Program Operations Manual System (POMS)
TN 81 (07-20)
NL 00703.632 MBA Less than SMI Premium (LESSDO) - No Prior Year Premium Balance
Document Identifier for Word Processor: E4031
A. Requesting instructions
This letter is used when COLA or No COLA applies and there is no premium balance remaining
from the previous year (prior year arrearage is paid in full.) See HI 01001.041B.3.a.
LIS004
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We are writing to give you new information about the (1) benefits which (2) on this
Social Security record.
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CHKC09
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Your Benefits |
CHK084 |
(1) monthly benefit amount is $(2) effective (3) and (4) monthly Medicare medical
insurance premium is $(5).
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HIBC01
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Information About Medicare
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HIB703 |
Since (1) monthly benefit amount is less than (2) Medicare premium, we will continue
to 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).
After adjusting (10) benefits, (11) $(12) in Medicare premiums. We enclosed a bill
for that amount and a return envelope.
We will continue to bill (13) on a yearly basis as long as (14) monthly benefit is
lower than the monthly Medicare medical insurance premium.
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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.
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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)
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Return the bottom portion of this notice with your payment and use the enclosed envelope
to mail your payment.
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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.
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If you have changed your address, be sure to write your new address in the space provided
below.
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If you have any questions concerning this Medicare Premium Bill, please write or visit
any Social Security Office.
PLEASE DETACH AT DOTTED LINE
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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.
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LIS004
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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's, disabled
divorced widower's, Medicare, or null
2. you receive or Beneficiary's name receives
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CHK084 |
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5.
Current SMI premium amount
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HIB703
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5.
you owe, he owes or she owes
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6.
Month YYYY through Month YYYY
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8.
Month YYYY through Month YYYY
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11.
you owe, he owes or she owes
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CTDO |
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6.
Local Office Address Line #1
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7.
Local Office Address Line #2
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8.
Local Office Address Line #3
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9.
City & State of Local Office
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HBN001
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1.
Billing Date (Equal to the Date of the Notice)
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5.
Medicare Beneficiary Identifier
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