TN 47 (04-24)

NL 00725.265 “HIB” UTIs – Health Insurance Benefits

HIBC01 Caption

Information About Medicare

HIBC05 Caption

Why (1) Cannot Qualify for Medicare

Fill-in:

(1) “You”/SN

HIBC14 Caption

How to Apply for Immunosuppressive Drug Coverage

HIBC16 Caption

If You Need Coverage for Immunosuppressive Drugs Only

HIBC18 Caption

If You Need Help With Costs for the Immunosuppressive Drug Coverage

HIBC20 Caption

Apply for Medicare

HIBC21 Caption

If You Need Health Coverage through Marketplace or Medicaid

HIBD01 Dictated Text

 

HIB001 Entitled to HI and/or SMI (This can also be an introductory statement (HIBI01))

(1) Medicare (2) (3) (4) (5) .

Fill-ins:

(1) “Your”/FN

(2) “Part A (hospital insurance) starts”/“Part B (medical insurance) starts”/“Part A (hospital insurance) and Part B (medical insurance) start”

(3) Date in format June 2013

(4) “and Part B (medical insurance) starts”

(5) Date in format June 2013

HIB002 New Medicare Card – PIC Change Conversion Award

(1) will get a Medicare card within 2 weeks. (2) show this card when (3) medical care. To learn more about what Medicare covers, visit Medicare.gov. If (4) questions about (5) Medicare coverage, call 1-800-MEDICARE (1-800-633-4227).

Fill-ins:

(1) “You”/“BGN plus BLN”

(2) “You should”/“He should”/“She should”

(3) “you need”/“he needs”/“she needs”

(4) “you have”/“he has”/“she has”

(5) “your”/“his”/“her”

HIB003 Medicare Disallowance – Filed Before Initial Enrollment Period

(1) not entitled to (2) under Medicare because (3) application was filed too soon. (4) may apply again at any time during the period (5) through (6) . (7) must apply in the first three months of this period to make sure Medicare starts in the month (8) (9) age 65.

Fill-ins:

(1) “You are”/“She is”/“He is”

(2) “medical insurance coverage/medical or hospital insurance coverage”

(3) “your”/“her”/“his”

(4) “You”/“She”/“He”

(5) month and year

(6) month and year

(7) “You”/“She”/“He”

(8) “you”/“she”/“he”

(9) “reach”/“reaches”

HIB004 Medicare Disallowance – Not Timely Filed

(1) not entitled to (2) under Medicare because (3) application was filed too late. (4) should have filed before (5) . However, (6) may apply for coverage again during the next general enrollment period. A general enrollment period takes place in January, February, and March of each year.

Fill-ins:

(1) “You are”/“She is”/“He is”

(2) “medical insurance coverage”

(3) “your”/“her”/“his”

(4) “You”/“She”/“He”

(5) month and year

(6) “you”/“she”/“he”

HIB005 SMI Premium Billing

(1) monthly premium for Medicare Part B (medical insurance) is (2) beginning (3) (4) (5) .

Fill-ins:

(1) “Your”/“His”/“Her”

(2) Amount of Part B premium in $$$$$.¢¢ format

(3) Date in MonthCCYY format

(4) null/“and”/Null

(5) Show the amount of the Part B premium in the format $$$$$¢¢ plus the word “beginning” plus show the start date that corresponds to the second premium rate returned from the HSA utility in the format MMCCYY

HIB008 Premium Deductions

We will start to take premiums out of (1) (2) check.

Fill-ins:

(1) “your”/“her”/“his”

(2) “next”/month, day and year

HIB009 SMI Premium Billing

We will send your first bill for the premiums within a month. Each bill will be for a 3-month period.

HIB010 SMI Premium Deductions Followed by Suspension

Because (1) monthly benefits are stopping, we will bill (2) every 3 months for the premiums.

Fill-ins:

(1) “your”/“null”/FN possessive

(2) “you”/“her”/“him”

HIB011 HIB Premium Billing

The monthly premium for (1) hospital insurance is (2) . We will bill you each month for (3) .

Fill-ins:

(1) “your”/“her”/“his”

(2) “[2a] beginning [2b]”/“[2c] beginning [2d] and [2e] beginning [2f]”

[2a] money amount/null

[2b] Month YYYY/null

[2c] money amount/null

[2d] Month YYYY/null

[2e] money amount/null

[2f] Month YYYY/null

(3) “this premium”/“the combined premium for hospital and medical insurance”

HIB013 Medicare Premium Penalty

(1) a premium surcharge because (2) enrolled later than (3) could have.

Fill-ins:

(1) “This medical insurance premium includes”/“This hospital insurance premium includes”/“These hospital and medical insurance premiums include”

(2) “you”/“she”/“he”

(3) “you”/“she”/“he”

HIB014 State Buy-in

(1) (2) will pay the premiums for (3) Medicare coverage (4) .

Fill-ins:

(1) “The State of”/null

(2) name of jurisdiction making payments

(3) “your”/“her”/“his”

(4) beginning Month CCYY

HIB015 Premiums Deducted from Civil Service Annuity

The Office of Personnel Management will deduct the medical insurance premiums from (1) annuity checks. They will let (2) know when this will start.

Fill-ins:

(1) “your”/“Beneficiary's name (possessive)”

(2) “you”/“her”/“him”

HIB019 Premium Hospital Insurance (HI)

(1) cannot get Medicare Part A (hospital insurance) for free. However, (2) may be able to buy Medicare Part A for (3) a month. Please contact us for more information.

Fill-ins:

(1) “You”/FN

(2) “you”/“he”/“she”

(3) monthly premium HI amount

HIB020 Foreign Address

Normally Medicare will only pay for hospital and medical services which (1) (2) in the United States.

Fill-ins:

(1) “you”/“she”/“he”

(2) “receive”/“receives”

HIB021 Subsequent Award – Medicare Not Affected

This letter does not affect (1) Medicare benefits.

Fill-in:

(1) “your”/“her”/“his”

HIBR30 Equitable Relief, Untimely Processing

We did not give (1) earlier medical insurance because we did not process it timely. If you want to have these benefits earlier, you can choose medical insurance benefits beginning (2) . If you want this benefit to start earlier, you must do the following things within 30 days after the date of this notice:

tell us in writing that you want medical insurance benefits beginning (3) ;

pay us $(4) . (this covers premiums due from (5) through (6) );or,

tell us we can withhold this amount from the check.

Fill-ins:

(1) “you”/FN

(2) Earlier SMI entitlement date *

(3) Earlier SMI entitlement date *

(4) Amount of SMI premium from earlier date *

(5) Earlier SMI entitlement date *

(6) Month prior to current operating month

(*) indicates that fill-in is manual

HIB031 Private Third Party Buy-in

Another individual or organization will pay the premiums for (1) Medicare coverage beginning (2) . Even though the bill will be sent to them, you are still responsible for seeing that (3) premiums are paid. If they decide that they will no longer send the payments, we will start to send the premium notices to you.

Fill-ins:

(1) “your”/SN possessive

(2) date buy-in begins in format MMMM d, YYYY

(3) “your”/SN possessive

HIB032 SMI Option Presumed Refused, Puerto Rico

(1) (2) eligible for medical insurance beginning (3) . If you want this coverage or need more information, you should contact your nearest Social Security office.

Fill-ins:

(1) “You”/SN

(2) “are”/“is”

(3) date of entitlement to SMI - month and year

HIB035 SMI Deductions

We deduct medical insurance premiums from monthly benefit payments. If (1) (2) benefit payments, we will not bill (3) for (4) premiums.

Fill-ins:

(1) “you”/“she”/“he”

(2) “receive”/“receives”

(3) “you”/“her”/“him”

(4) “your”/“her”/“his”

HIB037 Equitable Relief, Untimely Processing (Used Only with HIBR30)

If you want the benefits beginning (1) but find it hard to pay the premium amount in a lump sum, ask us about other ways to pay the money.

Fill-in:

(1) earlier SMI entitlement date - month and year

HIB038 Medicare Disallowance – Crime Against United States

(1) cannot qualify for Medicare because (2) been convicted of a crime against the security of the United States.

Fill-ins:

(1) “You”/“She”/“He”

(2) “you have”/“she has”/“he has”

HIB042 Claimant Could be or is Covered Under the Federal Employees Health Benefits Act of 1959

(1) cannot qualify for Medicare because (2) covered under the Federal Employees Health Benefits Act.

Fill-ins:

(1) “You”/“She”/“He”

(2) ““you are”/“she is”/“he is”/you could be/she could be/he could be”

HIB044 Not Entitled, Application Filed too Late

(1) not entitled to medical insurance coverage under Medicare because (2) application was filed too late. (3) should have filed before (4) . However, (5) may apply for coverage again during the next general enrollment period. A general enrollment period takes place in January, February and March of each year.

Fill-ins:

(1) “You are”/“She is”/“He is”

(2) “your”/“her”/“his”

(3) “You”/“She”/“He”

(4) age 65 + 4 months in format (“April 1992”)

(5) “you”/“she”/“he”

HIB050 Number Holder Age 65 Before End of Waiting Period

You do not qualify for Medicare based on disability because your coverage cannot start before you reach age 65.

To receive Medicare coverage before age 65, a person must be disabled under our rules for 29 months before coverage begins. Based on the date you said you became disabled, coverage could not begin until after you reach age 65. For this reason, we have not decided whether or not you are disabled.

You may qualify for Medicare when you reach age 65, whether or not you are disabled under our rules.

HIB051 Death Within 29 Months of Onset

To receive Medicare coverage before age 65, a person must qualify for disability benefits for 29 months before coverage begins. We were told that (1) became disabled on (2) , and died on (3) . Therefore (4) did not qualify for Medicare.

Fill-ins:

(1) NH Name

(2) onset date

(3) date of death - NH

(4) “she”/“he”

HIB052 SMIB Refusal Statement

If you do not want medical insurance, please complete the enclosed card and return it to us in the envelope we have provided. You will need to do this by the date shown on the card. If you decide you do not want the insurance, we will return any premiums that you have paid.

HIBR60 Prisoner Suspension

Generally, Medicare will not pay for hospital or medical items or services (1) while (2) (3) . However, you may want to pay (4) Medicare medical insurance premiums for two reasons:

The premiums may be higher if you cancel the Medicare medical insurance now and re-enroll after (5) released from (6) .

(7) may not have medical insurance for a period of time after (8) released from (9) . This is because (10) will have to wait until a general enrollment period to re-enroll. A general enrollment period takes place in January, February and March of each year.

If you want to cancel (11) medical insurance, please let us know. If you decide to keep Medicare medical insurance, we will bill you for the premium. The first bill we send will be for a 3-month period and will be sent to you shortly before the payment is due.

Fill-ins:

(1) “you receive”/“FN receives”

(2) “you are”/“she is”/“he is”

(3) “imprisoned”/“confined in an institution” *

(4) “your”/“her”/“his”

(5) “you are”/“she is”/“he is”

(6) “prison”/“the institution” *

(7) “You”/“She”/“He”

(8) “you are”/“she is”/“he is”

(9) “prison”/“the institution” *

(10) “you”/“she”/“he”

(11) “your”/“her”/“his”

(*) indicates that the fill-in is manual

HIB062 Not Enrolling in SMI

(1) (2) through (3) to sign up for Medicare Part B (medical insurance).

People who have Medicare Part B pay a monthly premium. If (4) not sign up for Part B when (5) first eligible, (6) may have to pay a late enrollment penalty for as long as (7) Part B. (8) monthly premium may go up 10 percent for each full 12-month period that (9) could have had Part B coverage, but did not sign up for it. Usually, (10) will not have to pay a late enrollment penalty if (11) up during a special enrollment period.

If (12) to sign up for Part B after (13) , (14) will usually have to wait until the general enrollment period. The general enrollment period takes place in January, February, and March of each year. If (15) up in the general enrollment period, (16) Part B coverage will start the month after (17) .

(18) may be able to get Part B in a special enrollment period if (19) all of these conditions:

• •

  (20) age 65 or older, and

• •

  (21) health insurance under an employer's group plan because (22) spouse currently works, and

• •

  (23) had health insurance coverage under that plan since (24) became age 65.

(25) can sign up in a special enrollment period during these times:

• •

  At any time (26) coverage under that employer's group plan,

  or

• •

  During the 8 months after the work ends or (27) coverage under that plan ends, whichever occurs first.

Deciding when to sign up for Part B may depend on how (28) health insurance works with Medicare. For example, a group health plan is usually not the primary insurance if the employer has less than 20 employees. In this case, it is important to have Medicare coverage, and you may want to sign up now.

If (29) help deciding what to do, please contact (30) employee benefits office or contact us.

Fill-ins:

(1) “You”/FN

(2) “has”/“have”

(3) Date initial enrollment period ends (age 65 plus 3 months, in Month CCYY format)

(4) “you do”/“he does”/“she does”

(5) “you are”/“he is”/“she is”

(6) “you”/“he”/“she”

(7) “you have”/“he has”/“she has”

(8) “Your”/“His”/“Her”

(9) “you”/“he”/“she”

(10) “you”/“he”/“she”

(11) “you sign”/“he signs”/“she signs”

(12) “you want”/“he wants”/“she wants”

(13) Date initial enrollment period ends (age 65 plus 3 months, in Month CCYY format)

(14) “you”/“he”/“she”

(15) “you sign”/“he signs”/“she signs”

(16) “your”/“his”/“her”

(17) “you enroll”/“he enrolls”/“she enrolls”

(18) “You”/“He”/“She”

(19) “you meet”/“he meets”/“she meets”

(20) “You are”/“He is”/“She is”

(21) “You have”/“He has”/“She has”

(22) “you or your”/“he or his”/“she or her”

(23) “You”/“He”/“She”

(24) “you”/“he”/“she”

(25) “You”/“He”/“She”

(26) “you or your spouse is working and you have”/“he or his spouse is working and he has”/“she or her spouse is working and she has”

(27) “your”/“his”/“her”

(28) “your”/“his”/“her”

(29) “you need”/“he needs”/“she needs”

(30) “your”/“his”/“her”

HIB068 Equitable Relief

If (1) these benefits earlier, (2) can choose (3) insurance benefits beginning (4) . To start benefits earlier, within 60 days after the date of this notice. (5) must tell us in writing that (6) (7) insurance benefits beginning (8) . In addition, (9) must:

pay us (10) (this covers premiums due from (11) through (12) ); or

(13)

Fill-ins:

(1) “you want/she wants/he wants”

(2) “you”/“she”/“he”

(3) “hospital/medical/hospital and medical”

(4) HI or SMI NONEQRELST

(5) “you”/“she”/“he”

(6) “you want/she wants/he wants”

(7) “hospital/medical/hospital and medical”

(8) HI or SMI NONEQRELST

(9) “you”/“she”/“he”

(10) money amount (total premium(s) due for HI/SMI

(11) HI or SMI NONEQRELST

(12) date in format MM/YYYY

(13) tell us we can withhold this amount from the check/tell us to bill you for this amount.

HIB072 Medicare with Railroad Annuity Inv.

Since (1) (2) a railroad beneficiary, the RRB will start to withhold medical insurance premiums from (3) Railroad Retirement annuity. If (4) not currently receiving a Railroad Retirement annuity, the Social Security Administration will let the RRB know when (5) next premium is due. The RRB will send (6) a bill for premiums.

Fill-ins:

(1) “you”/FN

(2) “are”/“is”

(3) “your”/“her”/“his”

(4) “you are”/“she is”/“he is”

(5) “your”/“her”/“his”

(6) “you”/“her”/“him”

HIB074 New Medicare Card Issued

We will send (1) a new health insurance card. It will show that (2) entitled to (3) insurance.

Fill-ins:

(1) “you”/SN

(2) “you are”/“she is”/“he is”

(3) “hospital/medical/hospital and medical”

HIB075 Equitable Relief

If (1) benefits beginning (2) but (3) it hard to pay the premium amount in a lump sum, ask us about other ways to pay the money.

Fill-ins:

(1) “you want/she wants/he wants”

(2) show the HI/SMI NONEQRELST date in format “July 1999”

(3) “find”/“finds”

HIB090 Medicare Terminates, Destroy Card

(1) Medicare card will not be valid when (2) (3) coverage ends. Please destroy (4) card after (5) coverage ends.

Fill-ins:

(1) null plus FN possessive/“Your”

(2) “his”/“her”/“your”

(3) “Medicare Part A (hospital insurance) and Part B (medical insurance)”/“Medicare Part B (medical insurance)”/“Medicare Part A (hospital insurance)”

(4) “his”/“her”/“your”

(5) “his”/“her”/“your”

HIB094 Entitlement Conversion, No Change in HI/SMI

The decision on (1) (2) benefits does not affect (3) (4) coverage.

Fill-ins:

(1) “your”/SN possessive/FN possessive

(2) “retirement”/“disability”

(3) “your”/“her”/“his”

(4) “hospital insurance/medical insurance/hospital and medical insurance”

HIB095 Earlier HI/SMI Dates

We have changed the date of (1) entitlement to (2) under Medicare. (3) new entitlement date is (4) . (5) .

Fill-ins:

(1) “your”/SN possessive

(2) “Medicare Part A (hospital insurance)/Medicare Part B (medical insurance)/Medicare Part A (hospital insurance) and Medicare Part B (medical insurance)”

(3) “Your”/“Their”

(4) current HI/SMI date of entitlement in format “July 1999”

(5) “We will take any premiums due for the insurance out of your next payment”/“We will take any premiums due for the insurance out of their next payment”

HIB096 RRB Cert Beneficiary Entitled to HI/SMI

(1) entitled to Medicare. The Railroad Retirement Board (RRB) has jurisdiction of (2) Medicare. The RRB will issue (3) Medicare card. If (4) not receive (5) Medicare card in two weeks, you should contact the local office of the Railroad Retirement Board.

Fill-ins:

(1) “You are”/“He is”/“She is”

(2) “your”/“his”/“her”

(3) “your”/“his”/“her”

(4) “you do”/“he does”/“she does”

(5) “your”/“his”/“her”

HIB103 Third Party Buy-in, Closed Period

(1) (2) paid (3) Medicare (4) insurance premium for (5) .

Fill-ins:

(1) The State of/null

(2) state or territory in the format “Washington, D.C.”/“The Virgin Islands”/“Maryland” or “Guam”

(3) “your”/SN possessive

(4) “hospital/medical/hospital and medical”

(5) date(s), in format “Month YYYY” or “Month YYYY and Month YYYY” or “Month YYYY through Month YYYY”

HIB108 Third Party, Group Payer – Billing Terminates

The organization that was paying (1) Medicare (2) insurance premium will no longer pay it after (3) . (4) must pay the premium beginning (5) .

Fill-ins:

(1) “your”/SN possessive/FN possessive

(2) “hospital/medical/hospital and medical”

(3) date in format “MM/YYYY”

(4) “You”/“She”/“He”/FN possessive

(5) date in format “MM/YYYY”

HIB119 Third Party, Group Payer – Confirmation of Billing Arrangement

(1) recently arranged for an organization to pay (2) Medicare (3) insurance premium. Although we will send the bills to this organization, (4) responsible for seeing that they are paid.

If this organization decides to stop paying (5) premium, we will again send the bills to (6) .

If there is any other change in (7) Medicare premium, we will let (8) know.

Fill-ins:

(1) “You”/“beneficiary's given name”/“beneficiary's name”

(2) “your”/“her”/“his”

(3) “hospital/medical/hospital and medical”

(4) “you are”/“she is”/“he is”

(5) “your”/“her”/“his”

(6) “you”/“her”/“him”

(7) “your”/SN possessive

(8) “you”/“her”/“him”

HIB121 ESRD Awards (Introductory Paragraph)

We are writing to tell you that (1) entitled to Medicare coverage because of (2) kidney condition.

Fill-ins:

(1) NHFN plus “is”/you are

(2) “your”/“her”/“his”

HIB122 Entitlement Conversion Cases with Previous HI and/or SMI

(1) already entitled to (2) because (3) (4) . The date[s] of (5) entitlement to (6) did not change.

Fill-ins:

(1) “You are”/SN plus “is”

(2) “hospital insurance/medical insurance/hospital and medical insurance”

(3) “you are”/“he is”/“he is”

(4) disabled/over age 65

(5) “your”/“her”/“his”

(6) “hospital insurance/medical insurance/hospital and medical insurance”

HIB124 Awards – Previous SMI

However, (1) now (2) hospital insurance beginning (3) .

Fill-ins:

(1) “you”/“she”/“he”

(2) “has”/“have”

(3) Month CCYY hospital coverage begins

HIB125 DIB Awards, Beneficiary Previously Entitled to HI/SMI Based on ESRD

If (1) disability ends, (2) may still qualify for Medicare because of (3) kidney condition if:

(4) disability ends less than 12 months after (5) last regular dialysis, or

(6) disability ends less than 36 months after (7) last kidney transplant.

Fill-ins:

(1) “your”/“her”/“his”

(2) “you”/“she”/“he”

(3) “your”/“her”/“his”

(4) “your”/“her”/“his”

(5) “your”/“her”/“his”

(6) “your”/“her”/“his”

(7) “your”/“her”/“his”

HIB126 ESRD Awards, Beneficiary Previously Receiving Premium HI

(1) will no longer have to pay premiums for hospital insurance.

Fill-in:

(1) “You”/SN

HIB127 ESRD Awards, Beneficiary Previously Receiving Premium HI

But, (1) will still have to pay premiums for medical insurance. The monthly medical insurance premium rate is $(2) .

Fill-ins:

(1) “you”/“she”/“he”

(2) [2a] beginning [2b]./[2c] beginning [2d] and $[2e] beginning [2f]

[2a] money amount

[2b] date, in format “Month YYYY”

[2c] money amount

[2d] date, in format “Month YYYY”

[2e] money amount

[2f] date, in format “Month YYYY”

HIB128 ESRD Awards

Medicare coverage based on (1) kidney condition will end the last day of the (2) month after the month (3) (4) unless before then (5) again:

• •

  get(s) a kidney transplant, or

• •

  begin(s) regular dialysis.

Fill-ins:

(1) “your”/“her”/“his”

(2) 12th/36th

(3) “you”/“she”/“he”

(4) got your transplant/got her transplant/got his transplant/stops dialysis/stop dialysis

(5) “you”/“she”/“he”

HIB129 ESRD Awards, Previous Premium HI or SMI

Even if (1) no longer entitled to free hospital insurance based on (2) kidney condition, (3) will still be entitled to Medicare because (4) (5) .

Fill-ins:

(1) “you are”/“she is”/“he is”

(2) “your”/“her”/“his”

(3) “you”/“she”/“he”

(4) “you are”/“she is”/“he is”

(5) over age 65/disabled/a Railroad Retirement board beneficiary

HIB130 Closed Period ESRD Award

Our records show that (1) (2) in (3) . Therefore, (4) Medicare coverage based on (5) kidney condition ends the last day of (6) .

Fill-ins:

(1) “you”/“she”/“he”

(2) “stopped regular dialysis”/“received a kidney transplant”

(3) date of event in “Month CCYY” format

(4) “your”/“her”/“his”

(5) “your”/“her”/“his”

(6) month Medicare ends in “Month CCYY” format

HIB132 Closed Period Award for RRB Beneficiary

However, since the Railroad Retirement Board [RRB] handles (1) hospital and medical insurance (2) Medicare coverage will continue unless the RRB tells (3) they are stopping (4) coverage.

Fill-ins:

(1) “your”/“her”/“his”

(2) “your”/“her”/“his”

(3) “you”/“her”/“him”

(4) “your”/“her”/“his”

HIB136 ESRD Closed Period Awards

Let us know right away if (1) regular dialysis again or (2) a kidney transplant so (3) can file a new claim for Medicare coverage based on (4) kidney condition.

Fill-ins:

(1) “you resume”/“she resumes”/“he resumes”

(2) “get”/“gets”

(3) “you”/“she”/“he”

(4) “your”/“her”/“his”

HIB151 Closed Period Third Party Buy-in

(1) must pay the premium beginning (2) .

Fill-ins:

(1) “You”/“She”/“He”

(2) date, in format “Month CCYY”

HIB152

(1) (2) through (3) to enroll in Medicare Part B (medical insurance).

People who have Part B pay a monthly premium. If (4) not sign up for Part B when (5) first eligible, (6) may have to pay a late enrollment penalty for as long as (7) Part B. (8) monthly premium may go up 10 percent for each full 12-month period that (9) could have had Part B coverage, but did not sign up for it. Usually, (10) will not have to pay a late enrollment penalty if (11) up during a special enrollment period.

If (12) to sign up for Part B after (13) , (14) will usually have to wait until the general enrollment period. The general enrollment period takes place in January, February, and March of each year. If (15) up in the general enrollment period, (16) Part B coverage will start the month after (17) .

(18) may also be able to sign up during a special enrollment period. (19) can do this if (20) one of the conditions listed below:

• •

  (21) covered under a group health plan through (22) current work or (23) spouse's current work,

• •

  (24) covered under a large group health plan through (25) current work or any family member's current work.

(26) may sign up for medical insurance at any time (27) covered under the group health plan. However, (28) may wait and sign up during the 8-month period that begins when the work ends or (29) coverage under the plan ends, whichever occurs first. (30) may also sign up if the type of plan (31) changes.

Deciding when to sign up for Part B may depend on how (32) health insurance works with Medicare. For example, a group health plan is usually not the primary insurance if the employer has less than 20 employees. In this case, it is important to have Medicare coverage, and you may want to sign up now.

If (33) help deciding what to do, please contact (34) employee benefits office or contact us.

Fill-ins:

(1) FN/“You”

(2) “has”/“have”

(3) Hospital Insurance Start Date (HI-START) plus 3 months in Month CCYY format

(4) “you do”/“he does”/“she does”

(5) “you are”/“he is”/“she is”

(6) “you”/“he”/“she”

(7) “you have”/“he has”/“she has”

(8) “Your”/“His”/“Her”

(9) “you”/“he”/“she”

(10) “you”/“he”/“she”

(11) “you sign”/“he signs”/“she signs”

(12)“you want”/“he wants”/“she wants”

(13)Hospital Insurance Start Date (HI-START) plus 3 months in Month CCYY format

(14)“you”/“he”/“she”

(15) “you sign”/“he signs”/“she signs”

(16)“your”/“his”/“her”

(17)“you enroll”/“he enrolls”/“she enrolls”

(18) FN / “You”

(19)“You”/“He”/“She”

(20)“you meet”/“he meets”/“she meets”

(21)“You are”/“He is”/“She is”

(22)“your”/“his”/“her”

(23)“your”/“his”/“her”

(24)“You are”/“He is”/“She is”

(25)“your”/“his”/“her”

(26)“You”/“He”/“She”

(27)“you are”/“he is”/“she is”

(28) “you”/“he”/“she”

(29)“your”/“his”/“her”

(30)“You”/“He”/“She”

(31)“you have”/“he has”/“she has”

(32)“your”/“his”/“her”

(33)“you need”/“he needs”/“she needs”

(34)“your”/“his”/“her”

HIB157

If this notice is for a child under age 19 who is not covered by health insurance, there is a Children's Health Insurance Program that may help. To find out more, you can look on the Internet at (1) or call, toll free, 1-877-KIDS-NOW (1-877-543-7669). The number connects you to your state program.

Fill-in:

(1) www.insurekidsnow.gov

HIB170 ESRD, Monthly Benefits Terminating but HI/SMI Continuing

Even though (1) no longer receiving monthly payments, (2) will still have (3) coverage under Medicare. (4)

(5)

Fill-ins:

(1) “BN plus “is”/you are”

(2) “you”/“he”/“she”

(3) “Part A (hospital insurance)”/“Part A (hospital insurance) and Part B (medical insurance)”

(4) “Please keep the Medicare card.”/“Null”

(5) “There is a monthly premium for Medicare Part B. Because we stopped monthly payments, we will bill you every 3 months for premiums.”/“There is a monthly premium for Medicare Part B. Because we stopped monthly payments, we will bill him every 3 months for premiums.”/“There is a monthly premium for Medicare Part B. Because we stopped monthly payments, we will bill her every 3 months for premiums.”/“Null”

HIB171 ESRD, Monthly Benefits Terminating but HI/SMI with State Buy-in is Continuing

Even though (1) no longer receiving monthly payments, (2) will still have Part A (hospital insurance) and Part B (medical insurance) coverage under Medicare. (3) The State where (4) will continue to pay the premiums for (5) Part B coverage.

Fill-ins:

(1) “BN plus “is”/you are”

(2) “you”/“he”/“she”

(3) “Please keep the Medicare card.”/“Null”

(4) “you live/he lives/she lives”

(5) “your”/“his”/“her”

HIB186 Information Regarding Income Related Monthly Adjustment Amount (IRMAA)

Fill-ins:

(1) Show the IRMAA level 1 yearly amount for singles

(2) Show the IRMAA level 1 yearly amount for couples

(3) “his”/“her”“your”

(4) “he has”/“she has”/“you have”

(5) SMI start date in format July 2013

HIB215 Closed Period DIB Award and HI/SMI Terminates

Since (1) no longer entitled to monthly Social Security benefits, we are stopping (2) (3) insurance coverage under Medicare. (4) (5) insurance coverage ends on the last day of (6) . Please destroy (7) Medicare card after the coverage ends.

Fill-ins:

(1) “you are”/“she is”/“he is”

(2) “your”/“her”/“his”

(3) “hospital and medical”/“hospital”

(4) “Your”/“Her”/“His”

(5) “hospital and medical”/“hospital”

(6) HI termination date in the format May 1999

(7) “your”/“her”/“his”

HIB249 SMI Equitable Relief and Retroactive VSMI Exists

If you want your medical insurance to start earlier, you can choose to have it start in (1) . To start your medical insurance earlier, you must do the following things within 60 days after the date of this notice:

• •

  tell us in writing that you want medical insurance beginning (2) ;

  AND

• •

  pay us (3) or tell us we can withhold this amount from your check. This amount covers the premiums due from (4) through (5) .

If you would find it hard to pay the premium amount you would owe in a lump sum, ask us about other ways to pay the premium.

If you choose to have your medical insurance start in (6) , your current monthly premium will be (7) . If you do not choose the earlier date, your monthly premium will be (8) .

Fill-ins:

(1) date in format July 2013

(2) date in format July 2013

(3) Money amount

(4) date in format July 2013

(5) date in format July 2013

(6) date in format July 2013

(7) Money amount

(8) money amount

HIB316 Additional sources for health coverage when Medicare coverage ends - How to apply

For questions about Marketplace or Medicaid coverage, visit (1) , or call the Marketplace Call Center at 1-800-318-2596 (TTY 1-855-889-4325).

Fill-in:

HealthCare.gov

HIB317 How to apply for help for Immunosuppressive Drug coverage cost

Contact your state Medicaid agency to find out if you qualify for help paying for the premium and cost-sharing for your immunosuppressive drug benefit. Visit Medicaid.gov to find contact information for your state.

HIB318 How to apply for Immunosuppressive Drugs

• Call us toll-free at 1-877-465-0355 between 8:30 a.m. – 6:00 p.m. EST, Monday through Friday, to enroll over the phone.

• You can also use "Application for Enrollment in Part B Immunosuppressive Drug Coverage" Form CMS-10798. You may go to CMS.gov to find the form. Mail the completed form to:

SOCIAL SECURITY ADMINISTRATION

OFFICE OF CENTRAL OPERATIONS

PO BOX 32914

BALTIMORE, MARYLAND 21298-2703

HIB327 Availability of Immunosuppressive Drug coverage when ESRD or Medicare coverage ends

(1) may be eligible for a Medicare benefit called Part B Immunosuppressive Drug Coverage (Part B-ID) that helps pay for immunosuppressive drugs. This coverage is only for immunosuppressive drugs and not any otherMedicare services or prescriptions. You may be eligible to enroll in Part B-ID, but you are only eligible for payment of immunosuppressive drugs under Part B-ID if you are eligible for payment for those drugs under Medicare Part B.

You can only sign up for this benefit if (2) expect to get other health insurance such as:

• Employer group health plan or individual health plan (including Marketplace)

• TRICARE for Life

• Medicaid or the State Children’s Health Insurance Program (CHIP) coverage that includes immunosuppressive drugs

• Being enrolled in the patient enrollment system of the Department of Veterans Affairs (VA) or otherwise eligible to receive immunosuppressive drugs from the VA

Fill-ins:

(1)“You”/“Beneficiary's name”

(2)“You do not have and do not”/“Beneficiary's name + does not have and does not”

HIB331 Additional sources for obtaining health coverage when Medicare coverage ends - Applying for Medicare benefits

If (1) within three months of turning age 65 or older, contact Social Security to file an application for Medicare Part A and Part B. You must file an application to enroll in additional benefits under Medicare. Visit www.ssa.gov to file your application online or get the phone number for your local office.

Fill-in:

(1) “you are”/“Beneficiary name + is”

HIB333 Suspected Social Security or Medicare Fraud

Suspect Social Security or Medicare Fraud?

If you suspect Social Security fraud, please visit (1) or call the Inspector General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101). If you suspect Medicare fraud, please visit (2) or call the Health and Human Services Office of the Inspector General at 1-800-447-8477 (TTY 1-800-377-4950).

Fill-ins:

(1) https://oig.ssa.gov/report

(2) https://www.cms.gov/About-CMS/components/CPI/CPIReportingFraud

HIB334 Part B late enrollment penalties paid directly to the Centers for Medicare & Medicaid Services (CMS)

Individuals who have Medicare Part B pay a monthly premium. Eligible United States Postal Service (USPS) annuitants and their eligible family members who enrolled in Medicare Part B during the one-time Special Enrollment Period may be subject to Part B late enrollment penalties for as long as they have Part B, if they did not sign up for Part B when first eligible. However, the USPS will pay these penalties directly to the Centers for Medicare & Medicaid Services. Therefore, if (1)subject to these penalties, (2) not required to pay them.

Fill-ins:

(1) “you are”/“Beneficiary's name is”

(2) “you are”/“they are”

HIB335 Higher income persons to pay higher premium

IMPORTANT: A Medicare law requires some higher income persons to pay higher premiums. The law applies to premiums for Medicare Part B (Medical Insurance), prescription drug coverage, and Medicare Part B Immunosuppressive Drug coverage. The law generally affects individuals who reported incomes higher than (1) and couples with incomes higher than (2).

We will contact the Internal Revenue Service to get information about (3) income. If we decide that (4) to pay higher premiums, we will send a letter explaining our decision.

The higher amount will be effective January 2025 for the entire calendar year, and can change annually, depending on the income reported on (5) tax return. If (6) had a life-changing event that reduced (7) household income, (8) can ask to lower the additional amount.

For more information, please visit www.ssa.gov on the Internet or call us toll-free at 1-800-772-1213 (TTY 1-800-325-0778).

Fill-Ins:

(1) Requested As A Money Amount In Format $$$$$.¢¢

Show 2025 Medicare Part B Income-Related Monthly Adjustment Amount for individuals

(2) Requested As A Money Amount In Format $$$$$.¢¢

Show 2025 Medicare Part B Income-Related Monthly Adjustment Amount for couples

(3) “your”/“their”

(4) “you need”/“they need”

(5) “your”/“their”

(6) “you have”/“they have”

(7) “your”/“their”

(8) “you”/“they”

HIB336 Part D automatic enrollment

If (1) enrolled in a Postal Service Health Benefit plan, Part D prescription drug coverage will be included in (2) plan automatically. (3) not need to elect separate Part D coverage for (4) or for any family members on (5) plan.

Fill-Ins:

(1) “you are”/“Beneficiary’s name is”

(2) “your”/“their”

(3) “You do”/“They do”

(4) “yourself”/“them”

(5) “your”/“their”