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

(Requested/Generated)

Caption: Information About Medicare

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

HIB003 MEDICAL CLAIMANT ENROLLED BEFORE INITIAL ENROLLMENT PERIOD (H42)

(Requested)

Caption: Information About Medicare

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

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

(Requested)

Caption: Information About Medicare

 (1)  not entitled to  (2)  under Medicare because  (3)  application was filed too late.  (4)  should have filed before  (5)  . However,  (6)  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.

HIB011 PREMIUM BILLING FOR HOSPITAL INSURANCE ONLY (H46)

(Requested)

Caption: Information About Medicare

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

HIB015 CIVIL SERVICE BUY-IN (H31)

(Requested/Generated)

Caption: Information About Medicare

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

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

(Requested)

Caption: None

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

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

(Requested)

Caption: Information About Medicare

This letter does not affect  (1)  Medicare benefits.

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

(Requested)

Caption: Information About Medicare

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

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

(Requested)

Caption: Information About Medicare

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

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

(Requested/Generated)

Caption: Information About Medicare

We will charge a monthly premium for  (1)  medical insurance under Medicare. The first bill we send will be for all premiums now due. After that, each bill we send will be for a 3-month period, and will be sent to you shortly before payment is due.

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

(Requested)

Caption: Information About Medicare

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

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

(Requested/Generated)

Caption: Information About Medicare

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

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

(Requested)

Caption: Information About Medicare

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

HIB045 MEDICARE CLOSED PERIOD - PROVISIONAL BENEFITS CASE (P10)

(Requested)

Caption: Information About Medicare

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

HIB052 SMI REFUSAL PROCEDURE (H24)

(Requested)

Caption: Information About Medicare

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

HIB061 HMO ENROLLMENT CIVIL SERVICE INVOLVEMENT (H54)

(Requested)

Caption: Information About Medicare

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

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

(Requested)

Caption: Information About Medicare

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

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

(Requested)

Caption: Information About Medicare

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

HIB095 CHANGE IN DATE OF ENTITLEMENT TO HI AND/OR SMI (H13)

(Requested/Generated)

Caption: Information About Medicare

We changed the date of  (1)  entitlement to  (2)  under Medicare.  (3)  new entitlement date is  (4)  .  (5) 

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

(Requested/Generated)

Caption: Information About Medicare

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

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

(Requested/Generated)

Caption: Information About Medicare

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

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

If  (12)  to sign up for Part B after  (13)  ,  (14)  will usually have to wait until the general enrollment period. The general enrollment period takes place in January, February, and March of each year. If  (15)  up in the general enrollment period,  (16)  Part B coverage will start the month after  (17)  .

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

• •

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

• •

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

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

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

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

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

HIB157 CHILDREN'S HEALTH INSURANCE PROGRAM (H18)

(Requested/Generated)

Caption: Health Insurance For Children

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

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

(Requested/Generated)

Caption: Information About Medicare

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

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

(Requested/Generated)

Caption: Information About Medicare

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

HIB175 SMI PREMIUMS/ARREARAGE DEDUCTED FROM PMA OR CMA

(Requested/Generated)

Caption: Information About Medicare

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

If the deduction of past-due premiums causes a financial hardship, ask us about options for financial relief.

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

(Requested/Generated)

Caption: Information About Medicare

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

• •

  the standard Part B premium amount,

• •

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

• •

  an income-related monthly adjustment amount (IRMAA).

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

.

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

(Requested/Generated)

Caption: Information About Medicare

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

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

(Requested/Generated)

Caption: Information About Medicare

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

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

(Requested/Generated)

Caption: Information About Medicare

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

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

(Requested/Generated)

Caption: Information About Medicare

IMPORTANT: A Medicare law requires some higher income persons to pay higher premiums. The law applies to premiums for Medicare Part B (Medical Insurance), 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.ssa.gov on the Internet or call us toll-free at 1-800-772-1213 (TTY 1-800-325-0778).

HIB187 MEDICAL PREMIUM DEDUCTIONS CONTINUE (G24)

(System Generated)

Caption: Information About Medicare

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

HIB188 SMI REFUSAL (H01)

(Requested/Generated)

Caption: Your Benefits

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

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

HIB189 RAILROAD JURISDICTION (H02)

(Requested/Generated)

Caption: Information About Medicare

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

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

(Requested)

Caption: Information About Medicare

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

HIB191 HI AND SMI DATE OF ENTITLEMENT (H11)

(Requested/Generated)

Caption: Information About Medicare

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

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

(Requested)

Caption: Information About Medicare

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

HIB193 SMI PREMIUM AMOUNTS AND EFFECTIVE DATES (H21)

(Requested/Generated)

Caption: Information About Medicare

We charge a monthly premium for  (1)   (2)  . The rates are shown below:

Beginning Date Amount

 (3)   (4) 

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

HIB194 STATE BUY-IN (H30)

(Requested/Generated)

Caption: Information About Medicare

The State where  (1)  will pay the premiums for Medicare coverage beginning  (2)  . You may receive a refund for premiums you may have already paid if the State was responsible for paying the premiums during that time.

HIB195 PRIVATE GROUP BUY-IN (H32)

(Requested/Generated)

Caption: Information About Medicare

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

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

HIB196 TERMINATION OF PRIVATE GROUP BUY-IN (H40)

(Requested/Generated)

Caption: Information About Medicare

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

HIB197 TERMINATION OF CIVIL SERVICE BUY-IN (H41)

(Requested/Generated)

Caption: Information About Medicare

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

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

(Requested)

Caption: None

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

HIB199 BILLING FOR BOTH HI AND SMI PREMIUMS (H45)

(Requested)

Caption: Information About Medicare

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

HIB200 FULLY INSURED FOR MEDICARE AT AGE 65 (H47)

(Requested)

Caption: Information About Medicare

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

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

(Requested)

Caption: Information About Medicare

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

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

(Requested)

Caption: Information About Medicare

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

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

(Requested)

Caption: Information About Medicare

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

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

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

(Requested/Generated)

Caption: Information About Medicare

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

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

(Requested)

Caption: Information About Medicare

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

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

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

(Requested/Generated)

Caption: Information About Medicare

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

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

(Requested/Generated)

Caption: Information About Medicare

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

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

(Requested/Generated)

Caption: Information About Medicare

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

HIB220 INITIAL PREMIUM ADJUSTMENT DUE TO SMI ENTITLEMENT (H64)

(Requested/Generated)

Caption: Information About Medicare

We are taking  (1)  premiums due through  (2)  out of the check  (3)  will receive around  (4)  . These premiums total  (5)  . We will deduct premiums 1 month in advance.

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

(Requested/Generated)

Caption: Information About Medicare

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

HIB223 SUBSEQUENT PREMIUM AND PINQ RECORD ADJUSTMENT (H66)

(Requested)

Caption: Information About Medicare

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

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

(Requested/Generated)

Caption: Information About Medicare

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

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

(Requested)

Caption: Information About Medicare

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

HIB229 REVIEW REQUESTED VARIABLE SMI PREMIUM APPLIES (H73)

(Requested)

Caption: Information About Medicare

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

HIB231 ERRONEOUS SMI TERMINATION EQUITABLE RELIEF GIVEN (H75)

(Requested)

Caption: Information About Medicare

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

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

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

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

HIB232 PART B PREMIUM SURCHARGE ROLLBACK (H78)

(Requested)

Caption: Information About Medicare

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

HIB233 PART B ENROLLEE BENEFITS SUSPENDED FOR WORK (H79)

(Requested)

Caption: Information About Medicare

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

• •

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

• •

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

HIB234 SMI WITHDRAWAL (H81)

(Requested/Generated)

Caption: Information About Medicare

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

 (5) 

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

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

(System Generated)

Caption: Information About Medicare

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

HIB236 PREMIUM ADJUSTMENT DUE TO SMI TERMINATION (H85)

(Requested/Generated)

Caption: Information About Medicare

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

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

(Requested/Generated)

Caption: Information About Medicare

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

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

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

(Requested/Generated)

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

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

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

(Requested/Generated)

Caption: Information About Medicare

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

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

(Requested)

Caption: Information About Medicare

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

HIB241 FOREIGN ADDRESS GENERAL MEDICARE ELIGIBILITY (H96)

(Requested)

Caption: Information About Medicare

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

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

(Requested/Generated)

Caption: Information About Medicare

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

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

(Requested/Generated)

Caption: Information About Medicare

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

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

(Requested/Generated)

Caption: Information About Medicare

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

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

(Requested/Generated)

Caption: Information About Medicare

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

• •

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

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)  .

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

(System Generated)

Caption: Information About Medicare

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

HIB251 WORK REINSTATEMENT NO SMI (H77)

(Requested)

Caption: Information About Medicare

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

1. 1. 

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

2. 2. 

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

3. 3. 

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

HIB252 EQUITABLE RELIEF UNTIMELY PROCESSING (H49)

(Requested/Generated)

Caption: Information About Medicare

If (1)  medical insurance to start earlier,  (2)  can choose to have it start in  (3)  . If  (4)  this benefit to start earlier,  (5)  must do the following things within 60 days after the date of this notice:

• •

  tell us in writing that  (6)  the medical insurance benefits beginning  (7)  ;

• •

  pay us  (8)  (this covers the premiums due from  (9)  through  (10)  ); or,

• •

  tell us we can withhold this amount from the check.

If  (11)  the benefits beginning  (12)  but  (13)  it hard to pay the premium amount in a lump sum, ask us about other ways to pay the money.

HIB256 FUTURE MEDICARE COVERAGE (H07)

(Requested/Generated)

Caption: Information About Medicare

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

HIB257 WHAT HOSPITAL INSURANCE WILL PAY (H27)

(Requested/Generated)

Caption: Information About Medicare

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

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

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

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

(Requested/Generated)

Caption: None

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

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

(Systems Generated)

Caption: Information About Medicare

 (1)   (2) 

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

HIB260 IRMAA

(System Generated)

Caption: Information About Medicare

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

HIB261 IRMAA

(System Generated)

Caption: Information About Medicare

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

HIB262 IRMAA D

(System Generated)

Caption: Information About Medicare

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

HIB263 IRMAA B and D

(System Generated)

Caption: Information About Medicare

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

HIB264 IRMAA Waiver Request

(System Generated)

Caption: Information About Medicare

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

HIB265 IRMAA Deduction

(System Generated)

Caption: Information About Medicare

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

HIB266 IRMAA B Deduction

(System Generated)

Caption: Information About Medicare

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

HIB267 IRMAA D Deduction

(System Generated)

Caption: Information About Medicare

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

HIB268 IRMAA Partial Recovery

(System Generated)

Caption: Information About Medicare

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

HIB269 IRMAA Total Withholding

(System Generated)

Caption: Information About Medicare

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

HIB270 IRMAA PART B Arrearage

(System Generated)

Caption: Information About Medicare

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

HIB271 IRMAA D and/or B Installment Payment

(System Generated)

Caption: Information About Your Installment Payment

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

HIB315 SMI-PBID Billing

(Systems Generated)

Caption: Information About Medicare

The monthly premium for  (1)  Part B Immunosuppressive Drug coverage is  (2)  . We will bill you each month for this insurance.

HIB316 REFERRAL FOR MARKETPLACE OR MEDICAID COVERAGE

(Systems Generated)

Caption: If You Need Health Coverage through Marketplace or Medicaid

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).

HIB317 REFFERAL FOR MEDICAID ASSISTANCE WITH COST OF IMMUNOSUPPRESSIVE DRUG COVERAGE

(Systems Generated)

Caption:

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 APPLY FOR IMMUNOSUPPRESIVE DRUG COVERAGE

(Systems Generated)

Caption: 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

HIB321 HEALTH INSURANCE - EFFECTS OF CANCELING INURANCE SMI-PBID

(Systems Generated)

Caption: Information about Medicare

If you want to cancel  (1)  Medicare Part B Immunosuppressive Drug coverage, please contact us. If you cancel this insurance, the date coverage stops depends on when you cancel it:

• •

  If you cancel it within 30 days from the date of this letter, coverage stops when the State stops paying the premiums.

• •

  If you cancel it after 30 days, coverage stops at the end of the month in which you ask us to cancel it.

• •

  If you will get other health coverage, you can request termination of Part B Immunosuppressive Drug coverage up to 6 months in the future.

HIB322 SMI-PBID WITHDRAWAL

(Systems Generated)

Caption: Information About Medicare

You asked that we stop (1)  Part B Immunosuppressive Drug coverage under Medicare. This coverage ends the last day of (2)  .

HIB323 HEALTH INSURANCE - MAKE CHECK OR MONEY ORDER PAYABLE TO CMS

(Requested)

Caption: Information about Medicare

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

HIB324 HEALTH INSURANCE - THE STATE WILL NO LONGER PAY MEDICARE INSURANCE PREMIUMS

(Systems Generated)

Caption: Information about Medicare

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

If you disagree or have questions about the State’s determination to stop paying the premiums, please call the State Medicaid office. If you recently received a notice from the State Medicaid office telling you that  (8)  lost benefits, follow the instructions in the notice about the best way to contact them.

HIB325 HEALTH INSURANCE - MEDICARE CARD WILL NO LONGER BE VALID AFTER YOUR INSURANCE COVERAGE ENDS

(Systems Generated)

Caption: Information about Medicare

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

HIB326 MEDICARE PREMIUM WAS NOT PAID WITHIN THE TIME LIMIT - INSURANCE COVERAGE HAS STOPPED

(Systems Generated)

Caption: Information about Medicare

 (1)  Medicare premium  (2)   (3)  for  (4)  was not paid within the time limit. Therefore,  (5)   (6)  has stopped. (7)  last month of coverage  (8)   (9)  . Benefits will not be paid for any  (10)   (11)  after  (12)  last month of coverage.

NOTE: For fill-in 3, key A, followed by a comma, then key the SMI premiums or key B when omitting the money amount.

Example of How to Key UTI.

HIB326,A, A, 1.00,A

HIB327 INFORMATION ABOUT IMMUNOSUPPRESSIVE DRUG COVERAGE

(Systems Generated)

Caption: If You Need Coverage for Immunosuppressive Drugs Only

 (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 payment 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

HIB328 IRMAA — SMI-PBID PREMIUM BASED ON INCOME

(Systems Generated)

Caption: Information About Medicare

In another letter, we told you that (1)  Medicare Part B Immunosuppressive Drug coverage premium includes:

• •

  the standard Part B Immunosuppressive Drug coverage premium amount, and

• •

  an income-related monthly adjustment amount (IRMAA).

HIB329 NEW MEDICARE ENTITLEMENT – SMI-PBID ENDING

(Systems Generated)

Caption: Information About Medicare

Since  (1)  now entitled to Medicare (2)  ,  (3)  Part B Immunosuppressive Drug coverage ends (4)  .

HIB330 REFERRAL FOR FUTURE ENROLLMENT OF SMI-PBID

(Systems Generated)

Caption: If You Need Immunosuppressive Drug Coverage in the Future

If you need immunosuppressive drug coverage in the future, you can enroll any time by calling 1-877-465-0355 between 8:30 a.m. – 6:00 p.m. EST, Monday through Friday.

HIB331 APPLY FOR MEDICARE (WHEN AUTO-ENROLLMENT DOESN’T APPLY)

(Systems Generated)

Caption: Apply for Medicare

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.

HIB332 NEW MEDICARE CARD FOR SMI-PBID

(Systems Generated)

Caption: Information about Medicare

 (1)  will get a new Medicare card within 2 weeks.  (2)  should show this card when  (3)  immunosuppressive drug coverage. If  (4)  questions about  (5)  Medicare coverage, call 1-800-MEDICARE (1-800-633-4227) (TTY 1-877-486-2048).

HIB333 SUSPECT SOCIAL SECURITY OR MEDICARE FRAUD

(Requested)

Caption: None

Suspect Social Security or Medicare Fraud?

If you suspect Social Security fraud, please visit (1)  or call the Inspector General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101). If you suspect Medicare fraud, please visit  (2)  or call the Health and Human Services Office of the Inspector General at 1-800-447-8477 (TTY 1-800-377-4950).

HIB334 PSRA SEP ENROLLEE POTENTIAL LATE ENROLLMENT PENALTIES MAY BE PAID BY USPS

(Requested)

Caption: Information About Medicare

Individuals who have Medicare Part B pay a monthly premium. Eligible United States Postal Service (USPS) annuitants and their eligible family members who enrolled in Medicare Part B during the one-time Special Enrollment Period may be subject to Part B late enrollment penalties for as long as they have Part B, if they did not sign up for Part B when first eligible. However, the USPS will pay these penalties directly to the Centers for Medicare & Medicaid Services. Therefore, if  (1)  subject to these penalties,  (2)  not required to pay them.

HIB335 ADVISES PSRA SEP ENROLLEE THAT IRMAA MAY APPLY BASED ON INCOME LEVEL

(Requested)

Caption: Information About Medicare

IMPORTANT: A Medicare law requires some higher income persons to pay higher premiums. The law applies to premiums for Medicare Part B (Medical Insurance), prescription drug coverage, and Medicare Part B Immunosuppressive Drug coverage. The law generally affects individuals who reported 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 January 2025 for the entire calendar year, and can change annually, depending on the income reported on  (5)  tax return. If  (6)  had a life-changing event that reduced  (7)  household income, (8)  can ask to lower the additional amount.

For more information, please visit www.ssa.gov on the Internet or call us toll-free at 1-800-772-1213 (TTY 1-800-325-0778).

HIB336 PART D COVERAGE IS AUTOMATICALLY INCLUDED IN POSTAL SERVICE HEALTH BENEFIT PLAN

(Requested)

Caption: Information About Medicare

If  (1)  enrolled in a Postal Service Health Benefit plan, Part D prescription drug coverage will be included in  (2)  plan automatically.  (3)  not need to elect separate Part D coverage for (4)  or for any family members on  (5)  plan.

HIB337 SMID PARAGRAPH FOR MEDICARE AWARDS WITH RETROACTIVITY

(Requested/Generated)

For retroactive Medicare benefits, please give a copy of this letter to  (1)  provider or supplier immediately. Ask them to include a copy of this letter when they submit claims to Medicare for items and services they provided to  (2)  on or before the date you gave them a copy of this letter. The time limit for the provider or supplier to submit a claim will be extended through the last day of the sixth calendar month following the month they received notification of  (3)  retroactive enrollment. For example, if the doctor receives notice of  (4)  retroactive enrollment on January 15th, the doctor must submit a claim on or before July 31st of the same calendar year. If you are concerned that the provider or supplier will not submit a claim by the deadline mentioned above, then you should submit the claim. If you are submitting a claim directly to Medicare, you must submit the claim on or before the last day of the sixth calendar month after receiving this notice. If you need assistance submitting these claims, contact 1-800-MEDICARE (1-800-633-4227) (TTY 1-877-486-2048).

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

(Requested)

Caption: Information About Medicare

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

• •

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

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

• •

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