Under a special provision of the Social Security Act, now that you are full retirement age and your disability benefits have been changed to retirement benefits, your monthly medical insurance premium amount has been reduced from $ (1) to $ (2) . Therefore, effective
(3) , your monthly benefit payment has been increased to $ (4) .

If You Have Any Questions

3901C

This notice will be used when:

1. 1. 

   a DIB to RIB conversion has occurred and

2. 2. 

   payment status is current-pay to current-pay and

3. 3. 

   Form HCFA-1585A contains the following legend “FULL RETIREMENT AGE PAC REDUCTION MANUAL LETTER NECESSARY”

Fill-ins:

1. (1) 

   penalty PAC

2. (2) 

   new SMI premium amount

3. (3) 

   effective date of change in SMI premium amount

4. (4) 

   new monthly benefit payable

Refer to NL 00703.005E. for 3901C text.

Information for this letter will be shown on Form SSA-573. The name and address, if not given, can be taken from the latest Form SSA-3926-EP in file.