

she has

Choice 3

you have

Fill-in (11)

 

Choice 1

him

Choice 2

her

Choice 3

you

D. “MIS” Universal Text Identifier - Miscellaneous

MIS050 – BENEFICIARY DIES IN OR BEFORE THEIR CURRENT DATE OF ENTITLEMENT (DOEC)

We are sorry to learn of your recent loss. Please accept our sincere sympathy.

We are not processing the application for Social Security benefits for (1). This is because (2) could not have been entitled to benefits for any month before (3) death on (4).

Fill-in values:

 

Fill-in (1)

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

Fill-in (2)

 

Choice 1

he

Choice 2

she

Fill-in (3)

 

Choice 1

his

Choice 2

her

Fill-in (4)

Beneficiary Date of Death (BDOD) in format Month CCYY

E. “MOE” Universal Text Identifiers – Month Of Entitlement

MOE003 – SINGLE ENTITLEMENT RECORD AND MONTH OF ENTITLEMENT (MOE) DATE CHANGE DUE TO WORK AND EARNINGS

We reviewed (1) record. When (2) applied for benefits, (3) asked us to start (4) benefits in (5). We changed the month (6) benefits start to (7) because of (8) (9) work and earnings.

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

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

Fill-in (2)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (5)

Date of Entitlement (DOE) start date from the pre-MBR in the format Month CCYY

Fill-in (6)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (7)

Date of Entitlement (DOE) new start date from the post-MBR in the format Month CCYY

Fill-in (8)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (9)

 

Choice 1

Year prior to the Date of Entitlement (DOE) start in the format CCYY

Choice 2

Full Retirement Age (FRA) year in the format CCYY

Choice 3

Year prior to the Full Retirement Age (FRA) year in the format CCYY

Choice 4

Date of Entitlement (DOE) start year in the format CCYY

MOE004 – DUAL ENTITLEMENT RECORD AND THE MONTH OF ENTITLEMENT (MOE) DATES CHANGES DUE TO WORK AND EARNINGS FOR A CLOSED YEAR

We reviewed (1) record. When (2) applied, (3) asked us to start (4) benefits in (5). We changed the month (6) benefits start to (7) because of (8) (9) work and earnings.

(10) also receiving benefits on another record. We will send you another letter about those benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

Date of Entitlement (DOE) start date in the format Month CCYY

Fill-in (6)

 

Choice 1

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

Choice 2

your

Fill-in (7)

Date of Entitlement (DOE) new start date

Fill-in (8)

 

Choice 1

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

Choice 2

Number Holder First Name plus Number Holder Last Name

Choice 3

your

Fill-in (9)

 

Choice 1

Year prior to the Date of Entitlement (DOE) start in the format CCYY

Choice 2

Full Retirement Age (FRA) year in the format CCYY

Choice 3

Year prior to the Full Retirement Age (FRA) year in the format CCYY

Choice 4

Date of Entitlement (DOE) start year in the format CCYY

Fill-in (10)

 

Choice 1

He is

Choice 2

She is

Choice 3

You are

MOE005 – DUAL ENTITLEMENT RECORD AND MONTH OF ENTITLEMENT (MOE) CHANGES DUE TO WORK AND EARNINGS FOR A CLOSED YEAR FOR A BENEFICIARY WHO CHOSE AN EARLY MOE WITHOUT REDUCTION

We reviewed (1) record. When (2) applied, (3) asked us to start (4) benefits in (5). We changed the month (6) benefits start to (7) because of (8) (9) work and earnings. The change lets (10) get payments without permanently reducing (11) monthly benefits.

(12) also receiving benefits on another record. We will send you another letter about those benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

Original Date of Entitlement (DOE) start date in the format Month CCYY

Fill-in (6)

 

Choice 1

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

Choice 2

your

Fill-in (7)

New Month of Entitlement (MOE) start date

Fill-in (8)

 

Choice 1

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

Choice 2

NH First Name plus NH Last Name

Choice 3

your

Fill-in (9)

Enforcement year in the format CCYY

Fill-in (10)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (11)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (12)

 

Choice 1

He is

Choice 2

She is

Choice 3

You are

MOE006 – NEW MONTH OF ENTITLEMENT (MOE) TO AN AUXILIARY WHEN THE MOE CHANGED BASED ON THE NUMBER HOLDER'S MOE CHANGING

We changed the month (1) benefits start on (2) record from (3) to (4). We changed the month because of (5) (6) work and earnings. (7) is the earliest month (8) can get benefits on (9) record. (10) benefits must start before (11) benefits can start.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

NH First Name plus NH Last Name (possessive)

Fill-in (3)

Date of Entitlement (DOE) start date

Fill-in (4)

New Date of Entitlement (DOE) start date

Fill-in (5)

NH First Name plus NH Last Name

Fill-in (6)

Year of enforcement in the format CCYY

Fill-in (7)

Date of Entitlement (DOE) start date

Fill-in (8)

 

Choice 1

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

Choice 2

you

Fill-in (9)

NH First Name plus NH Last Name

Fill-in (10)

NH First Name plus NH Last Name

Fill-in (11)

 

Choice 1

NH First Name plus NH Last Name

Choice 2

your

MOE007 – SINGLE ENTITLEMENT RECORD AND THE MONTH OF ENTITLEMENT (MOE) DATE CHANGES DUE TO WORK AND EARNINGS FOR A CLOSED YEAR FOR A BENEFICIARY WHO CHOSE AN EARLY MOE WITHOUT REDUCTION

We reviewed (1) record. When (2) applied, (3) asked us to start (4) benefits in (5). We changed the month (6) benefits start to (7) because of (8) (9) work and earnings. This change lets (10) get payments without permanently reducing (11) monthly benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

Original Month of Entitlement (MOE) in the format Month CCYY

Fill-in (6)

 

Choice 1

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

Choice 2

your

Fill-in (7)

New Month of Entitlement (MOE) in the format Month CCYY

Fill-in (8)

 

Choice 1

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

Choice 2

First name of NH plus Last name of NH

Choice 3

your

Fill-in (9)

Year of enforcement in the format CCYY

Fill-in (10)

 

Choice 1

him

Choice 2

her

Choice 3

you

Fill-in (11)

 

Choice 1

his

Choice 2

her

Choice 3

your

F. “MPD” Universal Text Identifiers – Medicare Prescription Drug Plan

MPDC19 – Caption

Medicare Prescription Drug Plan Enrollment

MPDC31 – Caption

Information About The Prescription Drug Coverage Income-Related Monthly

Adjustment Amount

MPD346 – INCOME-RELATED MONTHLY ADJUSTMENT AMOUNT (IRMAA) D PREMIUMS REFUND IN PRIOR MONTH ACCRUAL AMOUNT (PAMT) OR CURRENT AMOUNT (CAMT) - NO OTHER INTRODUCTORY UTI APPLIES

Based on the information, we have (1) (2) due a refund for prescription drug coverage income-related monthly adjustment amounts.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

you

Fill-in (2)

 

Choice 1

is

Choice 2

are

MPD347 – INCOME-RELATED MONTHLY ADJUSTMENT AMOUNT (IRMAA) D PREMIUMS REFUND IN PRIOR MONTH ACCRUAL AMOUNT (PAMT) OR CURRENT AMOUNT (CAMT)

This payment includes a refund of (1) prescription drug coverage income-related monthly adjustment amount.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

MPD348 – INCOME-RELATED MONTHLY ADJUSTMENT AMOUNT (IRMAA) D PREMIUM DEDUCTED FROM CURRENT AMOUNT (CAMT)

We deducted (1) for (2) prescription drug coverage income-related monthly adjustment amount from the check (3) will receive for (4) on or about (5).

Fill-in values:

 

Fill-in (1)

Total Income Related Monthly Adjustment Amount (IRMAA) D amounts deducted from Current Amount (CAMT)

Fill-in (2)

 

Choice 1

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

Choice 2

your

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

Current Operating Month (COM)

Fill-in (5)

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

MPD349 - INCOME-RELATED MONTHLY ADJUSTMENT AMOUNT (IRMAA) D CONTINUES TO BE DEDUCTED FROM THE MONTHLY BENEFIT PAYABLE (MBP)

The monthly deduction for (1) prescription drug coverage income-related monthly adjustment amount is (2).

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

Total Income Related Monthly Adjustment Amount (IRMAA) D amounts deducted from Monthly Benefit Payable (MBP)

MPD350 – INCOME-RELATED MONTHLY ADJUSTMENT AMOUNT (IRMAA) D PREMIUM DEDUCTED FROM PRIOR MONTH ACCRUAL AMOUNT (PAMT)

We deducted (1) for (2) prescription drug coverage income-related monthly adjustment amount from the check you will receive on or about (3).

Fill-in values:

 

Fill-in (1)

Total Income-Related Monthly Adjustment Amount (IRMAA) D amounts deducted from Prior Month Accrual Amount (PAMT)

Fill-in (2)

 

Choice 1

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

Choice 2

your

Fill-in (3)

Run date plus 15 days

MPD351 – INCOME-RELATED MONTHLY ADJUSTMENT AMOUNT (IRMAA) D NO LONGER DEDUCTED FROM BENEFITS

We will no longer deduct (1) prescription drug coverage income-related monthly adjustment amount from (2) monthly benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

MPD352 – INCOME-RELATED MONTHLY ADJUSTMENT AMOUNT (IRMAA) D ARREARAGES DEDUCTED FROM PRIOR MONTH ACCRUAL AMOUNT (PAMT) OR CURRENT AMOUNT (CAMT)

We are deducting past-due prescription drug coverage income-related monthly adjustment amounts from (1) check.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

NL 00730.136 “R” Paragraphs and Captions

List of “R” Paragraphs and Captions

A. RCY Universal Text Identifiers - Recovery

RCYC01 – CAPTION

How to Pay Us Back

RCYC04 – CAPTION

Do You Think That You Do Not Owe This Money?

RCYC05 – CAPTION

Reduction To Collect Your SSI Overpayment

RCY002 – CROSS PROGRAM RECOVERY FOR SUPPLEMENTAL SECURITY INCOME (SSI) OVERPAYMENT

We paid (1) more in Supplemental Security Income (SSI) payments in the past than (2) due. Our records show that (3) us (4) in SSI payments. By law, we can collect SSI overpayments from the Social Security benefits that (5). We withheld (6) from (7) Social Security benefits to collect (8) the SSI payments that (9).

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

you

Fill-in (2)

 

Choice 1

he was

Choice 2

she was

Choice 3

you were

Fill-in (3)

 

Choice 1

he still owes

Choice 2

she still owes

Choice 3

you still owe

Fill-in (4)

Cross Program Recovery Overpayment Amount (CPR-OPAMT) in the format $$$$$$.¢¢

Fill-in (5)

 

Choice 1

he receives

Choice 2

she receives

Choice 3

you receive

Fill-in (6)

Cross Program Recovery Underpayment Amount (CPR-UPAMT) in the format $$$$$$.¢¢

Fill-in (7)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (8)

 

Choice 1

some of

Choice 2

Null

Fill-in (9)

 

Choice 1

he owes

Choice 2

she owes

Choice 3

you owe

RCY003 – CROSS PROGRAM RECOVERY FOR SUPPLEMENTAL SECURITY INCOME (SSI) OVERPAYMENT - USED WITH RCY002

You may ask us to review our finding that you still owe the money. You may have evidence to show that you already paid some or all of the money or that we previously waived collection of it. If so, give us this evidence when you ask for review. We will review the evidence you give us and the information we have. We will send you a letter with our decision. If we find that you do not owe us this amount, then we will correct our records.

For more information on requesting review, see "If You Disagree With The Decision" below.

RCY006 – BENEFITS RAISED - PARTIAL RECOVERY ENDS

We have raised (1) benefits back to (2) regular monthly payment amount. This is because (3) repaid the overpayment money (4) owed us.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

Beneficiary Given Name (BGN) (possessive)

Choice 3

your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

he

Choice 2

she

Choice 3

you

RCY007 – PARTIAL RECOVERY ENDS - NO REMAINING OVERPAYMENT

We are withholding (1) from (2) benefits. This is the remaining balance (3) owed on (4) overpayment.

Fill-in values:

 

Fill-in (1)

Monthly Recovery Amount (MRA) on the Pre-MBR in the format $$$$

Fill-in (2)

 

Choice 1

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

Choice 2

your

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

B. REF Universal Text Identifiers – Referral

REFC01 – CAPTION

Suspect Social Security Fraud?

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

If You Have Questions

REF020 – DEFERRAL - ADVANCE FILE MATURING

To make sure (1) the correct amount of benefits, you need to promptly report any changes in the amount (2) or (3) to earn. You should also report any other changes that may affect (4) payment.

The pamphlet (5) describes the events you need to report. Visit www.ssa.gov for a copy of the pamphlet.

Fill-in values:

 

Fill-in (1)

 

Choice 1

you get

Choice 2

Beneficiary's Given Name (BGN) plus Beneficiary's Last Name (BLN) plus "gets"

Fill-in (2)

 

Choice 1

you earn

Choice 2

BGN + BLN + earns

Fill-in (3)

 

Choice 1

expect

Choice 2

expects

Fill-in (4)

 

Choice 1

your

Choice 2

NULL + BGN + BLN (possessive)

Fill-in (5)

 

Choice 1

SSA Pub 05-10137, Your Payments While You Are Outside The United States

Choice 2

SSA Pub 05-10153, What You Need To Know When You Get Social Security Disability Benefits

Choice 3

SSA Pub 05-10077, What You Need To Know When You Get Retirement or Survivors Benefits

REF196 – STANDARD REFERRAL INFO FOR DOMESTIC ADDRESS

Need more help?

  1. 1. 

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

  2. 2. 

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

  3. 3. 

    You may also call your local office at (1).

(2)

(3)

(4)

(5)

(6)

(7)

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

Fill-in values:

 

Fill-in (1)

Field office telephone number in format 1-XXX-XXX-XXXX

Fill-in (2)

Field office address line 1 from DOORS database

Fill-in (3)

Field office address line 2 from DOORS database

Fill-in (4)

Field office address line 3 from DOORS database

Fill-in (5)

Field office address line 4 from DOORS database

Fill-in (6)

City, State and ZIP code from DOORS database

Fill-in (7)

Null (for future use)

REF197 – STANDARD REFERRAL INFO FOR FOREIGN ADDRESS

Need more help?

  1. 1. 

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

  2. 2. 

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

  3. 3. 

    You may also call your local Social Security office.

If you are outside the United States or its territories:

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

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

  • Write to the Social Security Administration at:

P.O. Box 17769

Baltimore, Maryland 21235-7769, USA

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

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

Fill-in values:

 

Fill-in (1)

www.ssa.gov/foreign/canada.htm

Fill-in (2)

www.ssa.gov/foreign/foreign.htm

REF198 – REFERRAL INFO FOR RAILROAD RETIREMENT

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

REF208 – REFERRAL INFO FOR STATE BUY-IN/BUY-OUT

If you have any questions about the State Medicaid program, please contact your State public assistance office.

REF209 – REFERRAL INFO FOR STATE RETIREMENT

If you have any questions about the State retirement system, please contact that office.

REF210 – REFERRAL INFO - NO FIELD OFFICE PHONE NUMBER IN DOORS FOR PUBLIC USE

Need more help?

  1. 1. 

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

  2. 2. 

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

  3. 3. 

    The office that serves your area is located at:

(1)

(2)

(3)

(4)

(5)

(6)

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

Fill-in values:

 

Fill-in (1)

Field office address line 1 from DOORS database

Fill-in (2)

Field office address line 2 from DOORS database

Fill-in (3)

Field office address line 3 from DOORS database

Fill-in (4)

Field office address line 4 from DOORS database

Fill-in (5)

City, State and ZIP code from DOORS database

Fill-in (6)

Null (for future use)

REF211 – REFERRAL INFO - NO FIELD OFFICE DETAILS IN DOORS (INVALID ZIP/OFFICE CLOSED)

Need more help?

  1. 1. 

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

  2. 2. 

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

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

C. REP Universal Text Identifiers – Claimant Representation

REPC01 – CAPTION

If You Want Help With Your Appeal

REP002 – APPEALS INFORMATION - NOT USED ON END-STAGE RENAL DISEASE (ESRD) TERMINATION NOTICE

You may choose to have a representative help you. We will work with this person just as we would work with you. If you decide to have a representative, you should find one quickly so that person can start preparing your case.

Many representatives charge a fee only if you receive benefits. Others may represent you for free. Usually, your representative may not charge a fee unless we approve it. Your local Social Security office can give you a list of groups that can help you find a representative.

If you get a representative, you or that person must notify us in writing. You may use our Form SSA-1696 “Appointment of Representative.” Any local Social Security office can give you this form.

REP005 – APPEALS INFORMATION FOR AN END-STAGE RENAL DISEASE (ESRD) TERMINATION NOTICE

You can have a friend, lawyer, or someone else help you. There are groups that can help you find a lawyer or give you free legal services if you qualify. There are also lawyers who do not charge unless you win your appeal. Your Social Security office has a list of groups that can help you with your appeal. If you get someone to help you, you should let us know.

D. RFU Universal Text Identifiers - Refund

R FU001 – OVERPAYMENT REQUESTED FROM TERMINATED BENEFICIARY

You should refund this overpayment of (1) 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 (2) Social Security claim number on your check or money order.

If you cannot refund the full (3) now, please send:

• A partial payment

• An explanation of why you cannot pay the full amount now, and

• A plan to repay the money

Fill-in values:

 

Fill-in (1)

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

Fill-in (2)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in ( 3 )

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

RFU002 – OVERPAYMENT REQUESTED - FOREIGN ADDRESS

If (1) us by check or money order, make sure that the check or money order is in United States (U.S.) dollars or in local currency equal to U.S. dollars. When (2) us in local currency, we use the exchange rates in effect at the time we get (3) payment. If this causes a difference between the amount (4) us and the amount (6) us, we will let you know. If you cannot mail your payment to us, please contact your nearest Federal Benefits Unit (FBU). Visit (7) for a list of FBUs. If you are in Canada, visit (8) to find the office that services your area. They will help you make the refund.

Fill-in values:

 

Fill-in (1)

 

Choice 1 you pay
Choice 2 he pays
Choice 3 she pays

Fill-in (2)

 

Choice 1

you pay

Choice 2

he pays

Choice 3

she pays

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3 her

Fill-in (4)

 

Choice 1 you pay
Choice 2 he pays
Choice 3 she pays

Fill-in (5)

 

Choice 1 you owe
Choice 2 he owes
Choice 3 she owes

Fill-in (6)

Choice 1

your

Choice 2

his

Choice 3 her

Fill-in (7)

www.ssa.gov/foreign/foreign.htm

Fill-in (8)

www.ssa.gov/foreign/canada.htm

RFU004 – SUPPLEMENTAL SECURITY INCOME (SSI) IS DETERMINED AND SOCIAL SECURITY RETROACTIVE BENEFITS ARE GREATER THAN THE SSI WINDFALL OFFSET AMOUNT

We compared (1) Social Security and SSI benefits. We found we should have paid (2) (3) less in SSI benefits. We will withhold this amount from (4) Social Security benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

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

Fill-in (2)

 

Choice 1

you

Choice 2

him

Choice 3

her

Choice 4

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

Fill-in (3)

Deductions Additions History Amount (DAH-AMOUNT) that corresponds to the Deductions Additions History Type of Payment (DAH-TOP) = PMA (P) and Deductions Additions History Item (DAH-ITEM) = 345 (DIB SSI offset) or the DAH ITEM = 346 (RIB SSI offset) in the format $$$$$$.¢¢

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

RFU006 – SUPPLEMENTAL SECURITY INCOME (SSI) IS DETERMINED AND THE SOCIAL SECURITY RETROACTIVE BENEFITS ARE LESS OR EQUAL TO THE WINDFALL OFFSET AMOUNT

We compared (1) Social Security and SSI benefits. We found that we should have paid (2) (3) less SSI benefits. As a result, we cannot pay (4) any of the Social Security benefits we withheld.

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

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

Fill-in (2)

 

Choice 1

you

Choice 2

him

Choice 3

her

Choice 4

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

Fill-in (3)

Deductions Additions History Amount (DAH-AMOUNT) that corresponds to the Deductions Additions History Type of Payment Code (DAH-TOP) = PMA (P) and [Deductions Additions History Item Code (DAH-ITEM) = 345 (DIB SSI offset or DAH-ITEM=346 (RIB SSI offset)] in the format $$$$$$.¢¢.

Fill-in (4)

 

Choice 1

you

Choice 2

him

Choice 3

her

Choice 4

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

RFU007 – SUPPLEMENTAL SECURITY INCOME (SSI) WINDFALL OFFSET IS DETERMINED AND THERE IS NO SSI OFFSET APPLIED TO SECURITY BENEFITS THEREFORE RETRO BENEFITS ARE PAYABLE TO THE BENEFICIARY

Our records show that (1) did not get SSI money for (2). We can refund all of the Social Security money withheld.

Fill-in values:

 

Fill-in (1)

 

Choice 1

you

Choice 2

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

Fill-in (2)

 

Choice 1

History Start date of the first month where Reason for Suspension = WINFAL in the format Month CCYY

Choice 2

Start date that corresponds to the Reason for Suspension = WINFAL plus ”through” plus the stop date of the last WINFAL Suspension month

RFU012 – TITLE II OVERPAYMENT ADJUSTMENT FROM BENEFITS WHEN OVERPAYMENT AMOUNT IS GREATER THAN MONTHLY BENEFIT AMOUNT (MBA)

You should refund this overpayment of (1) 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 (2) Social Security claim number on your check or money order.

If we do not receive your refund within 30 days, we will hold back (3) full benefit starting with the payment you would normally receive (4) about (5). We will continue holding back (6) benefits until we recover the overpayment.

If you cannot refund the full overpayment now or cannot afford to have us hold back (7) full benefit, you may ask us to hold back a smaller amount each month. Contact us to discuss your plan for repaying the balance. You may need to show us proof of (8) assets, monthly income, and expenses.

Fill-in values:

 

Fill-in (1)

Overpayment amount due in format $$$$$$.¢¢

Fill-in (2)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (4)

 

Choice 1

Null

Choice 2

for him

Choice 3

for her

Fill-in (5)

Date of payment in the format Month DD, CCYY

Fill-in (6)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (7)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (8)

 

Choice 1

your

Choice 2

his

Choice 3

her

E. RIN Universal Text Identifiers – Rate Information

RIN006 – EXPLAINS ADJUSTMENT REDUCTION FACTOR INCREASE

Because (1) retired early, we reduced (2) monthly Social Security benefit. The amount that we reduced it was based on the number of months (3) would receive benefits before (4). However, (5) didn't receive benefits some of these months because (6) worked and earned over certain limits. So, we must increase (7) benefit amount to give credit for these months.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

you

Fill-in (2)

 

Choice 1

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

Choice 2

his

Choice 3

her

Choice 4

your

Fill-in (3)

 

Choice 1

Beneficiary Given Name (BGN)

Choice 2

he

Choice 3

she

Choice 4

you

Fill-in (4)

 

Choice 1

full retirement age

Choice 2

age 62

Choice 3

age 60

Fill-in (5)

 

Choice 1

Beneficiary Given Name (BGN)

Choice 2

he

Choice 3

she

Choice 4

you

Fill-in (6)

 

Choice 1

Beneficiary Given Name (BGN)

Choice 2

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

Choice 3

he

Choice 4

she

Choice 5

you

Choice 6

he and his spouse

Choice 7

she and her spouse

Choice 8

you and your spouse

Choice 9

his spouse

Choice 10

her spouse

Fill-in (7)

 

Choice 1

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

Choice 2

his

Choice 3

her

Choice 4

your

RIN007 – EXPLAINS DELAYED RETIREMENT CREDIT INCREASE

When (1) filed for Social Security benefits, we figured the benefit amount based on (2) earnings history at that time. If after becoming entitled to benefits, (3) to work, (4) may earn credit for this additional work. So, we must increase (5) benefit amount to give credit for these months.

We apply the increase sometime after it is due. This is because earnings information is not available until after each tax year.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

you

Fill-in (2)

 

Choice 2

his

Choice 3

her

Choice 4

your

Fill-in (3)

 

Choice 1

he continues to work or later returns

Choice 2

she continues to work or later returns

Choice 3

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) plus “continues to work or later returns”

Choice 4

you continue to work or later return

Fill-in (4)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

RIN008 – MONTHLY BENEFIT AMOUNT (MBA) CHANGE - ANOTHER BENEFICIARY IS TERMINATED OR BECOMES ENTITLED ON THE RECORD

We changed (1) monthly benefit to (2) starting (3). We made this change because we (4) paying benefits to another person on this record.

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

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

Fill-in (2)

 

Choice 1

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA increase

Choice 2

NA-HIST-POST-MBA in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

Effective Date (EFD) on the Post-MBR associated with the Monthly Benefit Amount (MBA) increase

Choice 2

 

NA-HIST-START month in the format Month CCYY

Fill-in (4)

 

Choice 1

started

Choice 2

stopped

RIN012 – MONTHLY BENEFIT AMOUNT (MBA) CHANGE - COST OF LIVING INCREASE

We raised (1) monthly benefit to (2) beginning (3) because the cost of living increased.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA decrease

Choice 2

NA-HIST-POST-MBA in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

Effective Date (EFD) on the Post-MBR associated with the Monthly Benefit Amount (MBA) increase

Choice 2

NA-HIST-START month in the format Month CCYY

RIN013 – AUXILIARY'S MONTHLY BENEFIT AMOUNT (MBA) CHANGE DUE TO ANOTHER BENEFICIARY'S DEATH

We changed (1) monthly benefit to (2) starting (3). We changed (4) benefit because of the death of (5).

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA increase

Choice 2

NA-HIST-POST-MBA in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

Effective Date (EFD) on the Post-MBR associated with the Monthly Benefit Amount (MBA) increase due to death

Choice 2

NA-HIST-START month in the format Month CCYY

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

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

Choice 2

another person entitled on this record

RIN044 – AUXILIARY MONTHLY BENEFIT AMOUNT (MBA) CHANGE - ANOTHER BENEFICIARY ENTITLED AND COST-OF-LIVING ADJUSTMENT (COLA)

We changed (1) monthly benefit to (2) beginning (3) because we started paying another person(s) on this record. This change also includes the cost of living increase.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA change in the format $$$$$.¢¢

Choice 2

NA-HIST-POST-MBA in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

Effective Date (EFD) on the Post-MBR associated with the Monthly Benefit Amount (MBA) change in the format Month CCYY

Choice 2

NA-HIST-START month in the format Month CCYY

RIN045 – MONTHLY BENEFIT AMOUNT (MBA) CHANGE - ANOTHER BENEFICIARY TERMINATES AND COST-OF-LIVING ADJUSTMENT (COST-OF-LIVING ADJUSTMENT (COLA))

We changed (1) monthly benefit to (2) beginning (3) because benefits to another entitled person(s) stopped. This change also includes the cost of living increase.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA change in the format $$$$$.¢¢

Choice 2

NA-HIST-POST-MBA in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

Effective Date (EFD) on the Post-MBR associated with the Monthly Benefit Amount (MBA) change in the format Month CCYY

Choice 2

NA-HIST-START month in the format Month CCYY

RIN046 – NUMBER HOLDER NOTICE WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFIT (PDB) INVERSE OFFSET POSTPONED MONTHLY BENEFIT AMOUNT (MBA) CHANGE

We changed (1) monthly benefit to (2) beginning (3).

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA change in the format $$$$$.¢¢

Fill-in (3)

Effective Date (EFD) on the Post-MBR associated with the Monthly Benefit Amount (MBA) change in the format Month CCYY

RIN047 – MONTHLY BENEFIT AMOUNT (MBA) CHANGE - AGE REDUCTION FACTOR (ARF)

We changed (1) monthly benefit to (2) starting (3). We gave (4) credit for benefits that we did not pay at the full rate before (5) reached (6).

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA change in the format $$$$$.¢¢

Choice 2

Show the NA-HIST-POST-MBA in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

Effective Date (EFD) on the Post-MBR associated with the Monthly Benefit Amount (MBA) change in the format Month CCYY

Choice 2

NA-HIST-START month in the format Month CCYY

Fill-in (4)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (5)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (6)

 

Choice 1

age 60

Choice 2

age 62

Choice 3

full retirement age

RIN048 – MONTHLY BENEFIT AMOUNT (MBA) CHANGE - DELAYED RETIREMENT CREDIT (DRC)

We raised (1) monthly benefit amount beginning (2) to (3). We changed (4) benefit amount to give (5) credit for the past months that (6) delayed receiving retirement benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

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

Fill-in (2)

 

Choice 1

Effective Date (EFD) on the Post-MBR associated with the Monthly Benefit Amount (MBA) change in the format Month CCYY

Choice 2

TDA-RETAP-EVENT-DATE that corresponds to the TDA-EVENT-INDICATOR = A602 in the format Month CCYY

Fill-in (3)

 

Choice 1

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA change in the format $$$$$.¢¢

Choice 2

TDA-RETAP-EVENT-DATE that corresponds with TDA-EVENT-INDICATOR = A602 in the format $$$$$.¢¢

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (5)

 

Choice 1

you

Choice 2

him

Choice 3

her

Fill-in (6)

 

Choice 1

you

Choice 2

he

Choice 3

she

RIN049 – MONTHLY BENEFIT AMOUNT (MBA) CHANGE DUE TO INCORRECT MBA

We changed (1) monthly benefit to (2) as of (3). We found that (4) prior amount was incorrect.

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

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

Fill-in (2)

 

Choice 1

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA change in the format $$$$$.¢¢

Choice 2

NA-HIST-POST-MBA in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

Effective Date (EFD) on the Post-MBR associated with the Monthly Benefit Amount (MBA) change in the format Month CCYY

Choice 2

NA-HIST-START month in the format Month CCYY

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

RIN053 – MONTHLY BENEFIT AMOUNT (MBA) CHANGE DUE TO DUAL ENTITLEMENT (BENEFITS COMBINED OR DECOMBINED)

We changed (1) monthly benefit amount to (2) starting (3). We changed the amount because (4) also entitled on another record.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) on the MBA change in the format $$$$$$.¢¢

Fill-in (3)

Effective Date (EFD) on the Post-MBR associated with the Monthly Benefit Amount (MBA) change in the format Month CCYY

Fill-in (4)

 

Choice 1

you are

Choice 2

he is

Choice 3

she is

RIN059 – PRIMARY INSURANCE AMOUNT (PIA) CHANGE DUE TO CREDITABLE MILITARY SERVICE

We are changing (1) benefits to give (2) credit for time (3) spent in military service. This time was not included when we figured (4) benefit before.

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

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

Choice 3

his

Choice 4

her

Fill-in (2)

 

Choice 1

you

Choice 2

him

Choice 3

her

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

RIN060 – IDENTIFIES SPECIFIC YEAR(S) OF EARNINGS CREDITED TO THE NUMBER HOLDER, RESULTING IN A PRIMARY INSURANCE AMOUNT (PIA) INCREASE

We changed (1) benefit amount to give (2) credit for (3) (4) earnings. We did not include these earnings when we figured (5) benefit amount before.

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

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

Choice 3

his

Choice 4

her

Fill-in (2)

 

Choice 1

you

Choice 2

him

Choice 3

her

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (4)

 

Choice 1

Year of earnings in format CCYY

Choice 2

Year of earnings and year of earnings in format CCYY and CCYY

Choice 3

Year of earnings, year of earnings and year of earnings in format CCYY, CCYY and CCYY

Choice 4

Year of earnings, year of earnings, year of earnings and year of earnings in format CCYY, CCYY, CCYY and CCYY

Choice 5

Null

Fill-in (5)

 

Choice 1

your

Choice 2

his

Choice 3

her

RIN061 – DUALLY ENTITLED BENEFICIARY RECEIVING PRIMARY INSURANCE AMOUNT (PIA) INCREASE ON THE OTHER RECORD – NO INCREASE DUE ON OWN PIA

We reviewed our records to see if (1) due more money. We increased (2) benefits to give (3) credit for the earnings of (4) that we did not count before.

Fill-in values:

 

Fill-in (1)

 

Choice 1

you are

Choice 2

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

Fill-in (2)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (3)

 

Choice 1

you

Choice 2

him

Choice 3

her

Fill-in (4)

 

Choice 1

your spouse

Choice 2

his spouse

Choice 3

her spouse

Choice 4

Number Holder's (NH) Name (not possessive)

RIN062 – DUALLY ENTITLED BENEFICIARY RECEIVING PRIMARY INSURANCE AMOUNT (PIA) INCREASE ON OWN ACCOUNT – BENEFITS ON OTHER RECORD ARE ENDING BECAUSE BENEFICIARY’S OWN BENEFIT IS LARGER

We reviewed our records and found that we can increase (1) benefits. We increased (2) benefits because we gave (3) credit for earnings that we did not count before.

(4) benefits on (5) own record and as a (6) on another record. Since (7) benefits are now higher on (8) own record, we stopped the benefits (9) on the other record.

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

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

Choice 3

his

Choice 4

her

Fill-in (2)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (3)

 

Choice 1

you

Choice 2

him

Choice 3

her

Fill-in (4)

 

Choice 1

You receive

Choice 2

He receives

Choice 3

She receives

Fill-in (5)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (6)

 

Choice 1

spouse

Choice 2

parent

Choice 3

surviving spouse

Choice 4

divorced spouse

Choice 5

surviving former spouse

Fill-in (7)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (8)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (9)

 

Choice 1

you receive

Choice 2

he receives

Choice 3

she receives

RIN063 – DUALLY ENTITLED BENEFICIARY’S ONGOING MONTHLY PAYMENT AMOUNT REMAINS THE SAME OR IS SLIGHTLY DIFFERENT DUE TO ROUNDING – SMALLER PRIMARY INSURANCE AMOUNT (PIA) AND BENEFIT INCREASE ON OWN RECORD WHILE LARGER PIA ON OTHER RECORD REMAINS THE SAME BUT THE AMOUNT PAYABLE DECREASES

Since we increased the amount we pay (1) on (2) own record, we decreased the amount we pay (3) on another record.

Fill-in values:

 

Fill-in (1)

 

Choice 1

you

Choice 2

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

Choice 3

him

Choice 4

her

Fill-in (2)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (3)

 

Choice 1

you

Choice 2

him

Choice 3

her

RIN064 – DUALLY ENTITLED BENEFICIARY RECEIVES PRIMARY INSURANCE AMOUNT (PIA) INCREASE ON OWN RECORD AND ON THE OTHER RECORD

We increased the benefits on both Social Security records. To get the amount we can pay (1), we subtract the new benefit on (2) own record from the new benefit on the other record.

Fill-in values:

 

Fill-in (1)

 

Choice 1

you

Choice 2

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

Choice 3

him

Choice 4

her

Fill-in (2)

 

Choice 1

your

Choice 2

his

Choice 3

her

RIN065 – DUALLY ENTITLED BENEFICIARY RECEIVES PRIMARY INSURANCE AMOUNT (PIA) INCREASE ON OWN ACCOUNT – ONGOING MONTHLY PAYMENT AMOUNT REMAINS THE SAME OR IS SLIGHTLY DIFFERENT DUE TO ROUNDING – SMALLER PIA AND BENEFIT INCREASE ON OWN ACCOUNT WHILE LARGER PIA ON OTHER RECORD REMAINS THE SAME BUT AMOUNT PAYABLE DECREASES

Since we increased the amount we pay (1) on (2) own record, we decreased the amount we pay (3) on (4) spouse’s record.

Fill-in values:

 

Fill-in (1)

 

Choice 1

you

Choice 2

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

Choice 3

him

Choice 4

her

Fill-in (2)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (3)

 

Choice 1

you

Choice 2

him

Choice 3

her

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

RIN066 – MONTHLY BENEFIT AMOUNT (MBA) DECREASED BECAUSE ACTUAL EARNINGS WERE LESS THAN THE EXPECTED EARNINGS ORIGINALLY USED TO CALCULATE THE PRIMARY INSURANCE AMOUNT (PIA)

We reviewed (1) record and found that (2) earnings changed. These changes caused (3) monthly benefit amount to decrease effective (4).

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

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

Fill-in (2)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (4)

 

Choice 1

 

Post-MBR History Effective Date (EFD) associated with the first Primary Insurance Amount Effective Date (PIED) occurrence of Primary Insurance Amount (PIA) decrease in the format Month CCYY

F. RPA Universal Text Identifier – Representative Payee Annual Accounting

RPAC01 – CAPTION

It Is Important To Keep Track Of This Money

G. RPY Universal Text Identifiers – Representative Payee

RPY002 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF PAYEE DEVELOPMENT (DEVPYE) OR DEATH OF PAYEE (DTHPYE)

If you know someone who can be your payee, please call us at either of the telephone numbers shown at the end of this letter. We will consider this person for your new payee. Also, if you believe you are able to manage your own money, please let us know. Call us within the next 30 days if you do not hear from us. You may be able to get some payments directly while we make our decision.

RPY003 – SUSPENSION - HISTORY REASON FOR SUSPENSION OR TERMINATION (HRFST) OF PAYEE DEVELOPMENT (DEVPYE) OR DEATH OF PAYEE (DTHPYE)

If you know someone who can be your payee, please call us at either of the telephone numbers shown at the end of this letter. We will consider this person for your payee. Also, call us within the next 30 days if you do not hear from us. You may be able to keep getting some payments directly while we make our decision.

RPY015 – FORMER PAYEE NOTICE

Thank you for your willingness to serve as a representative payee. We have decided that it would be best for (1) to have (2) checks sent to another payee.

Fill-in values:

 

Fill-in (1)

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

Fill-in (2)

 

Choice 1

his

Choice 2

her

RPY016 – FORMER PAYEE NOTICE

We have decided that it would be best for (1) to have (2) checks sent to (3).

Fill-in values:

 

Fill-in (1)

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

Fill-in (2)

 

Choice 1

his

Choice 2

her

Fill-in (3)

 

Choice 1

him

Choice 2

her

RPY038 – PAYEE CHANGE TO SELF

We will begin to send your checks directly to you. The rest of this letter will give you more information about your benefits.

RPY039 – NEW PAYEE SELECTED

We have chosen you to be (1) representative payee. The rest of this letter will give you information about the checks you will receive while you are the payee.

Fill-in values:

 

Fill-in (1)

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

RPY041 – NEW PAYEE SELECTED

Please read the enclosed pamphlet, “A Guide for Representative Payees.” It lists the things you will need to know because you have been chosen as payee.

RPY042 – NEW PAYEE SELECTED

You will need to keep track of how you use all of the money we send you for (1). Each year we will ask you to report on how you used the money. We call this a representative payee accounting.

Fill-in values:

 

Fill-in (1)

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

RPY048 – NEW PAYEE SELECTED - NO BENEFITS PAYABLE

We have chosen you to be (1) representative payee. However, we cannot pay benefits at this time.

Fill-in values:

 

Fill-in (1)

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

RPY073 – PAYEE CHANGE - BENEFICIARY'S NOTICE

We have chosen (1) to be your representative payee. Your payee will receive your checks each month and will use this money for your needs.

Fill-in values:

 

Fill-in (1)

New Payee Name

RPY086 – BENEFICIARY DIES - PAYEE TOLD ABOUT CONSERVED FUNDS

You may have saved some Social Security money for (1). Any money that you have saved, plus any interest on that money, belongs to (2) estate.

Fill-in values:

 

 

Fill-in (1)

BGN plus BLN

Fill-in (2)

 

Choice 1

his

Choice 2

her

RPY087 – BENEFICIARY DIES - PAYEE TOLD OF DISPOSITION OF FUNDS

You need to do one of these things:

  • Give this money to the legal representative of the estate, or

  • If there is no legal representative, contact the state probate court. They will be able to tell you what to do with the money, or

  • If there is no legal representative, and you live outside the United States, contact the authorities who control the estate's money. They will be able to tell you what to do with the money.

H. RRB Universal Text Identifier – Railroad Board

RRBC01 – CAPTION

What The Railroad Retirement Board Will Do

I. RSD Universal Text Identifier – Not Qualified For Medicare

RSD003 – MEDICARE DISALLOWANCE - RESIDENCY

(1) cannot qualify for Medicare because (2) did not live in any of the 50 states, the District of Columbia, the Commonwealth of Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa or the Northern Mariana Islands at the time (3) applied for Medicare.

Fill-in values:

 

Fill-in (1)

 

Choice 1

He

Choice 2

She

Choice 3

You

Fill-in (2)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

NL 00730.146 "W" Paragraphs and Captions

List of “W” Paragraphs and Captions

A. WAV Universal Text Identifiers - Waiver

WAVC03 – CAPTION

If You Think You Should Not Have To Pay Us Back

WAV001 – WAIVER RIGHTS NEW OVERPAYMENT

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

  1. 1. 

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

  2. 2. 

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

    1. a. 

      The overpayment was not your fault in any way, and

    2. b. 

      You could not meet your necessary living expenses if we recovered the overpayment, or recovery would be unfair for some other reason.

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

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

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

WAV005 – CROSS PROGRAM RECOVERY FOR SUPPLEMENTAL SECURITY INCOME (SSI) OVERPAYMENT - USED WITH RCY002

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

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

AND

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

B. WCP Universal Text Identifiers – Workers’ Compensation

WCPC01 – CAPTION

Other Disability Payments Affect Benefits

WCP001 – NUMBER HOLDER INTENDS TO FILE FOR WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB)

We learned that (1) to file a claim for workers' compensation or public disability benefits. If (2) these payments, we may have to reduce (3) Social Security benefits.

At that time, (4) may also have to pay back any Social Security benefits that (5) not due. If (6) a claim, please tell us the decision made on the claim right away.

Fill-in values:

 

Fill-in (1)

 

Choice 1

NH-NAME plans

Choice 2

you plan

Fill-in (2)

 

Choice 1

you receive

Choice 2

he receives

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

Choice 4

your and your family’s

Choice 5

his and his family’s

Choice 6

her and her family's

Fill-in (4)

 

Choice 1

you

Choice 2

he

Choice 3

she

Choice 4

you and your family

Choice 5

he and his family

Choice 6

she and her family

Fill-in (5)

 

Choice 1

you were

Choice 2

he was

Choice 3

she was

Choice 4

you and your family were

Choice 5

he and his family were

Choice 6

she and her family were

Fill-in (6)

 

Choice 1

you file

Choice 2

he files

Choice 3

she files

WCP003 – NUMBER HOLDER RECEIVES WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB) PUBLICATION 05-10018

We have to consider workers' compensation and/or public disability payments when we figure a Social Security benefit. The following will explain how these payments affect Social Security benefits. For more information, please read the enclosed pamphlet, “How Workers' Compensation and Other Disability Payments May Affect Your Social Security Benefits.”

WCP004 – NUMBER HOLDER RECEIVES WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB) AND MONTHLY BENEFIT AMOUNT (MBA) IS NOT OFFSET

(1) present (2) payments of (3) do not affect (4) Social Security benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

NH-NAME plans

Choice 2

you plan

Fill-in (2)

 

Choice 1

workers' compensation

Choice 2

public disability

Choice 3

workers' compensation and public disability

Fill-in (3)

 

Choice 1

Workers’ Compensation Payment Amounts (WCPD-WC-AMT) in the format $$$$$.¢¢

Choice 2

Public Disability Benefits Amount (WCPD-PDB-AMT) in the format $$$$$.¢¢

Choice 3

Sum of Workers’ Compensation Payment Amounts (WCPD-WC-AMT) plus Public Disability Benefits Amount (WCPD-PDB-AMT) in the format $$$$$.¢¢

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Choice 4

his and his family’s

Choice 5

her and her family’s

Choice 6

your and your family’s

WCP007 – WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB) APPEAL PENDING

We will not reduce (1) benefit because of (2) (3) payments until a decision is made on the appeal of the claim. At that time, we may collect any money that should not have been paid.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

NH-NAME

Fill-in (3)

 

Choice 1

workers' compensation

Choice 2

public disability

Choice 3

workers' compensation and public disability

WCP008 – TELLS AUXILIARY THAT NUMBER HOLDER INTENDS TO FILE FOR WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB)

If (1) receives workers' compensation and/or public disability payments, we may have to reduce (2) Social Security benefits. At that time, we may also have to recover any money that should not have been paid.

Fill-in values:

 

Fill-in (1)

NH-NAME

Fill-in (2)

 

Choice 1

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

Choice 2

your

WCP009 – NUMBER HOLDER APPEALS WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB)

We will not reduce (1) benefit because of (2) payments until (3) a decision on (4) appeal of the claim. Please let us know the decision on the appeal right away. At that time, (5) may have to pay back any Social Security benefits that (6) not due.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

workers' compensation

Choice 2

public disability

Choice 3

workers' compensation and public disability

Fill-in (3)

 

Choice 1

you receive

Choice 2

he receives

Choice 3

she receives

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (5)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (6)

 

Choice 1

you were

Choice 2

he was

Choice 3

she was

WCP013 – ADVISES NUMBER HOLDER OF REVERSE JURISDICTION

Beginning (1), we are paying (2) a Social Security benefit that is not reduced due to (3) payments. This is because of a change caused by the State law which provides for the reduction of these payments to persons who receive Social Security disability benefits.

Fill-in values:

 

Fill-in (1)

IDET Reverse Jurisdiction Start Date (IDET-RJ-START) in Month CCYY format

Fill-in (2)

 

Choice 1

NH-NAME

Choice 2

you

Fill-in (3)

 

Choice 1

workers' compensation

Choice 2

public disability

Choice 3

workers' compensation and public disability

WCP015 – TRIENNIAL REDETERMINATION (EVERY 3 YEARS)

Based on (1) (2), every 3 years, we check to see if an increase in the national earnings level affects the amount of (3) monthly Social Security benefit. When we checked (4) monthly benefit amount, we found that (5) due more money.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

workers' compensation payment

Choice 2

public disability payment

Choice 3

workers' compensation and public disability payments

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

he is

Choice 2

she is

Choice 3

you are

WCP016 – MONTHLY BENEFIT AMOUNT (MBA) OFFSET DUE TO WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB) AND COST-OF-LIVING ADJUSTMENT (COLA) DUE

A cost-of-living increase is not reduced because of (1) workers' compensation and/or public disability payments.

Fill-in values:

 

Fill-in (1)

 

Choice 1

NH-NAME (possessive)

Choice 2

your

WCP019 – WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB) STOPS – NUMBER HOLDER AGE 65 MINUS ONE MONTH PRIOR TO DECEMBER 19, 2015

Beginning (1), we are not reducing (2) benefit because of (3) payments. We do not reduce benefits for months when the disabled worker is age (4) or over.

Fill-in values:

 

Fill-in (1)

Amount of Offset End Date (AMOF-STOP-REL) plus 1 month

Fill-in (2)

 

Choice 1

NH-NAME (possessive)

Choice 2

your

Choice 3

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

Fill-in (3)

 

Choice 1

workers' compensation

Choice 2

public disability

Choice 3

workers' compensation and public disability

Fill-in (4)

65

WCP020 – USED WITH WCP003

The pamphlet explains how we reduce (1) Social Security Disability benefits if the money which (2) and (3) family would receive from Social Security and (4) adds up to more than 80 percent of (5) monthly average earnings. We found that 80 percent of (6) average current earnings is (7).

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

workers' compensation

Choice 2

public disability

Choice 3

workers' compensation and public disability

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (6)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (7)

80 Percent Average Current Earnings (ACE-80) in format $$$$$.¢¢

WCP021 – NUMBER HOLDER NEEDS PROOF FOR EXPENSES

If (1) had any expenses related to (2) claim for (3) payments, please give us proof that (4) paid these expenses. These expenses may include medical, legal, or other related expenses. We may be able to deduct some of these expenses when we figure (5) Social Security benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

you

Fill-in (2)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (3)

 

Choice 1

workers' compensation

Choice 2

workers' compensation and public disability benefit

Choice 3

public disability benefit

Fill-in (4)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (5)

 

Choice 1

your and your family’s

Choice 2

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

Choice 3

your family’s

Choice 4

your

Choice 5

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) plus “and his family’s”

Choice 6

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) plus “and her family’s

Choice 7

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

WCP022 – CHANGE IN AVERAGE CURRENT EARNINGS (ACE) AMOUNT

We told (1) earlier that we might change the amount of (2) benefits when we got more facts about the money (3) earned while (4) (5) working. Using the new facts about (6) earnings, we found that 80 percent of (7) average current earnings was (8).

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

you

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (4)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (5)

 

Choice 1

was

Choice 2

were

Fill-in (6)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (7)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (8)

80 Percent Average Current Earnings (ACE-80) in format $$$$$.¢¢

WCP023 – NUMBER HOLDER BENEFITS SUSPENDED FOR WORKERS’ COMPENSATION OFFSET - NO LUMP SUM INVOLVED

We have to take into account (1) (2) of (3) when we figure (4) Social Security benefits. Because of (5), (6) monthly Social Security benefits are not payable (7).

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

workers' compensation payment

Choice 2

public disability payment

Choice 3

workers' compensation and public disability payments

Fill-in (3)

 

Choice 1

Workers’ Compensation Payment Amounts (WCPD-WC-AMT) in format $$$$$.¢¢

Choice 2

Public Disability Benefits Amount (WCPD-PDB-AMT) in format $$$$$.¢¢

Choice 3

Sum of the Workers’ Compensation Payment Amounts (WCPD-WC-AMT) and Public Disability Benefits Amount (WCPD-PDB-AMT) in format $$$$$.¢¢

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

this payment

Choice 2

these payments

Fill-in (6)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (7)

 

Choice 1

for this period

Choice 2

Null

WCP024 – NUMBER HOLDER'S MONTHLY BENEFIT AMOUNT (MBA) REDUCED DUE TO WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB)

We have to take into account (1) (2) of (3) when we figure (4) Social Security benefits. Because of (5), we changed (6) monthly Social Security benefits to (7) beginning (8).

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

workers' compensation payment

Choice 2

public disability payment

Choice 3

workers' compensation and public disability payments

Fill-in (3)

 

Choice 1

Workers’ Compensation Payment Amounts (WCPD-WC-AMT) in format $$$$$.¢¢

Choice 2

Public Disability Benefits Amount (WCPD-PDB-AMT) in format $$$$$.¢¢

Choice 3

Sum of the Workers’ Compensation Payment Amounts (WCPD-WC-AMT) and Public Disability Benefits Amount (WCPD-PDB-AMT) in format $$$$$.¢¢

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

this payment

Choice 2

these payments

Fill-in (6)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (7)

 

Choice 1

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA change in the format $$$$$.¢¢

Choice 2

NA-HIST-POST-MBA in the format $$$$$.¢¢

Fill-in (8)

 

Choice 1

Effective Date (EFD) on the post-MBR associated with the Monthly Benefit Amount (MBA) change in the format Month CCYY

Choice 2

NA-HIST-START month in the format Month CCYY

WCP025 – AUXILIARY MONTHLY BENEFIT AMOUNT (MBA) CHANGED DUE TO WCPDB AND ENTITLED AUXILIARY

We changed (1) monthly benefit to (2) beginning (3) because we started paying another person on this record. When we figured (4) benefit, we had to take into account (5) (6) payments.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA change in the format $$$$$.¢¢

Choice 2

NA-HIST-POST-MBA in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

Effective Date (EFD) on the post-MBR associated with the Monthly Benefit Amount (MBA) change

Choice 2

NA-HIST-START month in the format Month CCYY

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

NH-NAME (possessive)

Fill-in (6)

 

Choice 1

workers' compensation

Choice 2

public disability

Choice 3

workers' compensation and public disability

WCP026 – AUXILIARY MONTHLY BENEFIT AMOUNT (MBA) CHANGED DUE TO WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB) AND TERMINATED AUXILIARY

We changed (1) monthly benefit to (2) beginning (3) because benefits to another entitled person stopped. When we figured (4) benefit, we had to take into account (5) (6) payments.

WCP027 – NUMBER HOLDER HAS EXCLUDABLE AMOUNTS FOR EXPENSES

When we figure how much to reduce (1) benefits, we do not count certain medical, legal or other expenses which were paid out of (2) (3) payments. We excluded (4) when we figured (5) benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

NH-NAME (possessive)

Choice 2

NH-NAME (possessive) plus “and his family's”

Choice 3

NH-NAME (possessive) plus “and her family's”

Choice 4

NH-NAME (possessive) plus “family's”

Choice 5

your

Choice 6

your and your family's

Choice 7

your family's

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

workers' compensation

Choice 2

public disability

Choice 3

workers' compensation and public disability

Fill-in (4)

Total amount of excludable expenses

Fill-in (5)

 

Choice 1

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

Choice 2

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) plus “and his family's”

Choice 3

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) plus “and her family's”

Choice 4

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) plus “family's”

Choice 5

your

Choice 6

your and your family's

Choice 7

your family's

WCP028 – USED WITH WCP003 ONE BENEFICIARY’S MONTHLY BENEFIT AMOUNT (MBA) IS OFFSET- NUMBER HOLDER AGE 65 MINUS ONE MONTH PRIOR TO DECEMBER 19, 2015

We may continue to reduce or withhold (1) disability benefits until (2) age 65. We must take this action because of (3) (4) payments. (5) payments do not affect retirement benefits. (6) may be eligible for retirement benefits at age 62. To apply, please get in touch with us three months before (7) age 62.

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

your and your family’s

Choice 3

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

Choice 4

your family’s

Choice 5

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) plus “and his family’s”

Choice 6

Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) plus “and her family's”

Choice 7

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

Fill-in (2)

 

Choice 1

you reach

Choice 2

he reaches

Choice 3

she reaches

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (4)

 

Choice 1

workers' compensation

Choice 2

workers' compensation and public disability benefit

Choice 3

public disability benefit

Fill-in (5)

 

Choice 1

Workers' compensation

Choice 2

Workers' compensation and public disability benefit

Choice 3

Public disability benefit

Fill-in (6)

 

Choice 1

You

Choice 2

He

Choice 3

She

Fill-in (7)

 

Choice 1

you reach

Choice 2

she reaches

Choice 3

he reaches

WCP029 – NUMBER HOLDER'S WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB) CLAIM PENDING

If (1) workers' compensation and/or public disability benefit payments, we may have to reduce (2) Social Security benefits.

At that time, (3) may also have to pay back any Social Security benefits that (4) not due. Please let us know the decision on the claim right away.

Fill-in values:

 

Fill-in (1)

 

Choice 1

NH-NAME receives

Choice 2

you receive

Fill-in (2)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

you were

Choice 2

he was

Choice 3

she was

WCP030 – NUMBER HOLDER BENEFITS SUSPENDED FOR WORKERS’ COMPENSATION OFFSET (WCOFFS) LUMP SUM INVOLVED

We consider (1) (2) of (3) when we figure (4) Social Security benefits. Because of (5), we cannot pay (6) Social Security benefits (7).

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

workers’ compensation lump-sum payment

Choice 2

public disability benefit lump-sum payment

Choice 3

workers’ compensation and public disability benefit lump-sum payments

Fill-in (3)

 

Choice 1

Show the Lump Sum Gross Amount (INIL-LS-GROSS) amount in the format 99,999.99

Choice 2

Show the total of all Lump Sum Gross Amount (INIL-LS-GROSS) amounts in the format 99,999.99

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (5)

 

Choice 1

this lump-sum payment

Choice 2

these lump-sum payments

Fill-in (6)

 

Choice 1

you

Choice 2

him

Choice 3

her

Fill-in (7)

 

Choice 1

Null

Choice 2

for plus Month CCYY through plus Month CCYY

Choice 3

for plus Month CCYY

WCP031 – NUMBER HOLDER MONTHLY BENEFIT AMOUNT (MBA) REDUCED LUMP SUM AWARD PAYMENT INVOLVED

We consider (1) (2) of (3) when we figure (4) Social Security benefits. Because of (5), we changed (6) monthly Social Security benefits to (7) starting (8).

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

workers’ compensation lump-sum payment

Choice 2

public disability benefit lump-sum payment

Choice 3

workers’ compensation and public disability benefit lump-sum payments

Fill-in (3)

 

Choice 1

Show the Lump Sum Gross Amount (INIL-LS-GROSS) amount in the format 99,999.99

Choice 2

Show the total of all Lump Sum Gross Amount (INIL-LS-GROSS) amounts in the format 99,999.99

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (5)

 

Choice 1

this lump-sum payment

Choice 2

these lump-sum payments

Fill-in (6)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (7)

 

Choice 1

Show the post Master Beneficiary Record (MBR) Monthly Benefit Amount (MBA) associated with the ongoing History Effective Date (EFD) of the MBA change in the format 99,999.99

Choice 2

Show the NA-HIST-POST-MBA occurrence associated with the embedded History Effective Date (EFD) in the format 99,999.99

Fill-in (8)

 

Choice 1

Show the History Effective Date (EFD) on the post Master Beneficiary Record (MBR) associated with the MBA change in the format Month CCYY

Choice 2

Show the NA-HIST-START month in the format Month CCYY

WCP032 – USED WITH WCP003 - INFORMATIONAL REPORTING

Please let us know right away about any:

  • Changes in (1) workers' compensation or public disability benefit payments.

  • Lump-sum award(s) (2).

  • Other payments (3) that increase or decrease (4) workers’ compensation or public disability benefit payments.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

you receive

Choice 2

he receives

Choice 3

she receives

Fill-in (3)

 

Choice 1

you receive

Choice 2

he receives

Choice 3

she receives

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

WCP033 – NUMBER HOLDER'S WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB) STOPS < CURRENT OPERATING MONTH (COM) AND < (AGE 65 PRIOR TO DECEMBER 19, 2015 OR < FRA IF ON OR AFTER DECEMBER 19, 2015)

We do not reduce monthly Social Security benefits once (1) (2) payments stop. We changed (3) monthly benefit to the full rate of (4) beginning (5).

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

workers' compensation

Choice 2

public disability

Choice 3

workers' compensation and public disability

Choice 4

periodic

Fill-in (3)

 

Choice 1

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

Choice 2

your

Fill-in (4)

 

Choice 1

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA change in the format $$$$$.¢¢

Choice 2

NA-HIST-POST-MBA in the format $$$$$.¢¢

Fill-in (5)

 

Choice 1

Effective Date (EFD) on the post-MBR associated with the MBA change in the format Month CCYY

Choice 2

NA-HIST-START month in the format Month CCYY

WCP034 – EMBEDDED WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB) PERIOD MONTHLY BENEFIT AMOUNT (MBA) CHANGE AND EFDS

(1) monthly benefit is (2) (3) (4) (5) (6).

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

Monthly Benefit Amount (MBA) associated with the first Effective Date (EFD) of MBA change

Fill-in (3)

for

Fill-in (4)

First Effective Date (EFD) associated with the Monthly Benefit Amount (MBA) change

Fill-in (5)

 

Choice 1

and

Choice 2

through

Choice 3

Null

Fill-in (6)

 

Choice 1

Null

Choice 2

Last Effective Date (EFD) associated with this Monthly Benefit Amount (MBA) change

WCP035 – LUMP SUM AWARD PAYMENT - METHOD A USED

(1) (2) received a lump-sum award(s) of (3) to settle (4) (5) claim. A lump sum award affects Social Security benefits in the same way that periodic payments do. We treat a lump-sum award as if it were paid on a weekly basis.

When we figure how much to reduce (6) benefits, we treated the lump-sum as if (7) had been paid (8) each week. We excluded (9) for legal expenses, and (10) for medical expenses.

Fill-in values:

 

Fill-in (1)

 

Choice 1

NH-NAME

Choice 2

You

Fill-in (2)

 

Choice 1

has

Choice 2

have

Fill-in (3)

Using all changed occurrence of Injury/Illness (INIL) Data, show the sum of Lump Sum Gross Total (INIL-LS-GROSS) amounts

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

workers' compensation

Choice 2

public disability

Choice 3

workers' compensation and public disability

Fill-in (6)

 

Choice 1

NH-NAME (possessive)

Choice 2

NH-NAME (possessive) plus “and his family's”

Choice 3

NH-NAME (possessive) plus “and her family's”

Choice 4

NH-NAME (possessive) plus “family's”

Choice 5

your

Choice 6

your and your family's

Choice 7

your family's

Fill-in (7)

 

Choice 1

NH-NAME

Choice 2

you

Fill-in (8)

Sum of IDET Weekly Rate Method A (IDET-WK-RATE-A) amounts that correspond to the changed occurrence(s) of Lump Sum Gross Total (INIL-LS-GROSS) in the format $$$$$.¢¢

Fill-in (9)

Sum of Lump Sum Attorney Expenses (INIL-LS-ATY-EX) amounts that correspond to the changed occurrence(s) of Lump Sum Gross Total (INIL-LS-GROSS) in the format $$$$$.¢¢

Fill-in (10)

Sum of Lump Sum Medical Expenses (INIL-LS-MED-EX) amounts that correspond to the changed occurrence(s) of Lump Sum Gross Total (INIL-LS-GROSS) in the format $$$$$.¢¢

WCP036 – LUMP SUM AWARD PAYMENT - METHOD B USED

(1) (2) received a lump-sum award(s) of (3) to settle (4) (5) claim. A lump-sum award affects Social Security benefits in the same way that periodic payments do. We treat a lump-sum award as if it were paid on a weekly basis.

When we figured how much to reduce (6) benefits, we treated the lump-sum as if (7) had been paid (8) each week. We excluded (9) for legal expenses, medical and other expenses. For this reason, we lowered the weekly rate from (10) to (11).

Fill-in values:

 

Fill-in (1)

 

Choice 1

NH-NAME

Choice 2

You

Fill-in (2)

 

Choice 1

has

Choice 2

have

Fill-in (3)

Using all changed occurrence of Injury/Illness (INIL) Data, show the sum of Lump Sum Gross Total (INIL-LS-GROSS) amounts

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

workers' compensation

Choice 2

public disability

Choice 3

workers' compensation and public disability

Fill-in (6)

 

Choice 1

NH-NAME (possessive)

Choice 2

NH-NAME (possessive) plus “and his family's”

Choice 3

NH-NAME (possessive) plus “and her family's”

Choice 4

NH-NAME (possessive) plus “family's”

Choice 5

your

Choice 6

your and your family's

Choice 7

your family's

Fill-in (7)

 

Choice 1

NH-NAME

Choice 2

you

Fill-in (8)

Sum of Lump Sum Proration Amount (INIL-LS-PROAMT) amounts that correspond to the changed occurrence(s) of Injury/Illness (INIL) data in the format $$$$$.¢¢

Fill-in (9)

Sum of Lump Sum Attorney Expenses (INIL-LS-ATY-EX), Lump Sum Medical Expenses (INIL-MED-EX), Lump Sum Special Expenses (INIL-LS-SPECEX), and Lump Sum-Related Expenses (INIL-LS-RLTDEX) amounts that correspond to the changed occurrence(s) of Lump Sum Gross Total (INIL-LS-GROSS) in the format $$$$$.¢¢

Fill-in (10)

Sum of Lump Sum Proration Amounts (INIL-LS-PROAMT) that correspond to the changed occurrence(s) of Injury/Illness (INIL) data in the format $$$$$.¢¢

Fill-in (11)

Sum of IDET Weekly Rate Method B (IDET-WK-RATE-B) amounts that correspond to the changed occurrence(s) of Lump Sum Gross Total (INIL-LS-GROSS) in the format $$$$$.¢¢

WCP037 – LUMP SUM AWARD PAYMENT - METHOD C USED – USED FOR NUMBER HOLDER ONLY

(1) (2) received a lump-sum award(s) of (3) to settle (4) (5) claim. A lump-sum award affects Social Security benefits in the same way that periodic payments do. We treat a lump-sum award as if it were paid on a weekly basis.

When we figured how much to reduce (6) benefits, we excluded (7) for legal expenses, medical and other expenses. We treated the rest of the lump-sum, (8), as if (9) had been paid (10) per week. We will pay full benefits beginning (11).

Fill-in values:

 

Fill-in (1)

 

Choice 1

NH-NAME

Choice 2

You

Fill-in (2)

 

Choice 1

has

Choice 2

have

Fill-in (3)

Using all changed occurrence of Injury/Illness (INIL) data, show the sum of Lump Sum Gross Total (INIL-LS-GROSS) amounts

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

workers' compensation

Choice 2

public disability

Choice 3

 

Fill-in (6)

 

Choice 1

NH-NAME (possessive)

Choice 2

NH-NAME (possessive) plus “and his family's”

Choice 3

NH-NAME (possessive) plus “and her family's”

Choice 4

NH-NAME (possessive) plus “family's”

Choice 5

your

Choice 6

your and your family's

Choice 7

your family's

Fill-in (7)

Sum of Lump Sum Attorney Expenses (INIL-LS-ATY-EX), Lump Sum Medical Expenses (INIL-MED-EX), Lump Sum Special Expenses (INIL-LS-SPECEX), and Lump Sum-Related Expenses (INIL-LS-RLTDEX) amounts that correspond to the changed occurrence(s) of Lump Sum Gross Total (INIL-LS-GROSS) in the format $$$$$.¢¢

Fill-in (8)

Using all changed occurrence(s) of Injury/Illness (INIL) data, show the sum of Lump Sum Gross Total (INIL-LS-GROSS) amounts minus the total expenses that are shown in Fill-in (7) in the format $$$$$.¢¢

Fill-in (9)

 

Choice 1

he

Choice 2

she

Choice 3

you

Fill-in (10)

Sum of IDET Weekly Rate Method C (IDET-WK-RATE-C) amounts that corresponds to the changed occurrence(s) of Lump Sum Gross Total (INIL- LS-GROSS) in the format $$$$$.¢¢

Fill-in (11)

Changed occurrence of IDET Lump Sum Proration Stop Date Method C (IDET-STOP-C) plus one month that corresponds to the changed occurrence(s) of Lump Sum Gross Total (INIL-LS-GROSS) in the format Month CCYY

WCP038 – NUMBER HOLDER RECEIVES PERIODIC PAYMENTS NO PROOF

We may have to change the amount of (1) benefits when we receive proof of the amount of (2) (3) payments.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (3)

 

Choice 1

workers' compensation

Choice 2

public disability

Choice 3

workers' compensation and public disability

WCP039 – AUXILIARY BENEFITS SUSPENDED - WCOFFS DUE TO NUMBER HOLDER'S WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB)

We have to take into account (1) (2) when we figure (3) Social Security benefits. Because of (4), (5) monthly Social Security benefits are not payable (6).

Fill-in values:

 

Fill-in (1)

NH-NAME (possessive)

Fill-in (2)

 

Choice 1

workers' compensation payment

Choice 2

public disability payment

Choice 3

workers' compensation and public disability payments

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

this payment

Choice 2

these payments

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (6)

 

Choice 1

for this period

Choice 2

Null

WCP040 – AUXILIARY MONTHLY BENEFIT AMOUNT (MBA) CHANGED DUE TO NUMBER HOLDER'S WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB)

We have to take into account (1) (2) when we figure (3) Social Security benefits. Because of (4), we changed (5) monthly Social Security benefit to (6) beginning (7).

Fill-in values:

 

Fill-in (1)

NH-NAME (possessive)

Fill-in (2)

 

Choice 1

workers' compensation payment

Choice 2

public disability payment

Choice 3

workers' compensation and public disability payments

Fill-in (3)

 

Choice 1

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

Choice 2

your

Fill-in (4)

 

Choice 1

this payment

Choice 2

these payments

Fill-in (5)

 

Choice 1

 

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

Choice 2

your

Fill-in (6)

 

Choice 1

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA change in the format $$$$$.¢¢

Choice 2

NA-HIST-POST-MBA in the format $$$$$.¢¢

Fill-in (7)

 

Choice 1

EFD on the post-MBR associated with the MBA change in the format Month CCYY

Choice 2

NA-HIST-START month in the format Month CCYY

WCP041 – MONTHLY BENEFIT AMOUNT (MBA) CHANGE DUE TO WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB) AND COST-OF-LIVING ADJUSTMENT (COLA) NOT PIC A

We have to take into account (1) (2) when we figure (3) Social Security benefits. Because of (4), we changed (5) monthly Social Security benefit to (6) beginning (7). This change also includes the cost of living increase.

Fill-in values:

 

Fill-in (1)

NH-NAME (possessive)

Fill-in (2)

 

Choice 1

workers' compensation payment

Choice 2

public disability payment

Choice 3

workers' compensation and public disability payments

Fill-in (3)

 

Choice 1

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

Choice 2

your

Fill-in (4)

 

Choice 1

this payment

Choice 2

these payments

Fill-in (5)

 

Choice 1

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

Choice 2

your

Fill-in (6)

 

Choice 1

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA change in the format $$$$$.¢¢

Choice 2

NA-HIST-POST-MBA in the format $$$$$.¢¢

WCP042 – NUMBER HOLDER MONTHLY BENEFIT AMOUNT (MBA) CHANGE DUE TO WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB) AND COST-OF-LIVING ADJUSTMENT (COLA) NO LUMP SUM INVOLVED

We have to take into account (1) (2) of (3) when we figure (4) Social Security benefits. Because of (5), we changed (6) monthly Social Security benefit to (7) beginning (8). This change also includes the cost of living increase.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

workers' compensation payment

Choice 2

public disability payment

Choice 3

workers' compensation and public disability payments

Fill-in (3)

 

Choice 1

Workers’ Compensation Payment Amounts (WCPD-WC-AMT) in the format $$$$$.¢¢

Choice 2

Public Disability Benefits Amount (WCPD-PDB-AMT) in the format $$$$$.¢¢

Choice 3

Sum of the Workers’ Compensation Payment Amounts (WCPD-WC-AMT) and the Public Disability Benefits Amount (WCPD-PDB-AMT) and show this total as the value in the format $$$$$.¢¢

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

this payment

Choice 2

these payments

Fill-in (6)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (7)

 

Choice 1

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA change in the format $$$$$.¢¢

Choice 2

NA-HIST-POST-MBA in the format $$$$$.¢¢

Fill-in (8)

 

Choice 1

Effective Date (EFD) on the post-MBR associated with the Monthly Benefit Amount (MBA) change in the format Month CCYY

Choice 2

NA-HIST-START month in the format Month CCYY

WCP043 – NUMBER HOLDER MONTHLY BENEFIT AMOUNT (MBA) CHANGE DUE TO WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB) AND COST-OF-LIVING ADJUSTMENT (COLA) LUMP SUM INVOLVED

We have to take into account (1) lump-sum payment(s) of (2) when we figure (3) Social Security benefits. Because of (4), we changed (5) monthly Social Security benefit to (6) beginning (7). This change also includes the cost of living increase.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

Lump Sum Gross Total (INIL-LS-GROSS) amount in the format $$$$$.¢¢

Choice 2

Total of all Lump Sum Gross Total (INIL-LS-GROSS) amounts in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (4)

 

Choice 1

this payment

Choice 2

these payments

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (6)

 

Choice 1

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA change in the format $$$$$.¢¢

Choice 2

NA-HIST-POST-MBA in the format $$$$$.¢¢

Fill-in (7)

 

Choice 1

Effective Date (EFD) on the post-MBR associated with the Monthly Benefit Amount (MBA) change in the format Month CCYY

Choice 2

NA-HIST-START month in the format Month CCYY

WCP044 – AUXILIARY MONTHLY BENEFIT AMOUNT (MBA) CHANGE FOR WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB), COST-OF-LIVING ADJUSTMENT (COLA) AND BENEFICIARY TERMINATED

We changed (1) monthly benefit to (2) beginning (3) because benefits to another entitled person(s) stopped. When we figured (4) benefit, we had to take into account (5) (6) payments. This change also includes the cost-of-living increase.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA change in the format $$$$$.¢¢

Choice 2

NA-HIST-POST-MBA in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

Effective Date (EFD) on the post-MBR associated with the Monthly Benefit Amount (MBA) change in the format Month CCYY

Choice 2

NA-HIST-START month in the format Month CCYY

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

NH-NAME (possessive)

Fill-in (6)

 

Choice 1

workers' compensation

Choice 2

public disability

Choice 3

workers' compensation and public disability

WCP045 – AUXILIARY MONTHLY BENEFIT AMOUNT (MBA) CHANGE FOR NUMBER HOLDER’S WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB), COST-OF-LIVING ADJUSTMENT (COLA) AND ANOTHER BENEFICIARY STARTS RECEIVING BENEFITS

We changed (1) monthly benefit to (2) beginning (3) because we started paying another person(s) on this record. When we figured (4) benefit, we had to take into account (5) (6) payments. This change also includes the cost-of-living increase.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA change in the format $$$$$.¢¢

Choice 2

NA-HIST-POST-MBA in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

Effective Date (EFD) on the post-MBR associated with the Monthly Benefit Amount (MBA) change in the format Month CCYY

Choice 2

NA-HIST-START month in the format Month CCYY

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

NH-NAME (possessive)

Fill-in (6)

 

Choice 1

workers' compensation

Choice 2

public disability

Choice 3

workers' compensation and public disability

WCP046 – AUXILIARY NOTICE – NUMBER HOLDER'S WORKERS’ COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB) STOP – MONTHLY BENEFIT AMOUNT (MBA) NOT AFFECTED

We changed (1) monthly benefit to (2) beginning (3) because (4) present (5) payment(s) do not affect (6) monthly Social Security benefits.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA change in the format $$$$$.¢¢

Fill-in (3)

Effective Date (EFD) on the post-MBR associated with the Monthly Benefit Amount (MBA) change in the format Month CCYY

Fill-in (4)

NH-NAME (possessive)

Fill-in (5)

 

Choice 1

workers' compensation

Choice 2

public disability

Choice 3

workers' compensation and public disability

Fill-in (6)

 

Choice 1

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

Choice 2

your

WCP047 – NUMBER HOLDER MONTHLY BENEFIT AMOUNT (MBA) CHANGE AMOF DELETED FROM POST-MBR

We changed (1) monthly Social Security benefit to (2) beginning (3) because (4) benefits are not affected by (5) receipt of workers' compensation and/or public disability payments.

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

 

Choice 1

Post-MBR Monthly Benefit Amount (MBA) associated with the Effective Date (EFD) of the MBA change in the format $$$$$.¢¢

Choice 2

NA-HIST-POST-MBA in the format $$$$$.¢¢

Fill-in (3)

 

Choice 1

Effective Date (EFD) on the post-MBR associated with the Monthly Benefit Amount (MBA) change in the format Month CCYY

Choice 2

NA-HIST-START month in the format Month CCYY

Fill-in (4)

 

Choice 1

his

Choice 2

her

Choice 3

your

Fill-in (5)

 

Choice 1

his

Choice 2

her

Choice 3

your

WCP060 - WORKER’S COMPENSATION (WC)/PUBLIC DISABILITY BENEFITS (PDB) STOPS- NUMBER HOLDER AGE 65 MINUS ONE MONTH AFTER DECEMBER 19, 2015

Starting (1), we will stop reducing (2) Social Security disability benefits because of (3) (4) payments. We stop reducing disability benefits when (5) full retirement age.

Fill-in values:

 

Fill-in (1)

Date of FRA attainment in Month CCYY format

Fill-in (2)

 

Choice 1

NH-NAME (possessive)

Choice 2

your

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (4)

 

Choice 1

worker’s compensation

Choice 2

public disability benefit

Choice 3

worker’s compensation and public disability benefit

Fill-in (5)

 

Choice 1

you reach

Choice 2

he reaches

Choice 3

she reaches

WCP061 - BENEFICIARY’S MONTHLY BENEFIT AMOUNT (MBA) IS OFFSET- NUMBER HOLDER AGE 65 MINUS ONE MONTH AFTER DECEMBER 19, 2015

We will continue to reduce or withhold (1) disability benefits until (2) full retirement age in (3). We must take this action because of (4) (5) payments.

(6) (7) payments do not affect retirement benefits. (8) may be eligible for reduced retirement benefits at age 62. If (9) to apply for retirement benefits, please contact us three months before (10) age 62.

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

NULL plus BGN plus BLN (possessive)

Choice 3

your and your family’s

Choice 4

your family’s

Choice 5

null plus BGN plus BLN (possessive) plus and his family’s

Choice 6

NULL plus BGN plus BLN (possessive) plus and her family’s

Choice 7

NULL plus BGN plus BLN (possessive) plus family’s

Fill-in (2)

 

Choice 1

you reach

Choice 2

he reaches

Choice 3

she reaches

Fill-in (3)

Date of FRA attainment in the format Month CCYY

Fill-in (4)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (5)

 

Choice 1

worker’s compensation

Choice 2

public disability benefit

Choice 3

worker’s compensation and public disability benefit

Fill-in (6)

 

Choice 1

Your

Choice 2

His

Choice 3

Her

Fill-in (7)

 

Choice 1

worker’s compensation

Choice 2

public disability benefit

Choice 3

worker’s compensation and public disability benefit

Fill-in (8)

 

Choice 1

You

Choice 2

He

Choice 3

She

Fill-in (9)

 

Choice 1

you decide

Choice 2

he decides

Choice 3

she decides

Fill-in (10)

 

Choice 1

you reach

Choice 2

he reaches

Choice 3

she reaches

C. WDS Universal Text Identifiers – Work And Earnings Deduction/Suspension

WDS009 – THIS UTI EXPLAINS TO THE BENEFICIARY THAT THE FOLLOWING YEAR WHEN HIS OR HER EARNINGS ARE KNOWN THE BENEFICIARY'S BENEFITS WILL BE REEVALUATED

After the year has ended and we know (1) actual earnings, we will review (2) record. We will compare the actual and estimated earnings to decide if we paid (3) more or less than (4) due. We will then pay any benefits due, or we will ask (5) to pay us back if we paid too much.

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

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

Fill-in (2)

 

Choice 1

your

Choice 2

his

Choice 1

her

Fill-in (3)

 

Choice 1

you

Choice 2

him

Choice 1

her

Fill-in (4)

 

Choice 1

you were

Choice 2

he was

Choice 3

she was

Fill-in (5)

 

Choice 1

you

Choice 2

him

Choice 3

her

WDS010 – REFER TO WORKSHEET HEADER NL 00730.149D

WDS012 – REFER TO WORKSHEET HEADER NL 00730.149D

WDS014 – REFER TO WORKSHEET HEADER NL 00730.149D

 

D. WDW Universal Text Identifiers - Withdrawal

WDWC02 – CAPTION

(1) Withdrawal Can Be Cancelled

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

WDW002 – REQUEST TO WITHDRAWAL CLAIM

We have approved (1) request to withdraw (2) claim for all Social Security benefits. This cancels our earlier decisions on (3) claim. (4) may withdraw a retirement claim only once in (5) lifetime.

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

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

Fill-in (2)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (3)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (4)

 

Choice 1

You

Choice 2

He

Choice 3

She

Fill-in (5)

 

Choice 1

your

Choice 2

his

Choice 3

her

WDW006 – CLAIM WITHDRAWAL

If you change your mind and want to receive these benefits, you may cancel your withdrawal by filing a written request with us. You have up to 60 days from the date you receive this letter to ask for cancellation. After the 60 days are over, you have to file a new application if you want to receive these benefits. You will not lose any benefits if you cancel your withdrawal within the 60 days.

 

E. WEP Universal Text Identifiers – Windfall Elimination Provision

WEP003 – WINDFALL ELIMINATION PROVISION APPLIED FOR THE FIRST TIME

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

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

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

Choice 2

your

Fill-in (2)

Date in the format Month CCYY

Fill-in (3)

 

Choice 1

you

Choice 2

he

Choice 3

she

Fill-in (4)

 

Choice 1

you receive

Choice 2

he receives

Choice 3

she receives

Fill-in (5)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (6)

 

Choice 1

your

Choice 2

his

Choice 3

her

Fill-in (7)

 

Choice 1

Your

Choice 2

His

Choice 3

Her

Fill-in (8)

 

Choice 1

you were

Choice 2

he was

Choice 3

she was

Fill-in (9)

www.ssa.gov/pubs/

WEP004 – WINDFALL ELIMINATION PROVISION REMOVED

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

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

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

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

Fill-in values:

 

Fill-in (1)

 

Choice 1

your

Choice 2

null plus Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (B