TN 81 (07-20)
Document Identifier for Word Processor: E4032
This letter is used when COLA or No COLA applies, a premium arrearage balance from the prior year(s) exists, and the prior year(s) balance is less than three months premiums at the standard rate. See HI 01001.041B.3.b.
LIS004
We are writing to give you new information about the (1) benefits which (2) on this Social Security record.
CHKC09
Your Benefits
HIBC01
Information About Medicare
Since (1) monthly benefit amount is less than (2) Medicare premium, we will withhold (3) monthly benefits to pay part of (4) Medicare premium. The difference between the premiums (5) for (6) and (7) monthly benefit amount for (8) is $(9).
In addition, our records show that (10) $(11) in past due premiums for (12).
Enclosed is a bill for the total amount due of $(13), and a return envelope. We will continue to bill (14) on a yearly basis as long as (15) monthly benefit is lower than the monthly Medicare medical insurance premium.
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.
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.
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. you receive or Beneficiary's name receives
CHK084
Your, His or Her
Monthly benefit amount
Month YYYY
your, his or her
Current SMI premium amount
HIB704
you owe, he owes or she owes
Month YYYY through Month YYYY
Money amount difference
Billing Amount for arrearage
Total Billing Amount
you, him or her
CTDO
Zipcode
Zip+4 or DO Code
Telephone Area Code
Phone Exchange
Phone Number
Local Office Address Line #1
Local Office Address Line #2
Local Office Address Line #3
City & State of Local Office
Local Office Zipcode
Zip+4 of Local Office
HBN001
Billing Date (Equal to the Date of the Notice)
SMI premiums due
Month DD, YYYY
Medicare Beneficiary Identifier
Beneficiary’s Full Name