HIBC01 – CAPTION
Information About Medicare
HIBC02 – CAPTION
Health Insurance For Children
HIBC05 – CAPTION
Why (1) Cannot Quality For Medicare
Fill-in values:
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Fill-in (1)
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show the BGN plus BLN (not possessive)
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HIBC14 – CAPTION
How to Apply for Immunosuppressive Drug Coverage
HIBC15 – CAPTION
To Cancel This Insurance
HIBC16 – CAPTION
If You Need Coverage for Immunosuppressive Drugs Only
HIBC18 – CAPTION
If You Need Help With Costs for the Immunosuppressive Drug Coverage
HIBC19 – CAPTION
Notice of Group Billing
HIBC20 – CAPTION
Apply for Medicare
HIBC21 – CAPTION
If You Need Health Coverage through Marketplace or Medicaid
HIB001 – ENTITLED TO HI AND/OR SMI
(1) Medicare (2) (3) (4) (5).
Fill-in values:
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Fill-in (1)
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Choice 1
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Your
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Choice 2
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Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
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Fill-in (2)
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Choice 1
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Part A (hospital insurance) starts
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Choice 2
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Part B (medical insurance) starts
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Choice 3
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Part A (hospital insurance) and Part B (medical insurance) start
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Fill-in (3)
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Date in format Month CCYY
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Fill-in (4)
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Choice 1
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and Part B (medical insurance) starts
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Choice 2
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Null
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Fill-in (5)
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Choice 1
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Date in format Month CCYY
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Choice 2
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Null
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HIB002 -TEMPORARY SUBSTITUTION OF NOTICE FOR HEALTH INSURANCE CARD
(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-in values:
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Fill-in (1)
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Choice 1
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You
|
Choice 2
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BGN plus BLN (not possessive)
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Fill-in (2)
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Choice 1
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You should
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Choice 2
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He should
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Choice 3
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She should
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Fill-in (3)
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Choice 1
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you need
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Choice 2
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he needs
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Choice 3
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she needs
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Fill-in (4)
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Choice 1
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you have
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Choice 2
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he has
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Choice 3
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she has
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Fill-in (5)
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Choice 1
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your
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Choice 2
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his
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Choice 3
|
her
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HIB005 – SMI PREMIUM BILLING
(1) monthly premium for Medicare Part B (medical insurance) is (2) beginning (3) (4)
(5).
Fill-in values:
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Fill-in (1)
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Choice 1
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Your
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Choice 2
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His
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Choice 3
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Her
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Fill-in (2)
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Amount of Part B premium in $$$$$.¢¢ format
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Fill-in (3)
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Date in MMCCYY format
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Fill-in (4)
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Choice 1
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null
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Choice 2
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and
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Fill-in (5)
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|
Choice 1
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null
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Choice 2
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Show the amount of the Part B premium in the format $$$$$¢¢ plus the word “beginning”
plus show the start date that corresponding to the second premium rate returned from
the HSA utility in the format MMCCYY
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HIB008 – SMI PREMIUM DEDUCTIONS
We will start to take premiums out of (1) (2) check.
Fill-in values:
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Fill-in (1)
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Choice 1
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his
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Choice 2
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her
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Choice 3
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your
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Fill-in (2)
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Choice 1
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next
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Choice 2
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MMDDYYYY (using the PCI, show the calendar date for the month following COM (e.g.
if PCI = 2 and the COM = 4/98, then fill-in 2 will equal the calendar date for the
second Wednesday in May)
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HIB011 – HI PREMIUM BILLING
The monthly premium for (1) hospital insurance is (2). We will bill you each month
for (3).
Fill-in values:
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Fill-in (1)
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Choice 1
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his
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Choice 2
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her
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Choice 3
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your
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Fill-in (2)
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Show the current HI premium rate in the format 999.99
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Fill-in (3)
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Choice 1
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this premium
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Choice 2
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the combined premium for hospital and medical insurance
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HIB013 – MEDICARE HI/SMI PREMIUM PENALTY
(1) a penalty because (2) enrolled later than (3) could have.
Fill-in values:
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Fill-in (1)
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Choice 1
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This medical insurance premium includes
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Choice 2
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This hospital insurance premium includes
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Choice 3
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These hospital and medical insurance premiums include
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Fill-in (2)
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Choice 1
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he
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Choice 2
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she
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Choice 3
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you
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Fill-in (3)
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Choice 1
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he
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Choice 2
|
she
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Choice 3
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you
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HIB015 – PREMIUMS DEDUCTED FROM CIVIL SERVICE ANNUITY
The Office of Personnel Management will deduct the premiums from (1) annuity checks.
They will let (2) know when this will start.
Fill-in values:
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Fill-in (1)
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Choice 1
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BGN plus BLN (possessive)
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Choice 2
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your
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Fill-in (2)
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Choice 1
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him
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Choice 2
|
her
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Choice 3
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you
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HIB026 – 3RD PARTY BUYIN TP STARTS DATES/CODES DO NOT MATCH
(1) (2) will pay (3) Medicare hospital insurance premiums beginning (4). (5)
(6) (7) will pay (8) Medicare medical insurance premiums beginning (9). (10)
Fill-in values:
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Fill-in (1)
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Choice 1
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Leave Blank
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Choice 2
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The State of
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Fill-in (2)
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show State name
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Fill-in (3)
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Choice 1
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BGN plus BLN (possessive)
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Choice 2
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your
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Fill-in (4)
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Show the TP START DATE in the format MMCCYY
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Fill-in (5)
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Choice 1
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This also means that he is entitled to this Medicare coverage for an earlier period
than shown on his current Medicare card.
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Choice 2
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This also means that she is entitled to this Medicare coverage for an earlier period
than shown on her current Medicare card.
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Choice 3
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This also means that you are entitled to this Medicare coverage for an earlier period
than shown on your current Medicare card.
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Choice 4
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Null
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Fill-in (6)
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Choice 1
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Leave Blank
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Choice 2
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The State of
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Fill-in (7)
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show State name
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Fill-in (8)
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Choice 1
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BGN plus BLN (possessive)
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Choice 2
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your
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Fill-in (9)
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Show the TP START date in the format MMCCYY
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Fill-in (10)
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Choice 1
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This also means that he is entitled to this Medicare coverage for an earlier period
than shown on his current Medicare card.
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Choice 2
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This also means that she is entitled to this Medicare coverage for an earlier period
than shown on her current Medicare card.
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Choice 3
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This also means that you are entitled to this Medicare coverage for an earlier period
than shown on your current Medicare card.
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Choice 4
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Null
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HIB027 – 3RD PARTY BUYOUT TP STARTS DATES/CODES DO NOT MATCH
(1) (2) will no longer pay (3) Medicare hospital insurance premiums after (4).
(5) must pay the premiums beginning (6).
(7) (8) will no longer pay (9) Medicare medical insurance premiums after (10).
(11) must pay the premiums beginning (12).
Fill-in values:
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Fill-in (1)
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Choice 1
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Leave Blank
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Choice 2
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The State of
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Fill-in (2)
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Show State name
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Fill-in (3)
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Choice 1
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BGN plus BLN (possessive)
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Choice 2
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your
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Fill-in (4)
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Show TP STOP date in the format MMCCYY
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Fill-in (5)
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Choice 1
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He
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Choice 2
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She
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Choice 3
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You
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Fill-in (6)
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Show the TP STOP date plus 1 month in the format MMCCYY
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Fill-in (7)
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Choice 1
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Leave Blank
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Choice 2
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The State of
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Fill-in (8)
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Show State name
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Fill-in (9)
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Choice 1
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BGN plus BLN (possessive)
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Choice 2
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your
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Fill-in (10)
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Show the TP STOP date in the format MMCCYY
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Fill-in (5)
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Choice 1
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He
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Choice 2
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She
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Choice 3
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You
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Fill-in (12)
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Show the TP STOP date plus 1 month in the format MMCCYY
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HIB029 – LIMITED BUYIN FOR HI/SMI DATES/CODES DO NOT MATCH
(1) (2) paid (3) Medicare hospital insurance premium for (4).
(5) (6) paid (7) Medicare medical insurance premium for (8).
Fill-in values:
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Fill-in (1)
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Choice 1
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Leave Blank
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Choice 2
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The State of
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Fill-in (2)
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Show the State name
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Fill-in (3)
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Choice 1
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BGN plus BLN (possessive)
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Choice 2
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your
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Fill-in (4)
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Choice 1
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MMCCYY
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Choice 2
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MMCCYY and MMCCYY
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Choice 3
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MMCCYY through MMCCYY
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Fill-in (5)
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Choice 1
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Leave Blank
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Choice 2
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The State of
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Fill-in (6)
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Show the State name
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Fill-in (7)
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Choice 1
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BGN plus BLN (possessive)
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Choice 2
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your
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Fill-in (8)
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Choice 1
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MMCCYY
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Choice 2
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MMCCYY and MMCCYY
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Choice 3
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MMCCYY through MMCCYY
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HIB030 – GROUP PAYER STOPS FOR HI/SMI DATES NOT EQUAL
The organization that was paying (1) Medicare hospital insurance premium will no longer
pay it after (2). (3) must pay the premium beginning (4).
The organization that was paying (5) Medicare medical insurance premium will no longer
pay it after (6). (7) must pay the premium beginning (8).
Fill-in values:
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Fill-in (1)
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Choice 1
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BGN plus BLN (possessive)
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Choice 2
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your
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Fill-in (2)
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MMCCYY
|
Fill-in (3)
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Choice 1
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He
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Choice 2
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She
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Choice 3
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You
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Fill-in (4)
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MMCCYY
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Fill-in (5)
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Choice 1
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BGN plus BLN possessive
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Choice 2
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your
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Fill-in (6)
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MMCCYY
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Fill-in (7)
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Choice 1
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He
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Choice 2
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She
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Choice 3
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You
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Fill-in (8)
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MMCCYY
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HIB034 –ADVISE THAT SMI DEDUCTION WILL START/CONTINUE
We will (1) to deduct Medicare Part B (medical insurance) premium of (2) from (3)
payments.
Fill-in values:
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Fill-in (1)
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Choice 1 |
start |
Choice 2 |
continue |
Fill-in (2)
|
Show the total of DAH-ITEMS = 430, 435 and 440 in the format $$$$$ |
Fill-in (3)
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Choice 1
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your
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Choice 2
|
BGN plus BLN (possessive)
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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-in values:
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Fill-in (1)
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Choice 1
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He
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Choice 2
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She
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Choice 3
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You
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Fill-in (2)
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Choice 1
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he has
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Choice 2
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she has
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Choice 3
|
you have
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HIB042 – MEDICARE DISALLOWANCE FEHB ACT OF 1959
(1) cannot qualify for Medicare because (2) covered under the Federal Employees Health
Benefits Act
Fill-in values:
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Fill-in (1)
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|
Choice 1
|
He
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Choice 2
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She
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Choice 3
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You
|
Fill-in (2)
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|
Choice 1
|
he is
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Choice 2
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she is
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Choice 3
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you are
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Choice 4
|
he could be
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Choice 5
|
she could be
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Choice 6
|
you could be
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HIB050 – MED DISAL NH 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.
HIB053 – PREMIUM HI DENIED AND/OR SMI DISALLOWED (RDD 107)
(1) not entitled to (2) insurance coverage under Medicare because the application
was not filed during an enrollment period and (3) did not qualify for a special enrollment
period. However, (4) 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-in values:
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|
Fill-in (1)
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Choice 1
|
BGN plus BLN plus the word “is”
|
Choice 2
|
You are
|
Fill-in (2)
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|
Choice 1
|
medical
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Choice 2
|
hospital
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Choice 3
|
hospital and medical
|
Fill-in (3)
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|
Choice 1
|
BGN plus BLN (not possessive)
|
Choice 2
|
you
|
Fill-in (4)
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|
Choice 1
|
BGN plus BLN (not possessive)
|
Choice 2
|
you
|
HIB054 – HI AND/OR SMI PERIOD NOT PREVIOUSLY COVERED
If (1) had any expenses that (2) should be covered by Medicare (3) insurance, please
contact your local Social Security office. The telephone number and address are shown
below.
Fill-in values:
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|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN the word “has”
|
Choice 2
|
Beneficiary First Name plus the word “has”
|
Choice 3
|
you have
|
Fill-in (2)
|
|
Choice 1
|
he believes
|
Choice 2
|
she believes
|
Choice 3
|
you believe
|
Fill-in (3)
|
|
Choice 1
|
hospital
|
Choice 2
|
medical
|
Choice 3
|
hospital and medical
|
HIB060 – SUSPENSE FOR PRISON/MENTAL ADVISES OF SMI PREMIUMS
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 reenroll
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 reenroll.
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 all premiums now due. After that, each bill we send will be for
a 3-month period and will be sent to you shortly before the payment is due.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN plus the word “receives”
|
Choice 2
|
you receive
|
Fill-in (2)
|
|
Choice 1
|
he is
|
Choice 2
|
she is
|
Choice 3
|
you are
|
Fill-in (3)
|
|
Choice 1
|
imprisoned
|
Choice 2
|
confined in an institution
|
Fill-in (4)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (5)
|
|
Choice 1
|
he is
|
Choice 2
|
she is
|
Choice 3
|
you are
|
Fill-in (6)
|
|
Choice 1
|
prison
|
Choice 2
|
the institution
|
Fill-in (7)
|
|
Choice 1
|
BGN plus BLN
|
Choice 2
|
You
|
Fill-in (8)
|
|
Choice 1
|
he is
|
Choice 2
|
she is
|
Choice 3
|
you are
|
Fill-in (9)
|
|
Choice 1
|
prison
|
Choice 2
|
the institution
|
Fill-in (10)
|
|
Choice 1
|
he
|
Choice 2
|
she
|
Choice 3
|
you
|
Fill-in (11)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
HIB061 – SMI PREMIUM CONTINUES DEDUCTION FROM CS ANNUITY
The Office of Personnel Management will continue to deduct (1) medical insurance premiums
from (2) annuity checks.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
Beneficiary Full Name (possessive)
|
Choice 2
|
your
|
Fill-in (2)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
HIB066 – HI/SMI PREMIUMS ALREADY PAID
Any (1) insurance premiums (2) already paid will be credited to (3) record.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
medical
|
Choice 2
|
hospital
|
Choice 3
|
hospital and medical
|
Fill-in (2)
|
|
Choice 1
|
BGN plus BLN plus “has”
|
Choice 2
|
BGN plus “has”
|
Choice 3
|
you have
|
Fill-in (3)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
HIB067 – SMI PREMIUM BILLING
We will send (1) first bill for the premiums within a month. Each bill after that
will be for a 3-month period.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
HIB068 – HI/SMI 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-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
he wants
|
Choice 2
|
she wants
|
Choice 3
|
you want
|
Fill-in (2)
|
|
Choice 1
|
he
|
Choice 2
|
she
|
Choice 3
|
you
|
Fill-in (3)
|
|
Choice 1
|
hospital
|
Choice 2
|
medical
|
Choice 3
|
hospital and medical
|
Fill-in (4)
|
|
Choice 1
|
Show the HI-NONEQRELST date in MMCCYY
|
Choice 2
|
Show the SMI-NONEQRELST date in MMCCYY
|
Fill-in (5)
|
|
Choice 1
|
he
|
Choice 2
|
she
|
Choice 3
|
you
|
Fill-in (6)
|
|
Choice 1
|
he wants
|
Choice 2
|
she wants
|
Choice 3
|
you want
|
Fill-in (7)
|
|
Choice 1
|
hospital
|
Choice 2
|
medical
|
Choice 3
|
hospital and medical
|
Fill-in (8)
|
|
Choice 1
|
Show the HI-NONEQRELST date in MMCCYY
|
Choice 2
|
Show the SMI-NONEQRELST date in MMCCYY
|
Fill-in (9)
|
|
Choice 1
|
he
|
Choice 2
|
she
|
Choice 3
|
you
|
Fill-in (10)
|
|
Choice 1
|
Show the total amount for HI premiums calculated
|
Choice 2
|
Show the total amount for SMI premiums calculated
|
Choice 3
|
Show the combined total amount for HI and SMI premiums calculated
|
Fill-in (11)
|
|
Choice 1
|
Show the HI-NONEQRELST date in MMCCYY
|
Choice 2
|
Show the SMI-NONEQRELST date in MMCCYY
|
Fill-in (12)
|
Show the COM month in MMCCYY
|
Fill-in (13)
|
|
Choice 1
|
tell us we can withhold this amount from the check.
|
Choice 2
|
tell us to bill you for this amount.
|
HIB069 – HI/SMI TERMINATION FOR NON-PAYMENT OF PREMIUMS
(1) Medicare premium (2) for (3) insurance was not paid within the time limit. Therefore,
(4) (5) insurance coverage has stopped. (6) last month of coverage (7) (8). Benefits
will not be paid for any (9) services (10) after (11) last month of coverage.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN (possessive)
|
Choice 2
|
Your
|
Fill-in (2)
|
|
Choice 1 |
in the amount of + money amount for HI/SMI premiums due in $99,999.99 format |
Choice 2 |
Null |
Fill-in (3)
|
|
Choice 1
|
hospital
|
Choice 2
|
medical
|
Choice 3
|
hospital and medical
|
Fill-in (4)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (5)
|
|
Choice 1
|
hospital
|
Choice 2
|
medical
|
Choice 3
|
hospital and medical
|
Fill-in (6)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (7)
|
|
Choice 1
|
is
|
Choice 2
|
was
|
Fill-in (8)
|
|
Choice 1
|
Show the HI TERM date minus 1 month in MMCCYY
|
Choice 2
|
Show the SMI TERM date minus 1 month in MMCCYY
|
Fill-in (9)
|
|
Choice 1
|
hospital
|
Choice 2
|
medical
|
Choice 3
|
hospital and medical
|
Fill-in (10)
|
|
Choice 1
|
he receives
|
Choice 2
|
she receives
|
Choice 3
|
you receive
|
Fill-in (11)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
HIB070 – PREMIUM HI DWI CONTINUES SMI TERMINATES NON-PAYMENT
This decision does not affect (1) (2) insurance coverage. (3) should continue to pay
(4) insurance premiums to keep this coverage.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (2)
|
|
Choice 1
|
medical
|
Choice 2
|
hospital
|
Fill-in (3)
|
|
Choice 1
|
He
|
Choice 2
|
She
|
Choice 3
|
You
|
Fill-in (4)
|
|
Choice 1
|
medical
|
Choice 2
|
hospital
|
HIB071 – RRB JURIS STARTS AND COLLECTS MEDICARE PREMIUMS
The Social Security Administration is no longer responsible for deducting Medicare
premiums from Social Security payments. The Railroad Retirement Board (RRB) is now
responsible for collecting medical insurance premiums for all railroad beneficiaries
and their families. This includes beneficiaries who are also entitled to Social Security
benefits.
HIB072 – RRB JURIS STARTS AND COLLECTS MEDICARE PREMIUMS
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-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN
|
Choice 2
|
You
|
Fill-in (2)
|
|
Choice 1
|
is
|
Choice 2
|
are
|
Fill-in (3)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (4)
|
|
Choice 1
|
he is
|
Choice 2
|
she is
|
Choice 3
|
you are
|
Fill-in (5)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (6)
|
|
Choice 1
|
him
|
Choice 2
|
her
|
Choice 3
|
you
|
HIB073 – RRB SENDS NEW MEDICARE CARD
(1) protection under Medicare will continue without any change in coverage.
The RRB will send (2) a new Medicare card. Until then, (3) may use (4) old card.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN (possessive)
|
Choice 2
|
Your
|
Fill-in (2)
|
|
Choice 1
|
him
|
Choice 2
|
her
|
Choice 3
|
you
|
Fill-in (3)
|
|
Choice 1
|
he
|
Choice 2
|
she
|
Choice 3
|
you
|
Fill-in (4)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
HIB074 – NEW MEDICARE CARD
We will send (1) a new health insurance card. It will show that (2) entitled to (3)
insurance.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN (not possessive)
|
Choice 2
|
BGN (not possessive)
|
Choice 3
|
you
|
Fill-in (2)
|
|
Choice 1
|
he is
|
Choice 2
|
she is
|
Choice 3
|
you are
|
Fill-in (3)
|
|
Choice 1
|
hospital
|
Choice 2
|
medical
|
Choice 3
|
hospital and medical
|
HIB075 – EQUITABLE RELIEF/HARDSHIP
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-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
he wants
|
Choice 2
|
she wants
|
Choice 3
|
you want
|
Fill-in (2)
|
|
Choice 1
|
Show the HI NONEQRELST date in MMCCYY
|
Choice 2
|
Show the SMI NONEQRELST date in MMCCYY
|
Fill-in (3)
|
|
Choice 1
|
find
|
Choice 2
|
finds
|
HIB076 – HI/SMI TERMINATION INFORMATIONAL
If (1) not sign up for Part B when (2) first eligible, (3) may have to pay a late
enrollment penalty for as long as (4) Part B. (5) monthly premium may go up 10 percent
for each full 12-month period that (6) could have had Part B coverage, but did not
sign up for it. Usually, (7) will not have to pay a late enrollment penalty if (8)
up during a special enrollment period.
If (9) to sign up for (10) later, (11) 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 (12) up in the general enrollment period, (13) Part B coverage
will start the month after (14).
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
you do
|
Choice 2
|
he does
|
Choice 3
|
she does
|
Fill-in (2)
|
|
Choice 1
|
you are
|
Choice 2
|
he is
|
Choice 3
|
she is
|
Fill-in (3)
|
|
Choice 1
|
you
|
Choice 2
|
he
|
Choice 3
|
she
|
Fill-in (4)
|
|
Choice 1
|
you have
|
Choice 2
|
he has
|
Choice 3
|
she has
|
Fill-in (5)
|
|
Choice 1
|
Your
|
Choice 2
|
His
|
Choice 3
|
Her
|
Fill-in (6)
|
|
Choice 1
|
you
|
Choice 2
|
he
|
Choice 3
|
she
|
Fill-in (7)
|
|
Choice 1
|
you
|
Choice 2
|
he
|
Choice 3
|
she
|
Fill-in (8)
|
|
Choice 1
|
you sign
|
Choice 2
|
he signs
|
Choice 3
|
she signs
|
Fill-in (9)
|
|
Choice 1
|
you want
|
Choice 2
|
BGN plus BLN plus “wants”
|
Fill-in (10)
|
|
Choice 1
|
Part A
|
Choice 2
|
Part B
|
Choice 3
|
Part A and Part B
|
Fill-in (11)
|
|
Choice 1
|
you
|
Choice 2
|
he
|
Choice 3
|
she
|
Fill-in (12)
|
|
Choice 1
|
you sign
|
Choice 2
|
he signs
|
Choice 3
|
she signs
|
Fill-in (13)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
Fill-in (14)
|
|
Choice 1
|
you enroll
|
Choice 2
|
he enrolls
|
Choice 3
|
she enrolls
|
HIB077 – SMI TERMINATION INFORMATIONAL
People who have Medicare Part B (medical insurance) pay a monthly premium. If (1)
not sign up for Part B when (2) first eligible, (3) may have to pay a late enrollment
penalty for as long as (4) Part B. (5) monthly premium may go up 10 percent for each
full 12-month period that (6) could have had Part B coverage, but did not sign up
for it. Usually, (7) will not have to pay a late enrollment penalty if (8) up during
a special enrollment period.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
you do
|
Choice 2
|
he does
|
Choice 3
|
she does
|
Fill-in (2)
|
|
Choice 1
|
you are
|
Choice 2
|
he is
|
Choice 3
|
she is
|
Fill-in (3)
|
|
Choice 1
|
you
|
Choice 2
|
he
|
Choice 3
|
she
|
Fill-in (4)
|
|
Choice 1
|
you have
|
Choice 2
|
he has
|
Choice 3
|
she has
|
Fill-in (5)
|
|
Choice 1
|
Your
|
Choice 2
|
His
|
Choice 3
|
Her
|
Fill-in (6)
|
|
Choice 1
|
you
|
Choice 2
|
he
|
Choice 3
|
she
|
Fill-in (7)
|
|
Choice 1
|
you
|
Choice 2
|
he
|
Choice 3
|
she
|
Fill-in (8)
|
|
Choice 1
|
you sign
|
Choice 2
|
he signs
|
Choice 3
|
she signs
|
HIB078 – HI TERMINATION INFORMATIONAL
(1) monthly premium for hospital insurance may be 10 percent higher when (2).
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
His
|
Choice 2
|
Her
|
Choice 3
|
Your
|
Fill-in (2)
|
|
Choice 1
|
he re-enrolls
|
Choice 2
|
she re-enrolls
|
Choice 3
|
you re-enroll
|
HIB079 – VOLUNTARY TERMINATION FOR PREMIUM HI OR SMI
Because (10) canceling (2) (3) insurance coverage, (4) no longer entitled to (5) insurance
coverage. (6) hospital and medical insurance coverage ends on the last day of (7).
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN plus the word “is”
|
Choice 2
|
BGN plus the word “is”
|
Choice 3
|
you are
|
Fill-in (2)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (3)
|
|
Choice 1
|
medical
|
Choice 2
|
hospital
|
Fill-in (4)
|
|
Choice 1
|
he is
|
Choice 2
|
she is
|
Choice 3
|
you are
|
Fill-in (5)
|
|
Choice 1
|
hospital
|
Choice 2
|
medical
|
Fill-in (6)
|
|
Choice 1
|
His
|
Choice 2
|
Her
|
Choice 3
|
Your
|
Fill-in (7)
|
Show the HI TERM date minus 1 month in MMCCYY format
|
HIB080 – VOLUNTARY SMI TERMINATION CIVIL SERVICE INVOLVED
The Office of Personnel Management will no longer deduct the medical insurance premiums
from (1) annuity checks. They will let (2) know when the deductions will stop.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN (possessive)
|
Choice 2
|
BGN (possessive)
|
Choice 3
|
your
|
Fill-in (2)
|
|
Choice 1
|
him
|
Choice 2
|
her
|
Choice 3
|
you
|
HIB082 – HI AND/OR SMI VOLUNTARY TERMINATION
(1) asked that we stop (2) (3) insurance coverage under Medicare. This coverage ends
the last day of (4).
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN
|
Choice 2
|
You
|
Fill-in (2)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (3)
|
|
Choice 1
|
hospital
|
Choice 2
|
medical
|
Choice 3
|
hospital and medical
|
Fill-in (4)
|
|
Choice 1
|
Show the HI TERM date minus 1 month in MMCCYY format
|
Choice 2
|
Show the SMI TERM date minus 1 month in MMCCYY format
|
HIB083 – SPECIAL ENROLLMENT PERIOD DISABILITY
(1) may also be able to enroll during a special enrollment period. (2) can do this
if (3) (4) one of the conditions listed below:
-
•
(5) covered under a group health plan through (6) current work or (7) spouse's current
work, or
-
•
(8) covered under a large group health plan through (9) current work or any family
member's current work.
(10) may enroll for Medicare (11) insurance at any time (12) covered under the group
health plan. However, (13) may wait and enroll during the 8-month period that begins
when the work ends or (14) coverage under the plan ends, whichever occurs first. (15)
may also enroll if the type of plan (16) changes.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN (not possessive)
|
Choice 2
|
BGN (not possessive)
|
Choice 3
|
You
|
Fill-in (2)
|
|
Choice 1
|
He
|
Choice 2
|
She
|
Choice 3
|
You
|
Fill-in (3)
|
|
Choice 1
|
he
|
Choice 2
|
she
|
Choice 3
|
you
|
Fill-in (4)
|
|
Choice 1
|
meets
|
Choice 2
|
meet
|
Fill-in (5)
|
|
Choice 1
|
He is
|
Choice 2
|
She is
|
Choice 3
|
You are
|
Fill-in (6)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (7)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (8)
|
|
Choice 1
|
He is
|
Choice 2
|
She is
|
Choice 3
|
You are
|
Fill-in (9)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (10)
|
|
Choice 1
|
He
|
Choice 2
|
She
|
Choice 3
|
You
|
Fill-in (11)
|
|
Choice 1
|
hospital
|
Choice 2
|
medical
|
Choice 3
|
hospital and medical
|
Fill-in (12)
|
|
Choice 1
|
he is
|
Choice 2
|
she is
|
Choice 3
|
you are
|
Fill-in (13)
|
|
Choice 1
|
he
|
Choice 2
|
she
|
Choice 3
|
you
|
Fill-in (14)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (15)
|
|
Choice 1
|
He
|
Choice 2
|
She
|
Choice 3
|
You
|
Fill-in (16)
|
|
Choice 1
|
he has
|
Choice 2
|
she has
|
Choice 3
|
you have
|
HIB084 – SPECIAL ENROLLMENT PERIOD AGED
(1) may also be able to enroll during a special enrollment period. (2) can do this
if (3) all of the conditions listed below:
-
•
(4) health insurance coverage is under an employer's plan because (5) or (6) spouse
is working, and
-
•
(7) had health insurance coverage under that plan since (8) became age 65.
(9) may enroll for Medicare (10) insurance at any time (11) covered under the group
health plan. However, (12) may wait and enroll during the 8-month period that begins
when the work ends or (13) coverage under the plan ends, whichever occurs first.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN (not possessive)
|
Choice 2
|
BGN (not possessive)
|
Choice 3
|
You
|
Fill-in (2)
|
|
Choice 1
|
He
|
Choice 2
|
She
|
Choice 3
|
You
|
Fill-in (3)
|
|
Choice 1
|
he meets
|
Choice 2
|
she meets
|
Choice 3
|
you meet
|
Fill-in (4)
|
|
Choice 1
|
His
|
Choice 2
|
Her
|
Choice 3
|
Your
|
Fill-in (5)
|
|
Choice 1
|
he
|
Choice 2
|
she
|
Choice 3
|
you
|
Fill-in (6)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (7)
|
|
Choice 1
|
He has
|
Choice 2
|
She has
|
Choice 3
|
You have
|
Fill-in (8)
|
|
Choice 1
|
he
|
Choice 2
|
she
|
Choice 3
|
you
|
Fill-in (9)
|
|
Choice 1
|
He
|
Choice 2
|
She
|
Choice 3
|
You
|
Fill-in (10)
|
|
Choice 1
|
hospital
|
Choice 2
|
medical
|
Choice 3
|
hospital and medical
|
Fill-in (11)
|
|
Choice 1
|
he is
|
Choice 2
|
she is
|
Choice 3
|
you are
|
Fill-in (12)
|
|
Choice 1
|
he
|
Choice 2
|
she
|
Choice 3
|
you
|
Fill-in (13)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
HIB085 – VOLUNTARY SMI TERMINATION CURRENT PAY
We will stop taking premiums for medical insurance out of (1) checks.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN (possessive)
|
Choice 2
|
BGN (possessive)
|
Choice 3
|
your
|
HIB086 – VOLUNTARY HI/SMI TERMINATION PREMIUMS DUE
(1) (2) (3) in premiums through (4). Please make (5) check or money order payable
to the "Centers for Medicare & Medicaid Services" and mail it to us in the enclosed
envelope. Include (6) Medicare number on (7) check or money order.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN (not possessive)
|
Choice 2
|
You
|
Fill-in (2)
|
|
Choice 1
|
owes
|
Choice 2
|
owe
|
Fill-in (3)
|
Show total past due amount in $999,999.99 format
|
Fill-in (4)
|
Show the HI/SMI termination date minus 1 month in the format May 1999
|
Fill-in (5)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
Fill-in (6)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
Fill-in (7)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
HIB087 – VOLUNTARY SMI TERMINATION HI CONTINUES / MEDICARE WILL CONTINUE AFTER REQUEST
FOR STATUTORY BENEFIT CONTINUATION (SBC) IS PROCESSED
(1) (2) coverage will continue.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN (possessive)
|
Choice 2
|
Your
|
Fill-in (2) |
|
Choice 1 |
Part A (hospital insurance) |
Choice 2 |
Part B (medical insurance) |
Choice 3
|
Part A (hospital insurance) and Part B (medical insurance)
|
HIB088 – HI/SMI FOREIGN ADDRESS
Normally, Medicare will only pay for (1) services which (2) (3) in the United States.
Since (4) living outside the U.S., Medicare will not pay for (5) services unless (6)
to the U.S. for services.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
hospital
|
Choice 2
|
medical
|
Choice 3
|
hospital and medical
|
Fill-in (2)
|
|
Choice 1
|
BGN plus BLN (not possessive)
|
Choice 2
|
BGN (not possessive)
|
Choice 3
|
you
|
Fill-in (3)
|
|
Choice 1
|
receives
|
Choice 2
|
receive
|
Fill-in (4)
|
|
Choice 1
|
he is
|
Choice 2
|
she is
|
Choice 3
|
you are
|
Fill-in (5)
|
|
Choice 1
|
hospital
|
Choice 2
|
medical
|
Choice 3
|
hospital and medical
|
Fill-in (6)
|
|
Choice 1
|
he returns
|
Choice 2
|
she returns
|
Choice 3
|
you return
|
HIB089 – BENE AT FRA PROVISION PAYMENTS END HI/SMI ENDS
Since (1) no longer receiving provisional monthly Social Security benefits, we are
stopping (2) (3) insurance coverage. This coverage ends the last day of (4). Please
destroy (5) Medicare card after coverage ends.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN plus the word “is”
|
Choice 2
|
you are
|
Fill-in (2)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (3)
|
|
Choice 1
|
hospital
|
Choice 2
|
hospital and medical
|
Fill-in (4)
|
Show HI-TERM date in MMCCYY format
|
Fill-in (5)
|
|
Choice 1
|
BGN plus BLN (possessive)
|
Choice 2
|
your
|
HIB090 – TERMINATION ALL MEDICARE COVERAGE
(1) Medicare card will not be valid when (2) (3) coverage ends. Please destroy (4)
card after (5) coverage ends.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN (possessive)
|
Choice 2
|
Your
|
Fill-in (2)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (3)
|
|
Choice 1
|
Medicare Part A (hospital insurance) and Part B (medical insurance)
|
Choice 2
|
Medicare Part B (medical insurance)
|
Fill-in (4)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (5)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
HIB092 – STATE/LOCAL GOVT CONTINUES TO PAY SMI PREMIUM
(1) State or local government retirement system will continue to pay (2) Medicare
medical insurance late enrollment premium penalty. (3) must continue to pay the basic
Medicare medical insurance premium.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN (possessive)
|
Choice 2
|
Your
|
Fill-in (2)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (3)
|
|
Choice 1
|
He
|
Choice 2
|
She
|
Choice 3
|
You
|
HIB093 – STATE OR GROUP CONTINUES TO PAY SMI PREMIUMS
Our records show that (1) will continue to pay the premiums for (2) Medicare (3) insurance
coverage.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
the State
|
Choice 2
|
an organization
|
Fill-in (2)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (3)
|
|
Choice 1
|
hospital and medical
|
Choice 2
|
medical
|
HIB101 – MEDICARE STATE BUY-IN
(1) (2) will pay (3) Medicare (4) insurance premium beginning (5). (6)
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
Leave blank
|
Choice 2
|
The State of
|
Fill-in (2)
|
show state corresponding to the HITP-CODE or the SMTP-CODE
|
Fill-in (3)
|
|
Choice 1
|
BGN plus BLN (possessive)
|
Choice 2
|
your
|
Fill-in (4)
|
|
Choice 1
|
hospital
|
Choice 2
|
medical
|
Choice 3
|
hospital and medical
|
Fill-in (5)
|
TP START date in MMCCYY format
|
Fill-in (6)
|
|
Choice 1
|
This also means that he is entitled to this Medicare coverage for an earlier period
than shown on his current Medicare card.
|
Choice 2
|
This also means that she is entitled to this Medicare coverage for an earlier period
than shown on her current Medicare card.
|
Choice 3
|
This also means that you are entitled to this Medicare coverage for an earlier period
than shown on your current Medicare card.
|
Choice 4
|
NULL
|
HIB102 – STATE BUY-OUT
(1) (2) will no longer pay (3) Medicare (4) insurance premiums after (5). (6) must
pay the premiums beginning (7).
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
Leave blank
|
Choice 2
|
The State of
|
Fill-in (2)
|
show state corresponding to the HITP-CODE or the SMTP-CODE
|
Fill-in (3)
|
|
Choice 1
|
BGN plus BLN (possessive)
|
Choice 2
|
your
|
Fill-in (4)
|
|
Choice 1
|
hospital
|
Choice 2
|
medical
|
Choice 3
|
hospital and medical
|
Fill-in (5)
|
Show the TP STOP date in MMCCYY format
|
Fill-in (6)
|
|
Choice 1
|
He
|
Choice 2
|
She
|
Choice 3
|
You
|
Fill-in (7)
|
Show the TP STOP date plus 1 month in MMCCYY format
|
HIB103 – LIMITED BUY-IN AND BUY-OUT
(1) (2) paid (3) Medicare (4) insurance premium for (5).
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
Leave blank
|
Choice 2
|
The State of
|
Fill-in (2)
|
Show state corresponding to the HITP-CODE or the SMTP-CODE
|
Fill-in (3)
|
|
Choice 1
|
BGN plus BLN (possessive)
|
Choice 2
|
your
|
Fill-in (4)
|
|
Choice 1
|
hospital
|
Choice 2
|
medical
|
Choice 3
|
hospital and medical
|
Fill-in (5)
|
|
Choice 1
|
MMCCYY
|
Choice 2
|
MMCCYY and MMCCYY
|
Choice 3
|
MMCCYY through MMCCYY
|
HIB104 – LIMITED ST BUY-IN/BUY-OUT NO CHANGE IN COVERAGE
This does not change our records, which show that (1) Medicare (2) insurance coverage.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
he currently has
|
Choice 2
|
she currently has
|
Choice 3
|
you currently have
|
Choice 4
|
he does not currently have
|
Choice 5
|
she does not currently have
|
Choice 6
|
you do not currently have
|
Fill-in (2)
|
|
Choice 1
|
hospital
|
Choice 2
|
medical
|
Choice 3
|
hospital and medical
|
HIB105 – RETRO BUYIN/BUYOUT PAST DUE PREMIUMS
Our records also show that (1) premiums through (2).
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
he still owes
|
Choice 2
|
she still owes
|
Choice 3
|
you still owe
|
Fill-in (2)
|
MMCCYY
|
HIB106 – STATE BUYIN FOR SMI PREMIUM PENALTY ONLY
We must charge a premium penalty on (1) Medicare medical insurance because (2) enrolled
later than (3) could have. (4) State or local government retirement system will pay
(5) medical insurance late enrollment premium penalty beginning (6). However, (7)
must pay the basic Medicare medical insurance premium.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN (possessive)
|
Choice 2
|
your
|
Fill-in (2)
|
|
Choice 1
|
he
|
Choice 2
|
she
|
Choice 3
|
you
|
Fill-in (3)
|
|
Choice 1
|
he
|
Choice 2
|
she
|
Choice 3
|
you
|
Fill-in (4)
|
|
Choice 1
|
His
|
Choice 2
|
Her
|
Choice 3
|
Your
|
Fill-in (5)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (6)
|
MM/YYYY
|
Fill-in (7)
|
|
Choice 1
|
he
|
Choice 2
|
she
|
Choice 3
|
you
|
HIB107 – STATE STOPS PAYING SMI PREMIUM PENALTY
(1) State or local government retirement system will no longer pay (2) Medicare medical
insurance late enrollment premium penalty after (3). (4) must pay the basic premium
and the penalty beginning (5).
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN (possessive)
|
Choice 2
|
Your
|
Fill-in (2)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (4)
|
show date in MMCCYY format
|
Fill-in (5)
|
|
Choice 1
|
He
|
Choice 2
|
She
|
Choice 3
|
You
|
Fill-in (6)
|
show date in MMCCYY format
|
HIB108 – GROUP PAYER BUY-OUT
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-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN (possessive)
|
Choice 2
|
your
|
Fill-in (2)
|
|
Choice 1
|
hospital
|
Choice 2
|
medical
|
Choice 3
|
hospital and medical
|
Fill-in (3)
|
show date in MMCCYY format
|
Fill-in (4)
|
|
Choice 1
|
He
|
Choice 2
|
She
|
Choice 3
|
You
|
Fill-in (5)
|
Show date in MMCCYY format
|
HIB109 – 3RD Party SMI PREMIUM DEDUCTED FROM MBA
We will deduct the (1) of (2) from (3) monthly payment. Later in this letter, we tell
(4) what to do if (5) with this change in the amount of (6) monthly payment.
Fill-in values:
|
|
Fill-in (1)
|
Medicare medical insurance premium
|
Fill-in (2)
|
SMI premium amount in $9999.99 format
|
Fill-in (3)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (4)
|
|
Choice 1
|
him
|
Choice 2
|
her
|
Choice 3
|
you
|
Fill-in (5)
|
|
Choice 1
|
he disagrees
|
Choice 2
|
she disagrees
|
Choice 3
|
you disagree
|
Fill-in (6)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
HIB110 – SMI PREMIUM DEDUCTED FROM MBA PAST DUE PREMIUMS
We will deduct the (1) of (2) from (3) monthly payment. We will also deduct the past
due premiums, which total (4). Later in this letter, we tell (5) what to do if (6)
with this change in the amount of (7) monthly payment.
Fill-in values:
|
|
Fill-in (1)
|
Medicare medical insurance premium
|
Fill-in (2)
|
SMI premium amount in $9999.99 format
|
Fill-in (3)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (4)
|
premium amount due in 99999.99 format
|
Fill-in (5)
|
|
Choice 1
|
him
|
Choice 2
|
her
|
Choice 3
|
you
|
Fill-in (6)
|
|
Choice 1
|
he disagrees
|
Choice 2
|
she disagrees
|
Choice 3
|
you disagree
|
Fill-in (7)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
HIB111 – BUY-IN AND REFUND OF MEDICARE PREMIUMS
This is the money due (1) for the Medicare insurance premiums that (2) already paid.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
him
|
Choice 2
|
her
|
Choice 3
|
you
|
Fill-in (2)
|
|
Choice 1
|
he
|
Choice 2
|
she
|
Choice 3
|
you
|
HIB112 – BUYIN PREMIUM NO LONGER DEDUCTED FROM MBA
We will no longer deduct the premium from (1) monthly payment. Later in this letter,
we tell (2) what to do if (3) with this change in the amount of (4) monthly payment.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (2)
|
|
Choice 1
|
you
|
Fill-in (3)
|
|
Choice 1
|
you disagree
|
Fill-in (4)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
HIB113 – BUY-OUT NOT IN PAY STATUS PREMIUM BILLING
We will send (1) first bill for the (2) within a month. The monthly (3) (4). (5) Please
contact us if (6) not receive the first bill within a month.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN (possessive)
|
Choice 2
|
BGN (possessive)
|
Choice 3
|
your
|
Fill-in (2)
|
|
Choice 1
|
Medicare hospital insurance premium
|
Choice 2
|
Medicare medical insurance premium
|
Choice 3
|
Medicare hospital and medical insurance premiums
|
Fill-in (3)
|
|
Choice 1
|
premium is
|
Choice 2
|
premiums total
|
Fill-in (4)
|
money amount in format 999,999.99
|
Fill-in (5)
|
|
Choice 1
|
After that, we will bill him each month for this premium. (Use in Medicare Part A
and combined Part A and Part B billing.)
|
Choice 2
|
After that, we will bill her each month for this premium. (Use in Medicare Part A
and combined Part A and Part B billing.)
|
Choice 3
|
After that, we will bill you each month for this premium. (Use in Medicare Part A
and combined Part A and Part B billing.)
|
Choice 4
|
Each bill after that will be for a 3-month period. (Use in Medicare Part B billing
situations including those which include a premium penalty.)
|
Fill-in (6)
|
|
Choice 1
|
he does
|
Choice 2
|
she does
|
Choice 3
|
you do
|
HIB114 – BENEFITS TERM PROFRA MEDICARE CONTINUES
(1) Medicare coverage will continue because (2) age 65 or older.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN (possessive)
|
Choice 2
|
Your
|
Fill-in (2)
|
|
Choice 1
|
he is
|
Choice 2
|
she is
|
Choice 3
|
you are
|
HIB115 – HI/SMI BUY-OUT
If (1) to cancel this insurance, please contact the local Social Security office at
the telephone number and address shown below. Remember that the date (2) insurance
coverage ends depends on when (3) it:
If (4) it within 30 days from the date of this notice, (5) coverage will end at the
same time the State stopped paying the premiums.
If (6) it after 30 days but within six months of when the State stopped paying the
premiums, coverage will stop at the end of the same month in which (7) us.
If (8) more than 6 months to contact us, coverage will stop at the end of the month
after the month in which (9) us.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN plus “wants”
|
Choice 2
|
you want
|
Fill-in (2)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (3)
|
|
Choice 1
|
he cancels
|
Choice 2
|
she cancels
|
Choice 3
|
you cancel
|
Fill-in (4)
|
|
Choice 1
|
he cancels
|
Choice 2
|
she cancels
|
Choice 3
|
you cancel
|
Fill-in (5)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (6)
|
|
Choice 1
|
he cancels
|
Choice 2
|
she cancels
|
Choice 3
|
you cancel
|
Fill-in (7)
|
|
Choice 1
|
he contacts
|
Choice 2
|
she contacts
|
Choice 3
|
you contact
|
Fill-in (8)
|
|
Choice 1
|
he waits
|
Choice 2
|
she waits
|
Choice 3
|
you wait
|
Fill-in (9)
|
|
Choice 1
|
he contacts
|
Choice 2
|
she contacts
|
Choice 3
|
you contact
|
HIB119 – BILLING TO CONFIRM GROUP PAYER
(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-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN
|
Choice 2
|
You
|
Fill-in (2)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (3)
|
|
Choice 1
|
hospital
|
Choice 2
|
medical
|
Choice 3
|
hospital and medical
|
Fill-in (4)
|
|
Choice 1
|
he is
|
Choice 2
|
she is
|
Choice 3
|
you are
|
Fill-in (5)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (6)
|
|
Choice 1
|
him
|
Choice 2
|
her
|
Choice 3
|
you
|
Fill-in (7)
|
|
Choice 1
|
BGN plus BLN (possessive)
|
Choice 2
|
your
|
Fill-in (8)
|
|
Choice 1
|
him
|
Choice 2
|
her
|
Choice 3
|
you
|
HIB120 – BUY-OUT FOR HI AND SMI
(1) can cancel hospital insurance coverage and keep medical insurance coverage, or
cancel both. However, (2) cannot keep hospital insurance coverage without medical
insurance coverage. So if (3) medical insurance coverage, hospital insurance coverage
will end at the same time.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
He
|
Choice 2
|
She
|
Choice 3
|
You
|
Fill-in (2)
|
|
Choice 1
|
he
|
Choice 2
|
she
|
Choice 3
|
you
|
Fill-in (3)
|
|
Choice 1
|
he cancels
|
Choice 2
|
she cancels
|
Choice 3
|
you cancel
|
HIB131 – MEDICARE CONTINUES BASED ON AGE, DIB, OR ESRD
However, Medicare coverage will continue because (1) (2).
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
he is
|
Choice 2
|
she is
|
Choice 3
|
you are
|
Choice 4
|
he has
|
Choice 5
|
she has
|
Choice 6
|
you have
|
Fill-in (2)
|
|
Choice 1
|
disabled
|
Choice 2
|
over age 65
|
Choice 3
|
end stage renal disease
|
HIB132 – ESRD TERMINATES AND RRB JURISDICTION
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-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (2)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (3)
|
|
Choice 1
|
him
|
Choice 2
|
her
|
Choice 3
|
you
|
Fill-in (4)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
HIB133 – ESRD TERMINATION - SAME HI/SMI TERMINATION DATES
We are writing to tell (1) that Medicare coverage based on (2) kidney condition ends
with the last day of (3).
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN (not possessive)
|
Choice 2
|
you
|
Fill-in (2)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (3)
|
Show HI-TERM date minus 1 month in MMCCYY format
|
HIB134 – ESRD TERM HI TERM DATE EARLIER THAN SMI TERM DATE
We are writing to tell (1) that (2) hospital insurance coverage ended on the last
day of (3). (4) medical insurance coverage will end on the last day of (5).
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN (not possessive)
|
Choice 2
|
you
|
Fill-in (2)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (3)
|
Show HI-TERM date minus 1 month in MMCCYY format
|
Fill-in (4)
|
|
Choice 1
|
His
|
Choice 2
|
Her
|
Choice 3
|
Your
|
Fill-in (5)
|
Show SMI-TERM date minus 1 month in MMCCYY format
|
HIB135 – ESRD TERM HI TERM DATE EARLIER THAN SMI TERM DATE
Medicare coverage based on a kidney condition usually ends the last day of the (1)
month after the month (2) unless before then (3) again:
Since (6) in (7), (8) Medicare coverage should have ended the last day of (9). (10)
hospital insurance did end on that date. But, because we didn't take action in time,
we must continue (11) medical insurance coverage until the date shown above.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
12th
|
Choice 2
|
36th
|
Fill-in (2)
|
|
Choice 1
|
he gets a transplant
|
Choice 2
|
she gets a transplant
|
Choice 3
|
you get a transplant
|
Choice 4
|
regular dialysis stops
|
Fill-in (3)
|
|
Choice 1
|
he
|
Choice 2
|
she
|
Choice 3
|
you
|
Fill-in (4)
|
|
Choice 1
|
begins
|
Choice 2
|
begin
|
Fill-in (5)
|
|
Choice 1
|
gets
|
Choice 2
|
get
|
Fill-in (6)
|
|
Choice 1
|
he got a kidney transplant
|
Choice 2
|
she got a kidney transplant
|
Choice 3
|
you got a kidney transplant
|
Choice 4
|
his dialysis stopped
|
Choice 5
|
her dialysis stopped
|
Choice 6
|
your dialysis stops
|
Fill-in (7)
|
|
Choice 1
|
Show KDNY-TRNSDATE date in MMCCYY format
|
Choice 2
|
Show DLYS-STOP date in MMCCYY format
|
Fill-in (8)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (9)
|
Show HI-TERM date minus 1 month in format MMCCYY
|
Fill-in (10)
|
|
Choice 1
|
His
|
Choice 2
|
Her
|
Choice 3
|
Your
|
Fill-in (11)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
HIB136 – TERMINATION OF ESRD COVERAGE
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-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
he resumes
|
Choice 2
|
she resumes
|
Choice 3
|
you resume
|
Fill-in (2)
|
|
Choice 1
|
gets
|
Choice 2
|
get
|
Fill-in (3)
|
|
Choice 1
|
he
|
Choice 2
|
she
|
Choice 3
|
you
|
Fill-in (4)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
HIB137 – ESRD TERMINATES SAME HI/SMI TERMINATION DATES
Medicare coverage based on a kidney condition ends the last day of the (1) month after
(2), unless before then (3):
Our records show that (4) (5) (6).
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
12th
|
Choice 2
|
36th
|
Fill-in (2)
|
|
Choice 1
|
regular dialysis stops
|
Choice 2
|
a kidney transplant
|
Fill-in (3)
|
|
Choice 1
|
he gets
|
Choice 2
|
she gets
|
Choice 3
|
you get
|
Fill-in (4)
|
|
Choice 1
|
he
|
Choice 2
|
she
|
Choice 3
|
you
|
Fill-in (5)
|
|
Choice 1
|
stopped regular dialysis
|
Choice 2
|
received a kidney transplant
|
Fill-in (6)
|
|
Choice 1
|
Show DLYS-STOP date for the latest DLYS occurrence on the POST-MBR in format MMCCYY
|
Choice 2
|
Show KDNY-TRNSDATE date for the latest KDNY occurrence on the POST-MBR in format MMCCYY
|
HIB142 – CURRENT PAY TO SUSPENSE OR DEFERRED STATUS
We will continue to charge a monthly premium for (1) medical insurance under Medicare.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN (possessive)
|
Choice 2
|
your
|
HIB143 – SMI PENALTY RATE TO BASE RATE AT AGE 65
Under a special provision of the Social Security Act, now that (1) (2) for Medicare
medical insurance based on (3) age, (4) monthly medical insurance premium amount has
been reduced from (5) to (6).
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN (not possessive)
|
Choice 2
|
you
|
Fill-in (2)
|
|
Choice 1
|
qualifies
|
Choice 2
|
qualify
|
Fill-in (3)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (4)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (5)
|
Show the SMI premium penalty rate
|
Fill-in (6)
|
Show the SMI premium base rate
|
HIB151 – LIMITED BUY-IN/BUY-OUT - COVERAGE CONTINUES
(1) must pay the premium beginning (2).
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
He
|
Choice 3
|
She
|
Fill-in (2)
|
MMCCYY
|
HIB154 – EXPLANATION OF BENFITS WHEN MEDICARE IS THE SECONDARY PAYER WHEN THE BENEFICARY
IS WORKING AND COVERED BY HIS OR HER EMPLOYER
(1) working for an employer who has 20 or more employees? (2) covered under this employer's
group health plan? If so, the employer's plan will pay first for health care services.
Medicare will pay secondary benefits when the employer's plan doesn't cover all of
the expenses.
Contact your nearest Social Security office for more information about Part B Medicare
special enrollment.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
The word 'Is' BGN plus BLN
|
Choice 2
|
Are you
|
Fill-in (2)
|
|
Choice 1
|
Is he
|
Choice 2
|
Is she
|
Choice 3
|
Are you
|
HIB157 – PIC C'S NOTICE WHEN CHILD < AGE 19 AND NO OPEN HI
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 values:
|
|
Fill-in (1)
|
www.insurekidsnow.gov
|
HIB160 – HI/SMI REVERSAL - NOT TIMELY BUT IN GEP
We received (1) cancellation of (2) earlier request that (3) Medicare (4) insurance
coverage be terminated. Although this cancellation request was filed too late for
the coverage to be reinstated without interruption, it was filed during a period in
which (5) could reenroll. This difference is important because there are months for
which (6) not have Medicare (7) insurance coverage.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN (possessive)
|
Choice 2
|
your
|
Fill-in (2)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (3)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (4)
|
|
Choice 1
|
hospital
|
Choice 2
|
medical
|
Choice 3
|
hospital and medical
|
Fill-in (5)
|
|
Choice 1
|
he
|
Choice 2
|
she
|
Choice 3
|
you
|
Fill-in (6)
|
|
Choice 1
|
he does
|
Choice 2
|
she does
|
Choice 3
|
you do
|
Fill-in (7)
|
|
Choice 1
|
hospital
|
Choice 2
|
medical
|
Choice 3
|
hospital and medical
|
HIB161 – HI/SMI REVERSAL NOT FILED TIMELY NOT IN GEP
We stopped (1) Medicare (2) insurance at (3) request. Then (4) decided that (5) still
wanted it. (6) decided too late for us to start (7) Medicare (8) insurance again at
this time.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN (possessive)
|
Choice 2
|
your
|
Fill-in (2)
|
|
Choice 1
|
hospital
|
Choice 2
|
medical
|
Choice 3
|
hospital and medical
|
Fill-in (3)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (4)
|
|
Choice 1
|
he
|
Choice 2
|
she
|
Choice 3
|
you
|
Fill-in (5)
|
|
Choice 1
|
he
|
Choice 2
|
she
|
Choice 3
|
you
|
Fill-in (6)
|
|
Choice 1
|
He
|
Choice 2
|
She
|
Choice 3
|
You
|
Fill-in (7)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (8)
|
|
Choice 1
|
hospital
|
Choice 2
|
medical
|
Choice 3
|
hospital and medical
|
HIB162 – REFUSAL OVER AUTOMATIC ENROLLMENT
(1) told us that (2) not want (3) insurance under Medicare.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN (not possessive)
|
Choice 2
|
You
|
Fill-in (2)
|
|
Choice 1
|
he does
|
Choice 2
|
she does
|
Choice 3
|
you do
|
Fill-in (3)
|
|
Choice 1
|
hospital
|
Choice 2
|
medical
|
Choice 3
|
hospital and medical
|
HIB163 – SMI REFUSAL CURRENT PAY REFUND OF PREMIUMS
(1) not have to pay a premium for any months (2) not entitled to Medicare Part B (medical
insurance). If we took out premiums for any of these months, we will return the money
to (3).
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You do
|
Choice 2
|
BGN plus BLN plus does
|
Fill-in (2)
|
|
Choice 1
|
you were
|
Choice 2
|
he was
|
Choice 3
|
she was
|
Fill-in (3)
|
|
Choice 1
|
you
|
Choice 2
|
him
|
Choice 3
|
her
|
HIB164 – SMI REFUSAL PREMIUM BILLING AND NO OPEN THIRD PARTY
Since our records were previously annotated to show that (1) enrolled for Medicare
(2) insurance, a premium billing notice may have been prepared for mailing to (3).
If (4) a billing notice, (5) should destroy it.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
he was
|
Choice 2
|
she was
|
Choice 3
|
you were
|
Fill-in (2)
|
|
Choice 1
|
hospital
|
Choice 2
|
medical
|
Choice 3
|
hospital and medical
|
Fill-in (3)
|
|
Choice 1
|
him
|
Choice 2
|
her
|
Choice 3
|
you
|
Fill-in (4)
|
|
Choice 1
|
he receives
|
Choice 2
|
she receives
|
Choice 3
|
you receive
|
Fill-in (5)
|
|
Choice 1
|
he
|
Choice 2
|
she
|
Choice 3
|
you
|
HIB165 – REFUSAL/WITHDRAWAL STATE BUY-IN ESTABLISHED
Our records show that (1) State has agreed to pay the premiums for (2) Medicare (3)
insurance coverage. Therefore, (4) will continue to be enrolled.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (2)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (3)
|
|
Choice 1
|
hospital
|
Choice 2
|
medical
|
Choice 3
|
hospital and medical
|
Fill-in (4)
|
|
Choice 1
|
he
|
Choice 2
|
she
|
Choice 3
|
you
|
HIB170 – MEDICARE COVERAGE WILL CONTINUE WHILE MEDICAL CESSATION APPEAL IS PENDING
EVEN
THOUGH PAYMENTS HAVE CEASED (STATE BUY-IN IS NOT INVOLVED)
Even though (1) no longer receiving monthly payments, (2) will still have (3) coverage
under Medicare. (4)
(5)
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
Disabled Beneficiary’s Given Name plus Beneficiary's Last Name (not possessive) plus
“is”
|
Choice 2
|
you are
|
Fill-in (2)
|
|
Choice 1
|
you
|
Choice 2
|
he
|
Choice
|
she
|
Fill-in (3)
|
|
Choice 1
|
Part A (hospital insurance)
|
Choice 2
|
Part B (medical insurance)
|
Fill-in (4)
|
|
Choice 1
|
Please keep the Medicare card.
|
Choice 2
|
Null
|
Fill-in (5)
|
|
Choice 1
|
There is a monthly premium for Medical Part B. Because we stopped monthly payments,
we will bill you every 3 months for the premiums.
|
Choice 2
|
There is a monthly premium for Medical Part B. Because we stopped monthly payments,
we will bill him every 3 months for the premiums.
|
Choice 3
|
There is a monthly premium for Medical Part B. Because we stopped monthly payments,
we will bill her every 3 months for the premiums.
|
Choice 4
|
Null
|
HIB171 – MEDICARE COVERAGE WILL CONTINUE WHILE MEDICAL CESSATION APPEAL IS PENDING
EVEN
THOUGH PAYMENTS HAVE CEASED (STATE BUY-IN IS INVOLVED)
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-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
Disabled Beneficiary’s Given Name plus Beneficiary's Last Name (not possessive) plus
“is”
|
Choice 2
|
you are
|
Fill-in (2)
|
|
Choice 1
|
you
|
Choice 2
|
he
|
Choice 3
|
she
|
Fill-in (3)
|
|
Choice 1
|
Please keep the Medicare card.
|
Choice 2
|
Null
|
Fill-in (4)
|
|
Choice 1
|
you live
|
Choice 2
|
he lives
|
Choice 3
|
she lives
|
Fill-in (5)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
HIB175 – SMI PREMIUMS/ARREARAGE DEDUCTED FROM PMA OR CMA
We are deducting past-due premiums (1) from (2) check.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1 |
“of” plus the total past due SMI premiums in $999,999.99 format |
Choice 2 |
Null |
Fill-in (2)
|
|
Choice 1
|
Beneficiary's full name (possessive)
|
Choice 2
|
your
|
HIB176 – SMI PREMIUMS/ARREARAGE DEDUCTED FROM PMA OR CMA WHEN BENEFITS ARE
RESUMED
Since benefits are again payable we will resume withholding (1) medical premiums due
to date.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN (possessive)
|
Choice 2
|
your
|
HIB182 – IRMAA AMOUNT STARTS, IRMAA AMOUNT CHANGES OR IRMAA AMOUNT NO LONGER APPLIED
TO
SMI PREMIUM (PART B)
In an earlier letter, we told you that (1) Medicare Part B (medical insurance) premium
includes:
-
•
the standard Part B premium amount,
-
•
any surcharge that may apply for late enrollment or reenrollment, and
-
•
an income-related monthly adjustment amount (IRMAA).
If (2) prescription drug coverage, (3) also must pay a prescription drug coverage
IRMAA. The IRMAA is in addition to (4) monthly premium. We base the IRMAA on (5) income.
We deduct the IRMAA from (6) monthly Social Security benefits, regardless of how (7)
premiums.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
your
|
Choice 2
|
BGN plus BLN (possessive)
|
Fill-in (2)
|
|
Choice 1
|
you have
|
Choice 2
|
she has
|
Choice 3
|
he has
|
Fill-in (3)
|
|
Choice 1
|
you
|
Choice 2
|
she
|
Choice 3
|
he
|
Fill-in (4)
|
|
Choice 1
|
your
|
Choice 2
|
her
|
Choice 3
|
his
|
Fill-in (5)
|
|
Choice 1
|
your
|
Choice 2
|
her
|
Choice 3
|
his
|
Fill-in (6)
|
|
Choice 1
|
your
|
Choice 2
|
her
|
Choice 3
|
his
|
Fill-in (7)
|
|
Choice 1
|
you pay your
|
Choice 2
|
he pays his
|
Choice 3
|
she pays her
|
HIB183 – USE WITH HIB182 WHEN IRMAA AFFECTS PART B RATE
We sent you another letter that explained how we determined the amount of (1) premium.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
your
|
Choice 2
|
Beneficiary's name (possessive)
|
HIB184 – USE WITH HIB182 WHEN BENEFICIARY WILL CONTINUE TO BE BILLED FOR PART B SMI
PREMIUMS
We will continue to bill you for (1) Medicare Part B premiums.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
Part B (Medical Insurance)
|
Choice 2
|
Part B Immunosuppressive Drug Coverage
|
HIB185 – USE WHEN HIB182 IS GENERATED AS THE INTRODUCTORY UTI AND BENEFICIARY'S LAF
IS
CURRENT PAY OR DEFERRED
The amount you will receive around (1) was changed because of a change in (2) monthly
Medicare Part B premium.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
using the PCI show the calendar date of the COM check
|
Choice 2
|
using the PCI show the calendar date of the DPD check
|
Fill-in (2)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
HIB186 – SMI MATURITY AND NO IRMAA DATA ON POST MBR
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 with 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 (5). For more information, please visit
www.socialsecurity.gov on the Internet or call us toll-free at 1-800-772-1213 (TTY 1-800-325-0778).
Fill-in values:
|
|
Fill-in (1)
|
Show the IRMAA level 1 yearly amount for singles
|
Fill-in (2)
|
Show the IRMAA level 1 yearly amount for couples
|
Fill-in (3)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (4)
|
|
Choice 1
|
he has
|
Choice 2
|
she has
|
Choice 3
|
you have
|
Fill-in (5)
|
show the SMI START date
|
HIB215 – T2 BENEFITS TERMINATE 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-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
he is
|
Choice 2
|
she is
|
Choice 3
|
you are
|
Fill-in (2)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (3)
|
|
Choice 1
|
hospital
|
Choice 2
|
hospital and medical
|
Fill-in (4)
|
|
Choice 1
|
His
|
Choice 2
|
Her
|
Choice 3
|
Your
|
Fill-in (5)
|
|
Choice 1
|
hospital
|
Choice 2
|
hospital and medical
|
Fill-in (6)
|
Show HI-TERM date in format MMCCYY
|
Fill-in (7)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
HIB218 – REASON SMI PREMIUM/ARREARAGE IS BEING DEDUCTED
When we figured the amount of (1) payment, we took into account all medical insurance
premiums which were already paid or still due (2).
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
Fill-in (2)
|
|
Choice 1
|
Null
|
Choice 2
|
“through” plus date COM in Month CCYY format
|
HIB225 – HRFST LESSDO MBA LESS THAN SMI PREMIUM
(1) monthly medical insurance premium is (2). The monthly benefit that (3) should
get is less than (4) medical insurance premiums. We are stopping (5) monthly benefits
starting (6) to pay for part of this premium. After adjusting for (7) monthly benefits,
we find that we must bill (8) for (9).
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN (possessive)
|
Choice 2
|
Your
|
Fill-in (2)
|
Show the current SMI premium amount
|
Fill-in (3)
|
|
Choice 1
|
BGN plus BLN (not possessive)
|
Choice 2
|
you
|
Fill-in (4)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (5)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (6)
|
Show the first EFD in HIST Data that corresponds to LESSDO
|
Fill-in (7)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (8)
|
|
Choice 1
|
him
|
Choice 2
|
her
|
Choice 3
|
you
|
Fill-in (9)
|
Show money amount for the remaining premiums
|
HIB226 – HRFST LESSDO MBA > SMI BUT LESS THAN A DOLLAR
We are stopping (1) monthly benefit starting (2). When we take (3) monthly medical
insurance premium of (4) from (5) monthly benefit, the amount left is less than a
dollar. At the end of the year, we will adjust (6) record and pay all money (7) due.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN (possessive)
|
Choice 2
|
your
|
Fill-in (2)
|
Show the first EFD in HIST Data that corresponds to LESSDO
|
Fill-in (3)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (4)
|
Show current SMI premium amount
|
Fill-in (5)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (6)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (7)
|
|
Choice 1
|
he is
|
Choice 2
|
she is
|
Choice 3
|
you are
|
HIB248 – PREMIUM HI REDUCTION WHEN 30 QUARTERS ATTAINED NO OPEN ENTITLEMENT TO PREMIUM
HI
Currently, (1) not eligible for free Medicare hospital insurance. However, (2) may
be eligible to buy hospital insurance for the reduced premium of (3) per month. You
can get more information about this hospital insurance by contacting any Social Security
office.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN plus the word “is”
|
Choice 2
|
you are
|
Fill-in (2)
|
he / she / you
|
Choice 1
|
he
|
Choice 2
|
she
|
Choice 3
|
you
|
Fill-in (3)
|
Show the premium HI amount that pertains to the HIRE-30QTR date in HIRE data in the
format $$$$¢¢
|
HIB249 – OFFER RELIEF FOR SMI PREMIUMS (VSMI RATES)
If you want your medical insurance to start earlier, you can choose to have it start
in (1). To start your medical insurance earlier, you must do the following things
within 60 days after the date of this notice:
-
•
tell us in writing that you want medical insurance beginning (2);
AND
-
•
pay us (3) or tell us we can withhold this amount from your check. This amount covers
the premiums due from (4) through (5).
If you would find it hard to pay the premium amount you would owe in a lump sum, ask
us about other ways to pay the premium.
If you choose to have your medical insurance start in (6), your current monthly premium
will be (7). If you do not choose the earlier date, your monthly premium will be (8).
Fill-in values:
|
|
Fill-in (1)
|
Show the SMI-NONEQRELST date
|
Fill-in (2)
|
Show the SMI-NONEQRELST date
|
Fill-in (3)
|
Show the total amount of the SMI premiums
|
Fill-in (4)
|
Show the SMI-NONEQRELST date
|
Fill-in (5)
|
Show the current operating month date
|
Fill-in (6)
|
Show the SMI-NONEQRELST date
|
Fill-in (7)
|
Show the current VSMI rate
|
Fill-in (8)
|
Show the current Part B premium rate
|
HIB260 – PREMIUM RELIEF ESTABLISHED DUE TO IRMAA B AND/OR IRMAA D
As we told you in another letter, you owe more Medicare premiums because (1) income-related
monthly adjustment amounts changed.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN (possessive)
|
Choice 2
|
your
|
HIB261 – PREMIUM RELIEF ESTABLISHED DUE TO IRMAA B
You owe (1) for Medicare Part B (medical insurance) premiums for (2) (3) (4).
Fill-in values:
|
|
Fill-in (1)
|
Show the total amount of the SMI arrearages for IRMAA B in the format $$$$$$¢¢
|
Fill-in (2)
|
Show the RLF-START date in the first occurrence of Premium Relief data in the format
November 2009
|
Fill-in (3)
|
|
Choice 1
|
null
|
Choice 2
|
and
|
Choice 3
|
through
|
Fill-in (4)
|
|
Choice 1
|
Null
|
Choice 2
|
Show the RLF-STOP date in the last occurrence of Premium Relief data in the format
November 2009
|
HIB262 – PREMIUM RELIEF ESTABLISHED DUE TO IRMAA D
You owe (1) for Medicare prescription drug coverage income-related monthly adjustment
amounts for (2) (3) (4).
Fill-in values:
|
|
Fill-in (1)
|
Show the total amount of IRMAA D equitable relief arrearages in the format $$$$$$¢¢
|
Fill-in (2)
|
Show the RLF-START date in the first occurrence of Premium Relief data in the format
November 2009
|
Fill-in (3)
|
|
Choice 1
|
null
|
Choice 2
|
and
|
Choice 3
|
through
|
Fill-in (4)
|
|
Choice 1
|
Null
|
Choice 2
|
Show the RLF-STOP date in the last occurrence of Premium Relief data in the format
November 2009
|
HIB263 – PREMIUM RELIEF ESTABLISHED DUE TO IRMAA B AND ALSO IRMAA D
The total past-due Medicare amounts you owe are (1).
Fill-in values:
|
|
Fill-in (1)
|
Show the sum of the total amount of the IRMAA B equitable relief arrearages plus the
total amount of the IRMAA D equitable relief arrearages in the format $$$$$$¢¢
|
HIB264 – PREMIUM RELIEF ESTABLISHED - ALTERNATIVES TO FULL WITHHOLDING OF
BENEFITS
If you would find it hard to pay the past-due Medicare amounts (1) at one time, please
ask us about other ways to pay them. You may ask for waiver of these past-due Medicare
amounts if paying them would be a severe financial hardship for you. If we do not
hear from you within 30 days after the date of this letter, we will take the Medicare
amounts (2) out of (3) monthly Social Security payments beginning (4).
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
he owes
|
Choice 2
|
she owes
|
Choice 3
|
you owe
|
Fill-in (2)
|
|
Choice 1
|
he owes
|
Choice 2
|
she owes
|
Choice 3
|
you owe
|
Fill-in (3)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (4)
|
Show the current operating month (COM) plus 2 months in the format July 2009
|
HIB265 – DEDUCTION OF CURRENT SMI PREMIUMS
We will deduct (1) current Medicare Part B (medical insurance) premium from (2) monthly
Social Security payments beginning (3).
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN possessive
|
Choice 2
|
your
|
Fill-in (2)
|
|
Choice 1
|
his
|
Choice 2
|
her
|
Choice 3
|
your
|
Fill-in (3)
|
Show the current operating month (COM) plus 2 months in the format July 2009
|
HIB266 – FULL WITHHOLDING OF PART B RELIEF PREMIUMS WHEN CURRENT SMI PREMIUMS ARE
ALSO
DEDUCTED
We will also deduct (1) for past-due Medicare Part B (medical insurance) premiums.
Fill-in values:
|
|
Fill-in (1)
|
Show the sum of the RCVBL-TOTAMT for current PART B only arrearages in the format
$$$$$$¢¢
|
HIB267 – FULL WITHHOLDING OF IRMAA D RELIEF PREMIUMS WHEN CURRENT SMI PREMIUMS ARE
BEING
DEDUCTED
We will also deduct (1) for past-due Medicare prescription drug coverage income-related
monthly adjustment amounts.
Fill-in values:
|
|
Fill-in (1)
|
Show the sum of the RCVBL-TOTAMT for current IRMAA D only arrearages in the format
$$$$$$¢¢
|
HIB268 – FULL WITHHOLDING OF IRMAA D RELIEF PREMIUMS WHEN
NO CURRENT SMI PREMIUMS BEING
DEDUCTED
We will deduct past-due Medicare prescription drug coverage income-related monthly
adjustment amounts from your monthly Social Security payments beginning (1). The total
amount we will deduct is (2).
Fill-in values:
|
|
Fill-in (1)
|
Show the current operating month (COM) in the format July 2009
|
Fill-in (2)
|
Show the sum of the IRMAA D arrearages in the format $$$$$$¢¢
|
HIB269 – FULL WITHHOLDING CONTINUES UNTIL PREMIUMS PAID IN FULL
We will withhold (1) monthly payments until you have paid all of the past-due Medicare
amounts (2).
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
BGN plus BLN (possessive)
|
Choice 2
|
your
|
Fill-in (2)
|
|
Choice 1
|
he owes
|
Choice 2
|
she owes
|
Choice 3
|
you owe
|
HIB270 – FULL WITHHOLDING OF PART B RELIEF PREMIUMS WHEN
NO CURRENT SMI PREMIUMS BEING
DEDUCTED
We will deduct past-due Medicare Part B (medical insurance) premiums from your monthly
Social Security payments beginning (1). The total amount we will deduct is (2).
Fill-in values:
|
|
Fill-in (1)
|
Show the current operating month (COM) in the format July 2009
|
Fill-in (2)
|
Show the sum of the IRMAA B arrearages in the format $$$$$$¢¢
|
HIB271 – PARTIAL RECOVERY OF PART B OR IRMAA D RELIEF PREMIUMS
We will deduct past-due Medicare Part B (medical insurance) premiums from your monthly
Social Security payments beginning (1). The total amount we will deduct is (2).
Fill-in values:
|
|
Fill-in (1)
|
Add the RCVBL-PARTAMT for each occurrence and show this sum in the format $$$$$$¢¢
|
Fill-in (2)
|
|
Choice 1
|
BGN plus BLN (possessive)
|
Choice 2
|
your
|
Fill-in (3)
|
Show the current operating month (COM) in the format July 2009
|
Fill-in (4)
|
Add the RCVBL-PARTAMT for each occurrence and show this sum in the format $$$$$$¢¢
|
HIB288 – SUBSEQUENT NOTICE WITH CMS BILLING STATEMENT AND INSTRUCTIONS FOR
COMPLETING THE PAYMENT COUPON
We told you in another letter your Centers for Medicare & Medicaid Services (CMS)
Billing Statement would be mailed in another envelope. At the end of this letter,
you will find the CMS Billing Statement and instructions for completing the payment
coupon.
HIB289 – (CMS) BILLING STATEMENT WILL BE MAILED IN ANOTHER ENVELOPE
Your Centers for Medicare & Medicaid Services (CMS) Billing Statement will be mailed
in another envelope.
HIB316 – ADDITIONAL SOURCES FOR OBTAINING HEALTH INSURANCE
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 values:
|
|
Fill-in (1)
|
HealthCare.gov
|
HIB317 – HOW TO APPLY FOR HELP WITH THE COST OF IMMUNOSUPPRESSIVE DRUG
COVERAGE
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 DRUG COVERAGE
-
•
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 – IMMUNOSUPPRESSIVE DRUG COVERAGE ELIGIBILITY
(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 other Medicare 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 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)
-
-
•
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-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
BGN plus BLN (non-possessive)
|
Fill-in (2)
|
|
Choice 1
|
you do not have and do not
|
Choice 2
|
BGN plus BLN (non-possessive) + does not have and does not
|
HIB331 – APPLY FOR MEDICARE THREE MONTHS PRIOR TO TURNING 65
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 values:
|
|
Fill-in (1)
|
|
Choice 1
|
you are
|
Choice 2
|
BGN plus BLN (non-possessive) + is
|
HIB333 – REPORT FRAUD FOR USPS SEP ENROLLMENTS
IN
2024
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-in values:
|
|
Fill-in (1)
|
https://oig.ssa.gov/report
|
Fill-in (2)
|
https://www.cms.gov/About-CMS/components/CPI/CPIReportingFraud
|
HIB334 – LATE ENROLLMENT PENALTY IS PAID BY USPS SEP
IN
2024
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-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
you are
|
Choice 2
|
Beneficiary’s name (not possessive) + is
|
Fill-in (2)
|
|
Choice 1
|
you are
|
Choice 2
|
they are
|
HIB335 – INCOME-RELATED MONTHLY ADJUSTMENT OF SMI-ENROLLMENT PREMIUM
FOR USPS SEP IN
2024
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-in values:
|
|
Fill-in (1)
|
2025 Medicare Part B IRMAA for individual in the format $NNN,NNN; do not show the
positions for cents.
|
Fill-in (2)
|
2025 Medicare Part B IRMAA for couples in the format $NNN,NNN; do not show the positions
for cents.
|
Fill-in (3)
|
|
Choice 1
|
your
|
Choice 2
|
their
|
Fill-in (4)
|
|
Choice 1
|
you need
|
Choice 2
|
they need
|
Fill-in (5)
|
|
Choice 1
|
your
|
Choice 2
|
their
|
Fill-in (6)
|
|
Choice 1
|
you have
|
Choice 2
|
they have
|
Fill-in (7)
|
|
Choice 1
|
your
|
Choice 2
|
their
|
Fill-in (8)
|
|
Choice 1
|
you
|
Choice 2
|
they
|
HIB336 – AUTOMATIC ENROLLMENT OF MEDICARE PART D FOR USPS SEP
IN
2024
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-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
you are
|
Choice 2
|
Beneficiary’s name (not possessive) + is
|
Fill-in (2)
|
|
Choice 1
|
your
|
Choice 2
|
their
|
Fill-in (3)
|
|
Choice 1
|
You do
|
Choice 2
|
They do
|
Fill-in (4)
|
|
Choice 1
|
yourself
|
Choice 2
|
them
|
Fill-in (5)
|
|
Choice 1
|
your
|
Choice 2
|
their
|