Effective Dates: 10/17/2022 - Present Previous | Next

TN 88 (10-22)

NL 00703.636 MBA Less than SMI Premium (LESSDO) - Failure to Bill - Equitable Relief Period Ends

Document Identifier for Word Processor: E4035

A. Requesting instructions

This letter is used when no past-due premium remittance is received and the equitable relief period ends.

Choose HIB708 or HIB709:

  • •

    HIB708 is used when neither the past-due premiums nor the current year premiums have been paid.

  • •

    HIB709 is used when the past-due premiums have not been paid, but the current year premiums have been paid.

B. Exhibit letter

Universal Text Identifier (UTI) or Caption

Language

LIS004

 

We are writing to give you new information about the (1) benefits which (2) on this Social Security record.

HIBC01

 

Information About Medicare

HIB707

In our letter dated (1), we told you our records show you did not receive a bill for Medicare medical insurance premiums owed for (2). We explained you could contact your local Social Security office if paying the past-due amount would create a severe hardship for (3).

 

 

HIB708 (Choose HIB708 or HIB709)

We have not received a request for relief or a request for an alternate method of payment. Therefore, we must bill (1) for $(2) in past-due Medicare medical insurance premiums owed through (3) and $(4) for (5). We are enclosing a bill for $(6), which represents all premiums due for (7).

If the full payment of $(8) for past-due premiums owed through (9) is not received by (10), (11) Medicare Part B will end on (12) which is the last day of the third month following the date of this notice.

HIB709 (Choose HIB708 or HIB709)

We have not received a request for relief or a request for an alternate method of payment. Therefore, we must bill (1) for $(2) in past-due Medicare medical insurance premiums owed through (3). We are enclosing a bill for $(4).

If the full payment of $(5) for past-due premiums is not received by (6), (7) Medicare Part B will end on (8) which is the last day of the third month following the date of this notice.

CTDO

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

We invite you to visit our website at www.socialsecurity.gov on the Internet to find general information about Social Security. If you have any specific questions, you may call us toll-free at 1-800-772-1213, or call your local Social Security office at 1-(3)-(4)-(5). We can answer most questions over the phone. If you are deaf or hard of hearing, you may call our TTY number, 1-800-325-0778. You can also write or visit any Social Security office. The office that serves your area is located at:

(6)

(7)

(8)

(9)(10)-(11)

If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

HBN001

MEDICARE PREMIUM BILL

CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)

 

 

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.

  • •

    If you have any questions concerning this Medicare Premium Bill, please write or visit any Social Security Office.

 

PLEASE DETACH AT DOTTED LINE

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

CMS-500A

 

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

Name: (7)

 

Make Checks Payable To:

CMS MEDICARE INSURANCE

 

Send To:

Medicare Premium Collection Center

P.O. Box 790355

St. Louis, MO 63179-0355

 

( ) Check here if your address has changed.

Show new address below.

________________________________________

________________________________________

 

PAYMENTS BY CHECK

When you provide a check as a payment, you authorize the Medicare Premium Collection Center (MPCC) to use the information from your check to make a one-time electronic funds transfer from your bank account. When the MPCC uses information from your check to make an electronic funds transfer, they may withdraw funds from your bank account as soon as the same day they receive your payment. You will not get your check back from your bank. If the MPCC cannot process your payment electronically, they will process it as a check transaction. Your bank statement will show the transaction as "CMS Medicare" and this is your proof of payment.

C. Exhibit fill-ins

Universal Text Identifier (UTI)

Fill-ins

LIS004
  1. 1. 

    disability, retirement, wife's, husband's, child's, widow's, widower's, mother's, father's, disabled widow's, disabled widower's, disabled divorced widow, disabled divorced widower's, Medicare, or null

  2. 2. 

    you receive, or Beneficiary's name receives

 

HIB707
  1. 1. 

    Month DD, YYYY

  2. 2. 

    Month YYYY through Month YYYY

  3. 3. 

    you, or Beneficiary’s name

HIB708 (Choose HIB708 or HIB709)

  1. 1. 

    you, or Beneficiary's name

  2. 2. 

    Past-due arrearage

  3. 3. 

    Last month through which past-due premiums are owed

  4. 4. 

    Current year premiums due

  5. 5. 

    Month YYYY through Month YYYY

  6. 6. 

    Total billing amount

  7. 7. 

    Month YYYY through Month YYYY

  8. 8. 

    Past-due arrearage

  9. 9. 

    Last month of the past-due premium arrearage

  10. 10. 

    Last day of third month after date of notice

  11. 11. 

    your, or Beneficiary's name (possessive)

  12. 12. 

    Last day of third month after date of notice

HIB709 (Choose HIB708 or HIB709)

  1. 1. 

    you, or Beneficiary's name

  2. 2. 

    Past-due arrearage

  3. 3. 

    Last month through which past-due premiums are owed

  4. 4. 

    Past-due billing amount

  5. 5. 

    Past-due arrearage

  6. 6. 

    Last day of third month after date of notice

  7. 7. 

    your, or Beneficiary's name (possessive)

  8. 8. 

    Last day of third month after date of notice

CTDO
  1. 1. 

    Zipcode

  2. 2. 

    Zip+4 or DO Code

  3. 3. 

    Telephone Area Code

  4. 4. 

    Phone Exchange

  5. 5. 

    Phone Number

  6. 6. 

    Local Office Address Line #1

  7. 7. 

    Local Office Address Line #2

  8. 8. 

    Local Office Address Line #3

  9. 9. 

    City & State of Local Office

  10. 10. 

    Local Office Zipcode

  11. 11. 

    Zip+4 of Local Office

HBN001
  1. 1. 

    Billing Date (Equal to the Date of the Notice)

  2. 2. 

    Month YYYY

  3. 3. 

    SMI premiums due

  4. 4. 

    Month DD, YYYY

  5. 5. 

    Medicare Beneficiary Identifier

  6. 6. 

    SMI premiums due

  7. 7. 

    Beneficiary’s Full Name
To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900703636
NL 00703.636 - MBA Less than SMI Premium (LESSDO) - Failure to Bill - Equitable Relief Period Ends - 10/17/2022
Batch run: 10/17/2022
Rev:10/17/2022