EXHIBIT A — NOTICE OF POTENTIAL ELIGIBILITY
Dear Medicare Beneficiary:
If you are a former State, city, county or local government employee; or the spouse,
divorced spouse or
surviving
spouse of a former State, city, county or local government employee, please read
the information below. All others should disregard this notice.
You may qualify for free Medicare Part A (Hospital Insurance) if:
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1.
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You worked for a State, city, county or local government employer for at least 10
years (or your government work plus other non-government work equals at least 10 years),
and
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You receive payments based on your government work, and
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You have paid for Part A coverage for the last 7 years in a row; OR
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2.
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You are the spouse, divorced spouse or surviving spouse of a person who worked for
a State, city, county or local government employer for at least 10 years (or whose
government work plus other non-government work equals at least 10 years), and
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Your spouse or former spouse receives (or received) payments based on their government
work, and
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You have paid for Part A coverage for the last 7 years in a row; OR
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3.
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You are the spouse, divorced spouse or surviving spouse of a person who receives (or
received) payments based on their government work, and
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You worked for a State, city, county or local government employer for at least 10
years (or your government work plus other non-government work equals at least 10 years),
and
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You have paid for Part A coverage for the last 7 years in a row.
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If you believe you qualify for free Part A, contact your local Social Security office.
If you visit an office, please take this letter with you. If you need the address
of the nearest Social Security office or you have questions about this letter, you
may call Social Security at 1-800-772-1213 for assistance.
NOTE: You must continue to pay your Part A premiums until you are notified in writing
that your Part A coverage is free. This message does not apply to Part B (Medical
Insurance).
EXHIBIT B - CMS-R285, REQUEST FOR EMPLOYMENT INFORMATION
EXHIBIT C — DENIAL NOTICE
You asked us to determine if you qualify for premium-free Part A (Hospital Insurance)
based on a new Medicare law. You do not qualify for premium-free Part A because of
the reason(s) checked below:
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1.
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You have not been entitled to Medicare Part A for 7 years.
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2.
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You are not currently receiving payment under a State, city, county, or local retirement
system.
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Your retirement plan pays or reimburses you for the Part A premium payments.
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4.
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You or your spouse did not work at least 10 years under government or private employment.
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5.
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You are not age 65 or older.
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6.
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You did not submit your marriage certificate.
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7.
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You did not submit the death certificate for your deceased spouse.
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You did not submit your divorce decree.
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Other
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If You Have Any Questions
If you have any questions about this letter, please call Social Security toll-free
at 1-800-772-1213. You may write or visit Social Security at the address shown above.
Please have this letter with you if you call or visit an office. It will help us answer
your questions.
EXHIBIT D — AWARD NOTICE
A new provision was added to the Medicare law that allows certain Medicare beneficiaries
who are entitled to premium Part A (Hospital Insurance) to qualify for premium-free
Part A. This law is effective for premiums payable January 1998 and later.
You qualify for premium-free Medicare Part A beginning .
We will send you a refund of any Part A premiums you paid beginning .
You will now be billed for Medicare Part B premiums only. You will be billed quarterly
instead of monthly.
If You Have Questions
If you have any questions about this letter, please call Social Security at 1-800-772-1213.
You may also write or visit us at the address shown above. Please have this letter
with you if you call or visit an office. It will help us answer your questions.